HNY Policy and Pathway Repository - York

Ovarian cancer is the leading cause of death from gynecological cancer in the UK. It is the fifth most common cancer in women with a lifetime risk of about 2%. The outcome is often poor due to late stage at diagnosis, which is the most important prognostic indicator. Women will often experience symptoms for up to 12 months prior to diagnosis, due to vague and general nature of symptoms.

• Refer 2WW if physical examination identifies ascites and/or a pelvic or abdominal mass (which is not obviously uterine fibroids).
• USS suggestive of ovarian cancer – refer 2WW

Symptoms suggestive of ovarian cancer

• Ovarian cancer should be considered in any woman (especially if over 50) who has the following symptoms on a persistent or frequent basis – particularly more than 12 times a month
  • Persistent abdominal distension (bloating)
  • feeling full (early satiety) and/or loss of appetite
  • pelvic or abdominal pain
  • increased urinary urgency and/or frequency
  • new symptoms of IBS
• Also consider in women with:
  • unexplained weight loss
  • fatigue
  • change in bowel habit

Management

• Carry out abdominal, pelvic and speculum examination
• If any of the above symptoms or signs measure serum CA125 and wait for results before ordering ultrasound. When requesting CA 125, please additionally request a serum U&E in case contrast CT/MRI is required.
• If CA 125 >35 IU/ml - arrange urgent (within 2 weeks) USS of abdomen and pelvis
• For any woman who has normal serum CA125, or CA125 of 35 IU/ml or greater but a normal ultrasound; assess her carefully for other clinical causes of her symptoms and investigate if appropriate. If no other clinical cause is apparent, advise her to return to her GP if her symptoms become more frequent and/or persistent. Proactively review her within 1 month.
• Other non-ovarian cancer causes of an elevated CA 125:
  • Physiological conditions:
    • Ovulation
    • Pregnancy
    • Retrograde Menstruation
  • Benign Gynaecological Conditions:
    • Endometriosis (may or may not be associated with an endometrioma)
    • Benign Ovarian Cyst (in context of patient with adnexal cyst and raised Ca 125 please refer to Gynaecology 2WW)
    • Uterine fibroids (will be demonstrated on USS)
  • Other Non-malignant non-gynaecological causes:
    • Autoimmune disease-Sjogren’s syndrome, Polyarteritis nodosa, SLE
    • Sarcoidosis
    • Benign GI disease-colitis, diverticulitis
    • Chronic active hepatitis
    • Cirrhosis
    • Pericarditis
    • Pancreatitis (acute and chronic)
    • Renal disease with elevated creatinine
  • Non-ovarian malignant conditions:
    • Malignant ascites
    • Disseminated malignancy (e.g. Breast, Lung)
    • Disseminated malignancy involving pleural or peritoneal surfaces
    • A proportion of:
      • Non-Hodgkins lymphoma
      • Pancreatic cancer
      • Cervical Cancer
      • Endometrial Cancer
• If USS abnormal – refer 2WW

 

Investigations prior to referral

• CA 125 and USS if indicated

Information to include in referral letter

• Describe symptoms and duration
• Any FH of ovarian or breast cancer
• Current contraception/hormone therapy
• Abdominal, speculum and pelvic examination
• Cervical Screening (Smear) history
• Relevant past medical/surgical history
• Current regular medication
• BMI
• Smoking status

Patient information leaflets/ PDAs

• Ovarian Cancer -signs, symptoms and treatment Ovarian Cancer screening and treatment

 

References

• NICE Ovarian Cancer Clinical Guideline 122, 2011 Ovarian Cancer

• NICE Ovarian Cancer Quality Standard (QS18), 2012 Overview | Ovarian cancer | Quality standards | NICE

• BGCS Epithelial Ovarian/Fallopian tube/Primary Peritoneal Cancer Guidelines: Recommendations for Practice BGCS Guidelines Ovarian cancer: Recommendations for Practice