Ovarian cancer

Short Text

The recognition and management of ovarian cancer

Introduction

This pathway covers the recognition and management of ovarian cancer.
Ovarian cancer is the leading cause of death from gynaecological cancer in the UK, and its incidence is rising. It is the fifth most common cancer in women.
The overall 5-year survival rate for women with ovarian cancer is below 35%. Most women present with advanced disease, having had symptoms for months before presentation, and there are often delays between presentation and specialist referral. There is a need for greater awareness of ovarian cancer, and for initial investigations in primary and secondary care that enable earlier referral and optimum treatment.
This pathway does not cover the entire care pathway for ovarian cancer in detail. It focuses on areas where there is uncertainty or wide variation in clinical practice with regard to the detection, diagnosis and management of ovarian cancer. The recommendations are applicable to women with epithelial ovarian cancer (the most common type of ovarian cancer), as well as women with fallopian tube carcinoma, primary peritoneal carcinoma or borderline ovarian cancer.

Quality standards

Ovarian cancer quality standard

These quality statements are taken from the ovarian cancer quality standard. The quality standard defines clinical best practice in ovarian cancer care and should be read in full.

Quality statements

Symptoms and CA125

This quality statement is taken from the ovarian cancer quality standard. The quality standard defines clinical best practice in ovarian cancer care and should be read in full.

Quality statement

Women aged 50 years or over reporting one or more symptoms occurring persistently or frequently that suggest ovarian cancer are offered a CA125 test.

Quality measure

Structure
Evidence of local arrangements to ensure all women aged 50 years and over reporting one or more symptoms occurring persistently or frequently that suggest ovarian cancer are offered a CA125 test.
Process
Proportion of women aged 50 years and over reporting at least one symptom occurring persistently or frequently that suggests ovarian cancer who receive a CA125 test.
Numerator – the number of women in the denominator receiving a CA125 test.
Denominator – the number of women aged 50 years and over reporting at least one symptom occurring persistently or frequently that suggests ovarian cancer.

Description of what the quality statement means for each audience

Service providers ensure systems are in place for women aged 50 years or over reporting one or more symptoms occurring persistently or frequently that suggest ovarian cancer to be offered a CA125 test.
Healthcare professionals offer a CA125 test to women aged 50 years or over reporting one or more symptoms occurring persistently or frequently that suggest ovarian cancer.
Commissioners ensure they commission services that provide CA125 tests for women aged 50 years or over reporting one or more symptoms occurring persistently or frequently that suggest of ovarian cancer.
Women aged 50 years or over with one or more symptoms associated with ovarian cancer that occur often (more than 12 times a month) or for a while (over a month) are offered a blood test called a CA125 test. The CA125 test measures the amount of a protein produced by some ovarian cancers in the blood. Symptoms associated with ovarian cancer include feeling 'bloated', loss of appetite or feeling full quickly, pain in the abdomen or pelvic area, needing to pass urine urgently or more often than usual, and unexplained tiredness, weight loss or changes in bowel habit (for example, constipation or diarrhoea).

Source clinical guideline references

NICE clinical guideline 122 recommendations 1.1.1.2, 1.1.1.5, 1.1.2.1 (key priorities for implementation), 1.1.1.3 and 1.2.1.1.

Data source

Structure
Local data collection.
Process
Local data collection. Contained in NICE audit support for ovarian cancer (NICE clinical guideline 122): primary care, criteria 2, 3 and 4.

Definitions

The statement applies to women aged 50 years and over. However women under 50 years should be offered the CA125 test if clinically appropriate.
Symptoms suggestive of ovarian cancer include:
  • persistent abdominal distension (women often refer to this as 'bloating')
  • feeling full and/or loss of appetite
  • pelvic or abdominal pain
  • increased urinary urgency and/or frequency
  • unexplained weight loss
  • unexplained fatigue
  • unexplained changes in bowel habit or
  • symptoms that suggest irritable bowel syndrome if the woman is 50 years or over.
Persistent is defined as at least 1 month.
Frequent is defined as 12 times per month.

