Women's Health

Ovarian cancer

Ovarian, fallopian-tube and primary peritoneal cancers are closely related diseases that often spread across the peritoneum before causing obvious local symptoms; persistent or frequent bloating, early satiety, pelvic or abdominal pain and urinary symptoms need the current NICE symptom-triggered testing pathway.

In a nutshell

Ovarian, fallopian-tube and primary peritoneal cancers often produce peritoneal disease and vague symptoms before diagnosis. NICE 2026 uses symptom frequency, age, CA125 and ultrasound: people aged 40 or over with persistent symptoms have age-specific CA125 thresholds, while people aged 39 or under should not have CA125 used in isolation. Refer suspicious ultrasound or an RMI I of 250 or more to gynaecological oncology; treatment is stage- and biomarker-directed surgery, platinum chemotherapy and selected maintenance therapy.

Classic presentation

Persistent or frequent bloating, early satiety, pelvic or abdominal pain, urinary urgency/frequency or new IBS-like symptoms after age 50, with ascites or a mass in more advanced disease.

Key points

There is no recommended general-population ovarian cancer screening programme; investigate symptoms rather than offering opportunistic CA125 screening.
Ascites or a pelvic/abdominal mass not obviously due to fibroids warrants suspected cancer pathway referral.
For persistent symptoms at age 40 or over, use current age-specific CA125 thresholds: 35 at 40 to 49, 31 at 50 to 59, 24 at 60 to 69, 25 at 70 to 79 and 31 at 80 or over; arrange urgent ultrasound according to the pathway.
At age 39 or under, do not use CA125 alone; consider urgent ultrasound and assess for non-epithelial tumour markers in secondary care.
RMI I is calculated after ultrasound as U x M x CA125; an RMI I of 250 or more prompts referral to the specialist MDT.
Before chemotherapy for suspected advanced disease, obtain tissue diagnosis except in exceptional MDT-agreed cases.
Advanced disease aims for complete macroscopic cytoreduction plus platinum-based therapy; maintenance treatment depends on BRCA/HRD status, response and bevacizumab eligibility.
Current NICE maintenance options include olaparib, olaparib with bevacizumab, niraparib and rucaparib in distinct biomarker and treatment contexts.

First-line investigation

Clinical assessment followed by NICE symptom-triggered CA125 and urgent abdominal/pelvic ultrasound in the appropriate age group; use secondary-care RMI I and CT for suspected malignancy.

Management

Recognise an urgent cancer presentation

Refer using the suspected cancer pathway when examination identifies ascites or a pelvic/abdominal mass not obviously due to fibroids; urgently assess bowel obstruction, respiratory compromise, severe pain or rapid deterioration.^4,5

Apply age-specific symptom-triggered testing

For persistent or frequent symptoms, use CA125 and urgent ultrasound according to the current NICE age thresholds; in people aged 39 or under do not use CA125 in isolation and consider urgent ultrasound.^4,3
In secondary care, use ultrasound first, calculate RMI I and arrange CT abdomen/pelvis with thorax when clinically indicated; obtain tissue before chemotherapy whenever possible.²

Support genetics, fertility and complications

Offer germline testing and appropriate tumour testing, discuss fertility and menopause, and manage ascites, obstruction, pleural effusion, pain, nutrition, VTE and psychological needs through the specialist MDT.^8,9,2,6

Stage-adapt surgery and platinum treatment

Use specialist surgical staging for apparent stage 1 disease; for stage 2 to 4 disease, plan complete macroscopic cytoreduction as primary or interval surgery with platinum-based chemotherapy according to MDT assessment and fitness.^2,6
After response to first-line platinum treatment, select maintenance by BRCA/HRD status, bevacizumab use or suitability and current NICE criteria: olaparib, olaparib with bevacizumab, niraparib or rucaparib are not interchangeable.^2,10,11,12,7

Safety-net recurrence and treatment toxicity

Provide specialist follow-up and advise prompt review for recurrent distension, pain, vomiting, bowel or urinary change, breathlessness, new bleeding or treatment toxicity; involve palliative care early when disease is not curable.^2,6

Exam traps

CA125 is not a screening test and can be raised by benign disease; a normal value does not rule out ovarian cancer.
Do not calculate RMI I in primary care or use it to delay referral for a suspicious mass, ascites or ultrasound.
In people aged 39 or under, CA125 should not be used in isolation; consider non-epithelial tumour markers in secondary care.
Do not send a patient straight to chemotherapy for suspected advanced disease without tissue diagnosis unless the MDT agrees an exceptional pathway.
Do not describe PARP maintenance as one universal rule: BRCA status, HRD status, platinum response and bevacizumab exposure change eligibility.

Illustrations

Peritoneal spread of ovarian cancerDiagram showing related ovarian, fallopian-tube and primary peritoneal disease spreading across the peritoneum and omentum, with ascites and bowel or urinary effects.PassFinals · original

Key sources

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.