HNY Policy and Pathway Repository - North Yorkshire and York

This pathway supports timely recognition, assessment and referral of people with possible ovarian cancer in primary care. Ovarian cancer remains a significant cause of gynaecological cancer mortality in the UK, and outcomes are strongly influenced by stage at diagnosis. Symptoms may be vague, persistent and non-specific; a structured approach to assessment, investigation and safety-netting is therefore essential.

This pathway applies to adults with female reproductive organs who present with symptoms, signs or investigation findings that may suggest ovarian cancer. It should be used alongside current NICE guidance, local suspected cancer referral pathways and clinical judgement.

Assess for red flags requiring immediate referral, including ascites or a pelvic or abdominal mass that is not clearly uterine fibroids.

Clinical presentation: symptoms that should prompt assessment

• Consider ovarian cancer in any person with female reproductive organs, particularly those aged 50 and over, who reports persistent or frequent symptoms, especially if occurring more than 12 times per month:

  • Persistent abdominal distension or bloating

  • Feeling full quickly, early satiety and/or loss of appetite

  • Pelvic or abdominal pain

  • Increased urinary urgency and/or frequency

  • New symptoms suggestive of irritable bowel syndrome, particularly in those aged 50 and over

• Also consider ovarian cancer where any of the following are present:

  • Unexplained weight loss

  • Fatigue

  • Change in bowel habit

Primary care assessment

• Take a focused history, including symptom pattern, frequency, duration, associated bowel or urinary symptoms, weight change, appetite change and relevant family history.

• Carry out abdominal, pelvic and speculum examinations where clinically appropriate.

• Assess for red flags requiring immediate referral, including ascites or a pelvic or abdominal mass that is not clearly uterine fibroids.

• Where ovarian cancer is suspected but immediate referral criteria are not met, proceed to the investigation pathway below.

Primary care assessment

• Take a focused history, including symptom pattern, frequency, duration, associated bowel or urinary symptoms, weight change, appetite change and relevant family history.

• Carry out abdominal, pelvic and speculum examinations where clinically appropriate.

• Assess for red flags requiring immediate referral, including ascites or a pelvic or abdominal mass that is not clearly uterine fibroids.

Where ovarian cancer is suspected but immediate referral criteria are not met, proceed to the investigation pathway below.

Investigation pathway

1. For people aged 39 and under with persistent symptoms suggestive of ovarian cancer, do not use serum CA125 in isolation to guide decision-making. Consider urgent direct-access ultrasound of the abdomen and pelvis.

2. For people aged 40 and over with persistent symptoms suggestive of ovarian cancer, measure serum CA125 in primary care.

3. When requesting CA125, also request U&Es in case contrast CT or MRI is subsequently required.

4. If CA125 is above the age-related threshold in Table 1, arrange urgent direct-access ultrasound of the abdomen and pelvis within 2 weeks.

5. If ultrasound is suggestive of ovarian cancer, refer on a suspected cancer pathway.

Table 1. Age-related serum CA125 thresholds

Safety-netting and follow-up

If initial investigations do not confirm ovarian cancer, provide clear safety-netting advice. The patient should be advised to seek review if symptoms persist, worsen or become more frequent. Where symptoms remain unexplained, arrange proactive clinical review within 1 month.

• If serum CA125 is normal, or if CA125 is above the relevant threshold but ultrasound is normal, assess for other clinical causes and investigate as appropriate. If no alternative cause is identified, advise the patient to return if symptoms become more frequent or persistent and proactively review within 1 month.

• Consider alternative causes of raised CA125, including:

  • Physiological causes:

    • Ovulation

    • Pregnancy

    • Retrograde menstruation

  • Benign gynaecological conditions:

    • Endometriosis (may or may not be associated with an endometrioma)

    • Benign ovarian cyst; if there is an adnexal cyst with raised CA125, refer on a gynaecology suspected cancer pathway.

    • Uterine fibroids, which may be demonstrated on ultrasound

  • Other non-malignant, non-gynaecological causes:

    • Autoimmune disease, including Sjögren’s syndrome, polyarteritis nodosa and SLE

    • Sarcoidosis

    • Benign gastrointestinal disease, including colitis and diverticulitis

    • Chronic active hepatitis

    • Cirrhosis

    • Pericarditis

    • Pancreatitis (acute and chronic)

    • Renal disease with elevated creatinine

  • Non-ovarian malignant causes:

    • Malignant ascites

    • Disseminated malignancy, for example breast or lung cancer

    • Disseminated malignancy involving pleural or peritoneal surfaces

    • A proportion of:

      • Non-Hodgkin lymphoma

      • Pancreatic cancer

      • Cervical cancer

      • Endometrial cancer

• If ultrasound is abnormal or suggestive of ovarian cancer, refer on a suspected cancer pathway.

• Include CA125 and ultrasound results where these have been arranged through the pathway. Do not delay referral if examination findings already meet urgent suspected cancer referral criteria.

Investigations prior to Referral

• Presenting symptoms, including duration, frequency and progression
• Family history of ovarian, breast or related cancers
• Current contraception and/or hormone therapy
• Findings from abdominal, speculum and pelvic examinations
• Cervical screening history
• Relevant past medical and surgical history
• Current regular medication
• BMI
• Smoking status

Immediate suspected cancer referral criteria

• Refer on a suspected cancer pathway if physical examination identifies ascites and/or a pelvic or abdominal mass that is not clearly attributable to uterine fibroids.
• Refer on a suspected cancer pathway if ultrasound findings are suggestive of ovarian cancer.

Patient information and references

Patient information

• Ovarian cancer: signs, symptoms and treatment — Ovarian cancer screening and treatment

Use patient-facing information to support shared understanding of symptoms, investigations, referral rationale and safety-netting advice.

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

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