Equality and diversity considerations

The statement includes women aged 50 years and over as they have a higher risk of developing ovarian cancer than women aged under 50 years based on the epidemiological profile of the disease. Over 80% of women diagnosed with ovarian cancer are aged over 50 years. The highest age-specific incidence rates are seen for women aged 80-84 years at diagnosis (69 per 100,000), dropping to 64 per 100,000 in women aged 85 and over (Cancer Research UK). However ovarian cancer can occur in women aged under 50 years, and incidence increases with age, with the highest age-specific incidence rates for women under 50 years occurring in those aged 45-49 years at diagnosis (19 per 100,000). Therefore women under 50 years should be offered the CA125 test if clinically appropriate.

Ultrasound

This quality statement is taken from the ovarian cancer quality standard. The quality standard defines clinical best practice in ovarian cancer care and should be read in full.

Quality statement

Women with raised CA125 have an ultrasound of their abdomen and pelvis within 2 weeks of receiving the CA125 test results.

Quality measure

Structure
Evidence of local arrangements to ensure all women with raised CA125 have an ultrasound of their abdomen and pelvis within 2 weeks of receiving the CA125 test results.
Process
Proportion of women with raised CA125 who have an ultrasound of their abdomen and pelvis within 2 weeks of receiving the CA125 test results.
Numerator – the number of women in the denominator who have an ultrasound of their abdomen and pelvis within 2 weeks of receiving the CA125 test results.
Denominator – the number of women with raised CA125.

Description of what the quality statement means for each audience

Service providers ensure systems are in place for women with raised CA125 to have an ultrasound of their abdomen and pelvis within 2 weeks of receiving the CA125 test results. To meet the 2-week timescale, service providers ensure systems are in place for ultrasounds to be arranged directly from primary care.
Healthcare professionals ensure women with raised CA125 have an ultrasound of their abdomen and pelvis within 2 weeks of receiving the CA125 test results.
Commissioners ensure they commission services that provide an ultrasound of the abdomen and pelvis within 2 weeks of receiving the test results for women with raised CA125.
Women with raised CA125 levels in their blood have an ultrasound scan of their abdomen and pelvis within 2 weeks of receiving the results of their blood test.

Source clinical guideline references

NICE clinical guideline 122 recommendations 1.1.2.2 (key priority for implementation) and 1.2.3.1.
The Royal College of Radiologists iRefer: Making the best use of clinical radiology: referral guidelines recommendation CA42 diagnosis (US).

Data source

Structure
Local data collection.
Process
Local data collection. Contained in NICE audit support for ovarian cancer (NICE clinical guideline 122): primary care, criteria 5.

Definitions

Raised CA125 is defined as 35 IU/ml or greater.

Advice

This quality statement is taken from the ovarian cancer quality standard. The quality standard defines clinical best practice in ovarian cancer care and should be read in full.

Quality statement

Women with normal CA125, or raised CA125 but normal ultrasound, with no confirmed diagnosis but continuing symptoms, are reassessed by their GP within 1 month.

Quality measure

Structure
Evidence of local arrangements and written clinical protocols to ensure women with normal CA125, or raised CA125 but normal ultrasound, with no confirmed diagnosis but continuing symptoms, are reassessed by their GP within 1 month.
Process
a) Proportion of women with normal CA125 and no confirmed diagnosis but continuing symptoms, who are reassessed by their GP within 1 month.
Numerator – the number of women in the denominator who are reassessed by their GP within 1 month.
Denominator – the number of women with normal CA125 and no confirmed diagnosis but continuing symptoms.
b) Proportion of women with raised CA125 but normal ultrasound and no confirmed diagnosis but continuing symptoms, who are reassessed by their GP within 1 month.
Numerator – the number of women in the denominator who are reassessed by their GP within 1 month.
Denominator – the number of women with raised CA125 but normal ultrasound, and no confirmed diagnosis but continuing symptoms.

