Ovarian Cancer: Recognition and Initial Management in Secondary Care

This specialist Guidelines summary provides recommendations on detecting, diagnosing and treating women (18 years and older) who have, or are suspected of having, epithelial ovarian cancer, fallopian tube cancer, primary peritoneal cancer or borderline ovarian cancer. The guidance aims to enable earlier detection of ovarian cancer and improve initial treatment. This summary includes recommendations on:

• establishing the diagnosis in secondary care
• management of suspected early (stage I) ovarian cancer
• management of advanced (stage II to IV) ovarian cancer
• support needs of women with newly diagnosed ovarian cancer

This summary is intended for use in a secondary care setting by oncologists. For the complete set of recommendations, refer to the full guideline.

This guideline partially replaces CG61, is partially replaced by NG12, and is the basis of QS18.

Establishing the Diagnosis in Secondary Care

Tumour Markers: Which to Use?

• Measure serum cancer antigen 125 (CA125) in secondary care in all women with suspected ovarian cancer, if this has not already been done in primary care
• In women under 40 with suspected ovarian cancer, measure levels of alpha fetoprotein (AFP) and beta human chorionic gonadotrophin (beta-hCG) as well as serum CA125, to identify women who may not have epithelial ovarian cancer.

Malignancy Indices

• Calculate a risk of malignancy index I (RMI I) score (after performing an ultrasound; see recommendation below) and refer all women with an RMI I score of 250 or greater to a specialist multidisciplinary team.
  
  Refer to the full guideline for details of how to calculate an RMI I score.

Imaging in the Diagnostic Pathway: Which Procedures?

• Perform an ultrasound of the abdomen and pelvis as the first imaging test in secondary care for women with suspected ovarian cancer, if this has not already been done in primary care
• If the ultrasound, serum CA125 and clinical status suggest ovarian cancer, perform a computed tomography (CT) scan of the pelvis and abdomen to establish the extent of disease. Include the thorax if clinically indicated
• Do not use MRI routinely for assessing women with suspected ovarian cancer.

Tissue Diagnosis

Requirement for Tissue Diagnosis

• If offering cytotoxic chemotherapy to women with suspected advanced ovarian cancer, first obtain a confirmed tissue diagnosis by histology (or by cytology if histology is not appropriate) in all but exceptional cases
• Offer cytotoxic chemotherapy for suspected advanced ovarian cancer without a tissue diagnosis (histology or cytology) only:
  • in exceptional cases, after discussion at the multidisciplinary team and
  • after discussing with the woman the possible benefits and risks of starting chemotherapy without a tissue diagnosis.

Methods of Tissue Diagnosis Other Than Laparotomy

• If surgery has not been performed, use histology rather than cytology to obtain a tissue diagnosis. To obtain tissue for histology:
  • use percutaneous image-guided biopsy if this is feasible
  • consider laparoscopic biopsy if percutaneous image-guided biopsy is not feasible or has not produced an adequate sample
    Use cytology if histology is not appropriate.

Management of Suspected Early (Stage I) Ovarian Cancer

The Role of Systematic Retroperitoneal Lymphadenectomy

• Perform retroperitoneal lymph node assessment as part of optimal surgical staging in women with suspected ovarian cancer whose disease appears to be confined to the ovaries (that is, who appear to have stage I disease)
  
  Lymph node assessment involves sampling of retroperitoneal lymphatic tissue from the para-aortic area and pelvic side walls if there is a palpable abnormality, or random sampling if there is no palpable abnormality
  
  Optimal surgical staging constitutes: midline laparotomy to allow thorough assessment of the abdomen and pelvis; a total abdominal hysterectomy, bilateral salpingo-oophorectomy and infracolic omentectomy; biopsies of any peritoneal deposits; random biopsies of the pelvic and abdominal peritoneum; and retroperitoneal lymph node assessment
   
• Do not include systematic retroperitoneal lymphadenectomy (block dissection of lymph nodes from the pelvic side walls to the level of the renal veins) as part of standard surgical treatment in women with suspected ovarian cancer whose disease appears to be confined to the ovaries (that is, who appear to have stage I disease).

Adjuvant Systemic Chemotherapy for Stage I Disease

• Do not offer adjuvant chemotherapy to women who have had optimal surgical staging and have low-risk stage I disease (grade 1 or 2, stage Ia or Ib)
• Offer women with high-risk stage I disease (grade 3 or stage Ic) adjuvant chemotherapy consisting of 6 cycles of carboplatin
• Discuss the possible benefits and side effects of adjuvant chemotherapy with women who have had suboptimal surgical staging and appear to have stage I disease
  
  Optimal surgical staging constitutes: midline laparotomy to allow thorough assessment of the abdomen and pelvis; a total abdominal hysterectomy, bilateral salpingo-oophorectomy and infracolic omentectomy; biopsies of any peritoneal deposits; random biopsies of the pelvic and abdominal peritoneum; and retroperitoneal lymph node assessment.

Management of Advanced (Stage II to IV) Ovarian Cancer

For NICE technology appraisal guidance on first-line chemotherapy see the NICE topic page on ovarian cancer.

Primary Surgery

• If performing surgery for women with ovarian cancer, whether before chemotherapy or after neoadjuvant chemotherapy, the objective should be complete resection of all macroscopic disease.

Intraperitoneal Chemotherapy

• Do not offer intraperitoneal chemotherapy to women with ovarian cancer, except as part of a clinical trial.

Second-line and Subsequent Treatment

For NICE technology appraisal guidance on second-line and subsequent treatment for ovarian cancer, including genomic biomarker-based therapy, see the NICE topic page on ovarian cancer.

The point at which to use genomic biomarker-based therapy in solid tumour treatment pathways is uncertain. See the NICE topic page on genomic biomarker-based cancer treatments.

Support Needs of Women with Newly Diagnosed Ovarian Cancer

• Offer all women with newly diagnosed ovarian cancer information about their disease, including psychosocial and psychosexual issues, that:
  • is available at the time they want it
  • includes the amount of detail that they want and are able to deal with
  • is in a suitable format, including written information.
• Ensure that information is available about:
  • the stage of the disease, treatment options and prognosis
  • how to manage the side effects of both the disease and its treatments in order to maximise wellbeing
  • sexuality and sexual activity
  • fertility and hormone treatment
  • symptoms and signs of disease recurrence
  • genetics, including the chances of family members developing ovarian cancer
  • self-help strategies to optimise independence and coping
  • where to go for support, including support groups
  • how to deal with emotions such as sadness, depression, anxiety and a feeling of a lack of control over the outcome of the disease and treatment.