Overview
This specialist Guidelines summary provides recommendations on the management of epithelial ovarian cancer. Management of borderline tumours is not covered. This summary is intended for use in a secondary care setting by medical and clinical oncologists, gynaecologists, and radiologists.
For the complete set of recommendations, refer to the full guideline.
Recommendations are marked [R] and good-practice points are marked [✓].
Screening and the Role of Prophylactic Salpingo-oophorectomy
Screening for Ovarian Cancer in the General Population
[R] Screening for ovarian cancer in the general population should not be performed out with the research setting.
Identifying Women at High Risk of Developing Ovarian Cancer
- Family history can be used to define women who are at increased risk of ovarian cancer. A woman is defined as being at high risk of ovarian cancer if she meets one of the following criteria:
- she is a known carrier of relevant cancer gene mutations including BRCA1, BRCA2, or mismatch repair genes
- she is an untested first degree relative of an individual with a mutation in BRCA1, BRCA2, RAD51C, RAD51D, or mismatch repair genes
- she is an untested second degree relative, through an unaffected man, of an individual with a mutation in BRCA1, BRCA2, RAD51C, RAD51D, or mismatch repair genes
- she has a first-degree relative (mother, father, sister, brother, daughter, or son) affected by cancer within a family that meets one of the following criteria:
- two or more individuals with ovarian cancer, who are first-degree relatives of each other
- one individual with ovarian cancer at any age, and one with breast cancer diagnosed under age 50 years, who are first-degree relatives of each other
- one relative with ovarian cancer at any age, and two with breast cancer diagnosed under 60 years, who are connected by first-degree relationships
- three or more family members with colon cancer, or two with colon cancer and one with stomach, ovarian, endometrial, urinary tract, or small bowel cancer in two generations. One of these cancers must be diagnosed under age 50 years and affected relatives should be first degree relatives of each other
- one individual with both breast and ovarian cancer.
- Individuals meeting the above criteria may be eligible for referral for prophylactic salpingo-oophorectomy by age 40 and breast screening or, in some, prophylactic mastectomy.
[R] All women with non-mucinous ovarian or fallopian tube cancer should be offered BRCA1 and BRCA2 mutation testing.
[R] Women with ovarian cancer who have a family history of breast, ovarian, or colon cancer should have a genetic risk assessment.
[R] BRCA1 and BRCA2 mutation analysis should be considered in a family where there is a 10% or greater risk of a mutation being present.
[✓] Close collaboration between primary care and specialist cancer genetics services is to be encouraged so that genetic cancer risk assessment in individuals who are at medium or high risk can be carried out efficiently.
Screening in High-risk Groups
[R] Screening for ovarian cancer in high risk groups should only be offered in the context of a research study.
Prophylactic Salpingo-oophorectomy
[R] Women with genetic mutations of BRCA1 or BRCA2 genes should be offered prophylactic oophorectomy and removal of fallopian tubes at a relevant time in their life.
[✓] Women at high-risk in whom mutations have not been identified should have the opportunity to discuss the advantages and disadvantages of prophylactic salpingo-oophorectomy.
[✓] Hormone replacement can be used after oopherectomy until the time of natural menopause without losing the benefits of breast cancer risk reduction.
[✓] Women who decide to have prophylactic salpingo-oophorectomy should be offered counselling, support, and information before and after surgery.
Diagnosis in Secondary Care
For diagnosis in primary care, please refer to the full guideline.
Table 1: The Risk of Malignancy index (RMI) Scoring System
| Feature | RMI 1 Score | RM1 2 Score |
|---|---|---|
Ultrasound features:
| 0=none1=one abnormality 3=two or more abnormalities | 0=none 1=one abnormality 4=two or more abnormalities |
| Premenopausal | 1 | 1 |
| Postmenopausal | 3 | 4 |
| CA125 | U/ml | U/ml |
| RMI score=ultrasound score x menopausal score x CA125 (ovarian cancer-related tumour marker) level in U/mlAbbreviations: RMI=risk malignancy index | ||
[✓] In order to allow the calculation of RMI 1, ultrasound reports should ideally list the presence or absence of the features that make up the ultrasound component of this scoring system.
[✓] Although an RMI 1 threshold of 200 is recommended, benign conditions may cause elevation of the RMI score and early malignancy may not.