Description of what the quality statement means for each audience

Service providers ensure systems and written clinical protocols are in place for women with normal CA125, or raised CA125 but normal ultrasound, with no confirmed diagnosis but continuing symptoms, to be reassessed by their GP within 1 month.
GPs proactively reassess women who have normal CA125, or raised CA125 but normal ultrasound, with no confirmed diagnosis but continuing symptoms, within 1 month.
Commissioners ensure they commission services that reassess women who have normal CA125, or raised CA125 but normal ultrasound, with no confirmed diagnosis but continuing symptoms, by their GP within 1 month.
Women with normal CA125 results, or raised CA125 but a normal ultrasound scan, with no confirmed diagnosis but continuing symptoms, are reassessed by their GP within 1 month.

Source clinical guideline references

NICE clinical guideline 122 recommendations 1.1.2.4 (key priority for implementation) and 1.1.1.4.

Data source

Structure
Local data collection.
Process
a) and b) Local data collection.

Definitions

Normal CA125 is defined as less than 35 IU/ml.
Raised CA125 is defined as 35 IU/ml or greater.
1 month starts from receipt of the normal CA125 or normal ultrasound result.
Symptoms suggesting ovarian cancer include:
  • persistent abdominal distension (women often refer to this as 'bloating')
  • feeling full and/or loss of appetite
  • pelvic or abdominal pain
  • increased urinary urgency and/or frequency
  • unexplained weight loss
  • fatigue
  • changes in bowel habit or
  • symptoms that suggest irritable bowel syndrome if the woman is 50 or over.
Non-ovarian cancer reasons for raised CA125 (from the United Kingdom Collaborative Trial for Ovarian Cancer Screening protocol list:
Physiological conditions:
  • ovulation
  • pregnancy
  • retrograde menstruation.
Benign gynaecological conditions:
  • endometriosis
  • benign ovarian cysts
  • uterine leiomyomata (fibroids).
Other non-malignant disease:
  • autoimmune disease (such as Sjogrens syndrome, polyarteritis nodosa, systemic lupus erythematosus)
  • sarcoidosis
  • benign gastrointestinal diseases (such as colitis, diverticulitis)
  • chronic active hepatitis
  • cirrhosis
  • pericarditis
  • pancreatitis (acute and chronic)
  • renal disease with serum creatinine greater than 2.0.
Non-ovarian malignant conditions:
  • malignant ascites
  • disseminated malignancy (such as breast, lung)
  • disseminated malignancies from any site involving pleural or peritoneal surfaces
  • a proportion of:
­ - non-Hodgkin's lymphoma
­ - pancreatic cancers
­ - cervical cancers
­ - endometrial cancers.

Malignancy indices

This quality statement is taken from the ovarian cancer quality standard. The quality standard defines clinical best practice in ovarian cancer care and should be read in full.

Quality statement

Women with a risk of malignancy index (RMI I) score of 250 or greater are referred to a specialist gynaecological cancer multidisciplinary team.

Quality measure

Structure
Evidence of local arrangements to ensure women with an RMI I score of 250 or greater are referred to a specialist gynaecological cancer multidisciplinary team.
Process
Proportion of women with an RMI I score of 250 or greater referred to a specialist gynaecological cancer multidisciplinary team.
Numerator – the number of women in the denominator referred to a specialist gynaecological cancer multidisciplinary team.
Denominator – the number of women with an RMI I score of 250 or greater.

Description of what the quality statement means for each audience

Service providers ensure systems are in place for women with an RMI I score of 250 or greater to be referred to a specialist gynaecological cancer multidisciplinary team.
Healthcare professionals ensure women with an RMI I score of 250 or greater are referred to a specialist gynaecological cancer multidisciplinary team.
Commissioners ensure they commission services for women with an RMI I score of 250 or greater to be referred to a specialist gynaecological cancer multidisciplinary team.
Women with suspected ovarian cancer have their 'risk of malignancy' or RMI I score calculated (using their CA125 and ultrasound results and whether they have had the menopause) to help find out if ovarian cancer is likely. Women with a high RMI I score (250 or more) are referred to a team of healthcare professionals who are experienced in treating women with ovarian cancer, called a specialist gynaecological cancer multidisciplinary team.

