Diagnosis and investigation

• awareness of symptoms and signs
  • refer the woman urgently if physical examination identifies ascites and/or a pelvic or abdominal mass (which is not obviously uterine fibroids
    
    
  • carry out tests in primary care (see below) if a woman (especially if 50 or over) reports having any of the following symptoms on a persistent or frequent basis - particularly more than 12 times per month:
    • persistent abdominal distension (women often refer to this as 'bloating')
    • feeling full (early satiety) and/or loss of appetite
    • pelvic or abdominal pain
    • increased urinary urgency and/or frequency
      
      
  • consider carrying out tests in primary care (see below) if a woman reports unexplained weight loss, fatigue or changes in bowel habit
    
    
  • advise any woman who is not suspected of having ovarian cancer to return to her GP if her symptoms become more frequent and/or persistent
    
    
  • carry out appropriate tests for ovarian cancer (see below) in any woman of 50 or over who has experienced symptoms within the last 12 months that suggest irritable bowel syndrome (IBS) , because IBS rarely presents for the first time in women of this age
    
    
• primary care testing for possible ovarian cancer
  • measure serum CA125 in primary care in women with symptoms that suggest ovarian cancer
  • if serum CA125 is 35 IU/ml or greater, arrange an ultrasound scan of the abdomen and pelvis
  • f the ultrasound suggests ovarian cancer, refer the woman urgently for further investigation
  • for any woman who has normal serum CA125 (less than 35 IU/ml), 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
      
      
• secondary care invesstigations:
  • secondary care markers:
    • serum 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
      
      
  • imaging in the diagnostic pathway:
    • 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 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
    • 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

Reference:

• 1) NICE (March 2011). Ovarian cancer The recognition and initial management of ovarian cancer