[R] Computed tomography of the abdomen and pelvis should be performed in secondary care for all patients suspected of having ovarian cancer who have a RMI score greater than 200.
[R] Magnetic resonance imaging is not recommended for routine staging of ovarian cancer.
[R] Positron emission tomography–computed tomography is not recommended in the diagnosis or initial staging of ovarian cancer.
[✓] Magnetic resonance imaging should be considered for characterisation of indeterminate adnexal masses where an alternative diagnosis to ovarian cancer is thought more likely.
[✓] Computed tomography of the entire thorax is not routinely recommended unless intrathoracic metastatic disease is clinically suspected. Imaging of the abdomen and pelvis should, however, include the lung bases.
The Role of the Clinical Nurse Specialist
[R] Patients should be given their diagnosis of ovarian cancer in the presence of a clinical nurse specialist who is a fully integrated member of the gynaecological cancer team.
[R] Throughout their care pathway patients with ovarian cancer should have access to a clinical nurse specialist who should be an integral member of the gynaecological cancer team.
Surgical Management
Pathology
[R] To minimise the need for a second operative staging procedure, intraoperative frozen section assessment can be used to diagnose malignancy and to exclude metastatic disease.
Management of Early Disease
- Early disease refers to disease confined to the ovaries. There are two clinical scenarios where early disease could be encountered:
- the gynaecologist is alerted to the possibility of malignancy being present prior to the laparotomy
- the gynaecologist had no suspicion of cancer being present prior to surgery.
- To minimise the risk of the gynaecologist encountering the second scenario, use should be made of the RMI scoring system if an isolated pelvic mass is discovered on preoperative imaging. In young women the possibility of a non-epithelial ovarian tumour being present should also be considered.
[R] Retroperitoneal lymph node sampling should be considered as part of surgical staging for apparent early stage disease.
- In women who wish to conserve their fertility, adequate staging (excluding disease involving the liver, peritoneum, retroperitoneal nodes, appendix and diaphragm) is required and the risk of recurrent disease developing must be discussed.
- If fertility conservation is requested, it is an option in apparent stage Ia disease, but the benefits and drawbacks of this type of surgery must be discussed with the patient, particularly with regard to the need for a second procedure and the procedure being most appropriate if grade 1 disease is present.
Optimal Surgery for Advanced Disease
[R] In surgery for advanced ovarian cancer, the aim should be to achieve complete cytoreduction.
[R] The use of neoadjuvant chemotherapy in women with stage IIIc or IV ovarian cancer may be considered as an alternative to primary debulking surgery.
[✓] With regard to selecting who will benefit from neoadjuvant chemotherapy, treatment should be individualised to the patient taking into account resectability, age, histology, performance status and after ruling out the possibility of other primary tumours, and after full discussion at multidisciplinary team meetings.
Relapsed Disease
[R] In selected patients with relapsed epithelial ovarian cancer which is platinum-sensitive, secondary cytoreductive surgery may be appropriate and may improve overall survival. The aim should be complete resection of all macroscopic disease. Where possible, this should be done in the context of a clinical trial.
Chemotherapy
Early Disease
[R] All women with high-grade early stage (Ia–Ib) ovarian cancer should be considered for adjuvant chemotherapy.
[R] For early-stage disease, maintenance cytotoxic chemotherapy should not be given.
Advanced Disease
[R] First-line chemotherapy treatment of epithelial ovarian cancer should include a platinum agent either in combination or as a single agent, unless specifically contraindicated.
[R] Carboplatin is the platinum drug of choice in both single and combination therapy.
[R] Paclitaxel is recommended in combination therapy with platinum in the first-line post-surgery treatment of epithelial ovarian cancer where the potential benefits justify the toxicity of the therapy. In those unable to tolerate paclitaxel, peglated liposomal doxorubicin or gemcitabine in combination with carboplatin can be used as an alternative.
[R] Patients who are unfit for combination therapy should be offered single-agent carboplatin.
[R] A third cytotoxic agent should not be added to carboplatin and paclitaxel.
[R] Carboplatin AUC 6 (day 1 of a 21 day cycle) and paclitaxel 80 mg/m2 (day 1, 8, 15 of a 21 day cycle) may be considered for the treatment of first-line ovarian cancer. The increased toxicity and frequency of visits need to be discussed with the patient.