Source clinical guideline references

NICE clinical guideline 122 recommendation 1.2.2.1 (key priority for implementation).

Data source

Structure
Local data collection.
Process
Local data collection. Also contained in NICE audit support for ovarian cancer (NICE clinical guideline 122): secondary care, criteria 3.

Definitions

NICE clinical guideline 122 defines how RMI I should be calculated in appendix D. RMI I combines three pre-surgical features: CA125, menopausal status (M) and ultrasound score (U). The RMI is a product of the ultrasound scan score, the menopausal status and the CA125 level (IU/ml).
RMI = U x M x CA125
The ultrasound result is scored 1 point for each of the following characteristics: multilocular cysts, solid areas, metastases, ascites and bilateral lesions. U = 0 (for an ultrasound score of 0), U = 1 (for an ultrasound score of 1), U = 3 (for an ultrasound score of 2-5).
The menopausal status is scored as 1 = pre-menopausal and 3 = post-menopausal. The classification of 'post-menopausal' is a woman who has had no period for more than 1 year or a woman over 50 who has had a hysterectomy.
CA125 is measured in IU/ml and can vary between 0 and hundreds or even thousands of units.
Specialist core members of a multidisciplinary team are described in the National Cancer Peer Review Programme's Manual for Cancer Services in gynaecology measure 11-2E-101.

Initial staging CT

This quality statement is taken from the ovarian cancer quality standard. The quality standard defines clinical best practice in ovarian cancer care and should be read in full.

Quality statement

Women who are offered staging for ovarian cancer, following ultrasound, are offered computed tomography (CT) of the abdomen and pelvis as the initial staging investigation.

Quality measure

Structure
Evidence of local arrangements and written clinical protocols to ensure women who are offered staging for ovarian cancer, following ultrasound, are offered CT of the abdomen and pelvis as the initial staging investigation.
Process
Process: Proportion of women who are offered staging for ovarian cancer, following ultrasound, who receive CT of the abdomen and pelvis as the initial staging investigation.
Numerator – the number of women in the denominator receiving CT of the abdomen and pelvis as the initial staging investigation.
Denominator – the number of women who are offered staging for ovarian cancer, following ultrasound.

Description of what the quality statement means for each audience

Service providers ensure systems and written clinical protocols are in place so that women who are offered staging for ovarian cancer, following ultrasound, are offered CT of the abdomen and pelvis as the initial staging investigation.
Healthcare professionals ensure women who are offered staging for ovarian cancer, following ultrasound, are offered CT of the abdomen and pelvis as the initial staging investigation.
Commissioners ensure they commission services that offer women who are offered staging for ovarian cancer, following ultrasound, a CT of the abdomen and pelvis as the initial staging investigation.
Women who are offered investigations to find out the stage of the ovarian cancer, following ultrasound, are offered a CT scan of the abdomen and pelvis as the first investigation.

Source clinical guideline references

NICE clinical guideline 122 recommendations 1.2.3.2 and 1.2.3.3.
The Royal College of Radiologists iRefer: Making the best use of clinical radiology: referral guidelines recommendation CA43 diagnosis (US).

Data source

Structure
Local data collection.
Process
National Cancer Outcomes and Services Dataset (in development), available from the National Cancer Intelligence Network.
Also contained in NICE audit support for ovarian cancer (NICE clinical guideline 122): secondary care, criteria 5.

CT reporting

This quality statement is taken from the ovarian cancer quality standard. The quality standard defines clinical best practice in ovarian cancer care and should be read in full.

Quality statement

Women who have computed tomography (CT) for staging of ovarian cancer have the results reported by a radiologist who is a core member of the specialist gynaecological cancer multidisciplinary team.

Quality measure

Structure
Evidence of local arrangements and written clinical protocols to ensure that women who have CT for staging of ovarian cancer have the results reported by a radiologist who is a core member of the specialist gynaecological cancer multidisciplinary team.
Process
Proportion of women who have CT for staging ovarian cancer that have the results reported by a radiologist who is a core member of the specialist gynaecological cancer multidisciplinary team.
Numerator – the number of women in the denominator having their CT staging results reported by a radiologist who is a core member of the specialist gynaecological cancer multidisciplinary team.
Denominator – the number of women who have CT for staging of ovarian cancer.

