By Dr Stuart Salfinger, Gynaecologic Oncologist

Ovarian malignancy presents a difficult dilemma for all practitioners especially the GP. The vast majority of women are at low risk with a lifetime risk of the disease in the order of 1-1.5%. A smaller group are at higher risk coming from families with known BRCA 1 & 2 gene mutations or HNPCC. Others come from a  difficult-to-define increased risk group with strong family histories of breast and ovarian cancer; but no detected genetic mutation.

Dr Stuart Salfinger

Symptoms provide a weak clue

Most women who are diagnosed with ovarian carcinoma report symptoms, usually for a reasonable period of time before diagnosis. As the symptoms are vague and generalised and not classically “gynaecologic” in nature the diagnosis is usually made at an advanced stage of disease.

The classic symptomatology includes, abdominal bloating or increased abdominal girth, indigestion, early satiety or indigestion, change in weight or urinary/bowel habit. Pelvic pain or more commonly pressure is also reported but the majority of symptoms (75%) tend to be abdominal with only around 25% of women reporting “pelvic” symptoms.

Given these symptoms are very common, vague and non-specific, it is persistence of these symptoms for more than a month that should trigger further investigation.

After history and examination, ultrasound scan (USS) and serum ca125 levels are next in line.

Tests need experienced interpretation

A good quality trans-vaginal USS has a better sensitivity for detection of ovarian masses. Ca125 may be helpful but can be normal in 50% of women with early stage disease and can be elevated in many benign conditions.

Abnormalities on these tests should lead to referral to either an experienced gynaecologic surgeon or gynaecologic oncologist for ongoing care (depending on degree of risk). With the USS features such as complex areas with septations, papillary projections, solid elements or ascites are recognised as high risk. The Risk of Malignancy Index (RMI) scoring system is a useful triage tool but is not an absolute guide (see graphic).

Value of screening?

The current evidence and National recommendations are to not screen asymptomatic women. The UKCTOCS trial reported last year that there is no benefit to screening. The US Preventative Services Task Force (USPSTF) re-issued their guideline early this year reinforcing the decision against screening, as it does not improve survival and may carry unnecessary risk and also potentially be falsely reassuring.

For such a rare disease the current specificity of tests is not adequate in the general population. The risks and benefits of screening in the high-risk situation needs a careful and individualised discussion in conjunction with the known proven benefits of surgery in these women.

In the mean time we hope for better more specific and sensitive tests and better risk assessment tool to alter the course of this devastating disease.

Key Messages

  • Symptoms are vague and non specific – most disease presents late
  • Always investigate persistent symptoms
  • Ultrasound and Ca 125 good first line for investigations
  • Ovarian cancer screening is not recommended in line with national and international guidelines

Author competing interests: none to declare.

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