[✓] Where possible, patients receiving treatment with carboplatin AUC 6 (day 1 of a 21 day cycle) and paclitaxel 80mg/m2 (day 1, 8, 15 of a 21 day cycle) for first-line ovarian cancer should be enrolled in ongoing clinical trials in order to establish if this regimen should become the standard of care.
[R] Women with stage IV ovarian cancer should be offered bevacizumab in combination with carboplatin and paclitaxel.
[R] For advanced ovarian cancer, maintenance cytotoxic chemotherapy should not be given following standard first-line chemotherapy.
[R] Chemotherapy that includes an intraperitoneal element can be considered for women with a new diagnosis of epithelial ovarian cancer and residual disease of 1 cm or less after primary surgery, provided a regimen of proven benefit in a clinical trial compared to intravenous therapy is used, it is delivered in a centre with appropriate expertise and the potential toxicities are fully explained.
[✓] Where possible, women receiving intraperitoneal chemotherapy should be enrolled into ongoing clinical trials.
Relapsed Disease
Systemic Therapy in Recurrent Ovarian Cancer
- Relapse in ovarian cancer occurs in approximately 75% of patients and is therefore a significant problem, affecting approximately 375 patients a year in Scotland. Relapsed ovarian cancer is incurable but prolonged survival (over 1 year) is possible in the majority of patients and improved treatment following relapse has resulted in incremental increases in the overall survival from ovarian cancer.
[R] Women with platinum-sensitive relapsed ovarian cancer should be offered treatment with carboplatin combined with either paclitaxel or pegylated liposomal doxorubicin hydrochloride (depending on fitness, comorbidity, and toxicity experienced with previous treatment).
[R] Women with platinum-resistant ovarian cancer should be considered for treatment with paclitaxel or single-agent pegylated liposomal doxorubicin hydrochloride (depending on fitness, comorbidity, and patient’s wishes).
[R] Women with platinum-resistant relapsed ovarian cancer should be offered bevacizumab in combination with paclitaxel.
[R] Olaparib monotherapy should be considered for maintenance treatment after response to platinum for patients with relapsed platinum-sensitive BRCA-mutated ovarian cancer.
[R] Niraparib monotherapy should be considered for maintenance treatment after response to platinum for patients with relapsed platinum-sensitive non-germline BRCA-mutated ovarian cancer.
[R] Hormonal therapy with tamoxifen or an aromatase inhibitor can be used for women with recurrent, platinum-resistant ovarian cancer or in those wishing to avoid or delay further chemotherapy, particularly where their original tumour is expressing the oestrogen receptor.
Chemotherapy for Low-grade Serous, Clear Cell, and Mucinous Histological Subtypes
[✓] Patients with low-grade serous, clear cell, and mucinous histological subtypes should be considered for clinical trials.
Follow Up
[R] Treatment of first relapse of ovarian cancer should be guided by the development of symptoms.
[R] In the absence of symptoms, routine measurement of CA125 (ovarian cancer-related tumour marker) during follow up is not mandatory.
Management of Malignant Bowel Obstruction in Relapsed Disease
[R] Surgery for malignant bowel obstruction in patients with advanced ovarian cancer must be justified on the basis of achieving a significant benefit.
Table 2: Contraindications to Surgery for Malignant Bowel Obstruction in Patients With Advanced Ovarian Cancer
| Absolute Contraindications |
|---|
Patient refusal Previous abdominal surgery which showed diffuse metastatic cancer Involvement of proximal stomach Intra-abdominal carcinomatosis demonstrated radiologically with a contrast study revealing a severe motility problem Diffuse palpable intra-abdominal masses (having excluded faecal masses) Massive ascites which rapidly recurs after drainage |
| Relative Contraindications |
| Non-symptomatic extensive extra-abdominal malignant disease (e.g. widespread metastases and pleural effusion) Poor general performance status Poor nutritional status (e.g. marked weight loss/cachexia, marked hypoalbuminaemia and low lymphocyte count) Severe cachexia Small bowel obstruction Previous radiotherapy of the abdomen or pelvis |
Non-surgical Management
[R] Symptoms of bowel obstruction can be relieved by using the following drug categories either alone or in combination:
- antiemetic
- antisecretory
- analgesic
- corticosteroids.
Provision of Information
| Box 1: Checklist for Provision of Information |
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| Palliative Care |
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