Description of what the quality statement means for each audience

Service providers ensure systems are in place for women who have CT for staging of ovarian cancer to have it reported by a radiologist who is a core member of the specialist gynaecological cancer multidisciplinary team.
Healthcare professionals ensure women who have CT for staging of ovarian cancer have it reported by a radiologist who is a core member of the specialist gynaecological cancer multidisciplinary team.
Commissioners ensure they commission services in which CT for staging of ovarian cancer is reported by a radiologist who is a core member of the specialist gynaecological cancer multidisciplinary team.
Women who have a CT scan to find out the stage of the ovarian cancer, have the results reported by a radiologist who is a key member of the specialist gynaecological cancer multidisciplinary team.

Source clinical guideline references

TEG consensus.

Data source

Structure
Local data collection.
Process
Local data collection.

Definitions

A core member of the gynaecological cancer multidisciplinary team is one who attends (or, if unable to attend, is represented by a colleague who attends) at least two thirds of the multidisciplinary team meetings.
Specialist core members of a multidisciplinary team are described in the National Cancer Peer Review Programme's Manual for Cancer Services in gynaecology measure 11-2E-101.

Other imaging

This quality statement is taken from the ovarian cancer quality standard. The quality standard defines clinical best practice in ovarian cancer care and should be read in full.

Quality statement

Women with an indeterminate adnexal mass on ultrasound are offered magnetic resonance imaging (MRI) for further characterisation.

Quality measure

Structure
Evidence of local arrangements to ensure women with an indeterminate adnexal mass on ultrasound have MRI for further characterisation.
Process
Proportion of women with an indeterminate adnexal mass on ultrasound who have MRI for further characterisation.
Numerator – the number of women in the denominator who have MRI for further characterisation.
Denominator – the number of women with an indeterminate adnexal mass on ultrasound.

Description of what the quality statement means for each audience

Service providers ensure systems are in place for women with an indeterminate adnexal mass on ultrasound to have MRI for further characterisation.
Healthcare professionals ensure women with an indeterminate adnexal mass on ultrasound are offered MRI for further characterisation.
Commissioners ensure they commission services in which women with an indeterminate adnexal mass on ultrasound have MRI for further characterisation.
Women with a mass, growth or lump next to their womb, which usually arises from the ovary or fallopian tube, (called an adnexal mass), found by ultrasound, are offered an MRI scan to help find out if it is cancerous or non-cancerous.

Source clinical guideline references

The Royal College of Radiologists iRefer: Making the best use of clinical radiology: referral guidelines recommendations CA42 diagnosis (MRI) and CA43 staging (MRI).

Data source

Structure
Local data collection.
Process
National Cancer Outcomes and Services Dataset (in development), available from the National Cancer Intelligence Network.

Optimal surgical staging

This quality statement is taken from the ovarian cancer quality standard. The quality standard defines clinical best practice in ovarian cancer care and should be read in full.

Quality statement

Women with suspected stage I ovarian cancer have optimal surgical staging.

Quality measure

Structure
Evidence of local arrangements and written clinical protocols to ensure women with suspected stage I ovarian cancer have optimal surgical staging.
Process
a) Proportion of women with stage I ovarian cancer that had optimal surgical staging.
Numerator – the number of women in the denominator who had optimal surgical staging.
Denominator – the number of women with stage I ovarian cancer.
b) Proportion of women with stage I ovarian cancer that had up-front systematic retroperitoneal lymphadenectomy.
Numerator – the number of women in the denominator who had up-front systematic retroperitoneal lymphadenectomy.
Denominator – the number of women with stage I ovarian cancer.
Up-front systematic retroperitoneal lymphadenectomy is not recommended for women with stage I ovarian cancer therefore an audit standard of 0% should be expected in this process measure.

Description of what the quality statement means for each audience

Service providers ensure systems are in place for women with suspected stage I ovarian cancer to have optimal surgical staging.
Healthcare professionals ensure women with suspected stage I ovarian cancer have optimal surgical staging.
Commissioners ensure they commission services in which women with suspected stage I ovarian cancer have optimal surgical staging.
Women with suspected stage I ovarian cancer (which is cancer that has not spread from the ovaries) have surgery (known as optimal surgical staging) that involves removing the cancerous tissue and making a full assessment of the stage of the cancer.

Source clinical guideline references

NICE clinical guideline 122 recommendations 1.3.1.2 and 1.3.2.1 (key priorities for implementation) and 1.3.1.1.

Data source

Structure
Local data collection.
Process
a) and b) National Cancer Outcomes and Services Dataset (in development), available from the National Cancer Intelligence Network.
Also contained in NICE audit support for ovarian cancer (NICE clinical guideline 122): secondary care, criteria 9 and 10.

Definitions

Optimal surgical staging does not include up-front systematic retroperitoneal lymphadenectomy. NICE clinical guideline 122 states systematic retroperitoneal lymphadenectomy should not be included as part of standard surgical treatment for women who appear to have stage I disease.
NICE clinical guideline 122 defines the constituents of optimal surgical staging as: midline laparotomy to allow thorough assessment of the abdomen and pelvis; a total abdominal hysterectomy, bilateral salpingo-oophorectomy and infracolic omentectomy; biopsies of any peritoneal deposits; random biopsies of the pelvic and abdominal peritoneum; and retroperitoneal lymph node assessment.

Effective interventions library

Successful effective interventions library details

Implementation

Education and learning

NICE produces resources for individual practitioners, teams and those with a role in education to help improve and assess users' knowledge of relevant NICE guidance and its application in practice.

Pathway information

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, care should be planned and managed according to the best practice guidance described in the Department of Health’s Transition: getting it right for young people.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Updates to this pathway

25 February 2014 Minor maintenance updates.
26 November 2013 'Ultra-radical (extensive) surgery for advanced ovarian cancer' (NICE interventional procedure guidance 470) added to primary surgery in the 'Management of advanced (stage II-IV) ovarian cancer' path.
22 May 2013 'Bevacizumab in combination with paclitaxel and carboplatin for first-line treatment of advanced ovarian cancer' (NICE technology appraisal guidance 284) added to 'First-line chemotherapy' in the management of advanced (stage II-IV) ovarian cancer path and 'Bevacizumab in combination with gemcitabine and carboplatin for treating the first recurrence of platinum-sensitive advanced ovarian cancer' (NICE technology appraisal guidance 285) added to 'Second-line and subsequent chemotherapy' in the management of advanced (stage II-IV) ovarian cancer path.
12 February 2013 Minor maintenance updates.
30 October 2012 Minor maintenance updates.
23 October 2012 'Denosumab for the prevention of skeletal-related events in adults with bone metastases from solid tumours' (NICE technology appraisal guidance 265) added to the management of advanced (stage II-IV) ovarian cancer path.
25 May 2012 Ovarian cancer quality standard added to the pathway.

Supporting information

Glossary

Multidisciplinary team
Risk of malignancy index I

Woman presents to GP with symptoms suggestive of ovarian cancer

Woman presents to GP with symptoms suggestive of ovarian cancer

Woman presents to GP with symptoms suggestive of ovarian cancer

For details of symptoms that are suggestive of ovarian cancer, see ovarian cancer: detection in primary care in this pathway.

Source guidance

Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-node

Management of suspected early (stage 1) ovarian cancer

View the 'Management of suspected early (stage I) ovarian cancer' path

Management of advanced (stage II-IV) ovarian cancer

View the 'Management of advanced (stage II-IV) ovarian cancer' path

Ovarian cancer services

Ovarian cancer services

Ovarian cancer services

Cancer service guidance has been published by the Department of Health on improving outcomes in gynaecological cancers, and by NICE on improving supportive and palliative care for adults with cancer.

Paths in this pathway

Pathway created: February 2012 Last updated: February 2014

Copyright © 2014 National Institute for Health and Care Excellence. All Rights Reserved.

Recently viewed