Nice | Ovarian cancer

This is well worth a read – it changes our way of investigating women with abdominal symptoms quite a lot. Using our current system, most women are diagnosed at a late stage, so we need to do something different.

The basis of this guideline is:

1) Identify women

    • Women over 50 who have had symptoms in the last 12m suggestive of IBS.
    • Women who have unexplained weight loss, change in bowels or fatigue and where ovarian cancer is suspected.
    • Women who fit the ‘Goff Index’ for their symptoms:
      • Any of the following symptoms at least 12 times a month (present for less than one year):
        • Pelvic / abdo pain
        • Urinary frequency / urgency
        • Increased abdo size / bloating
        • Difficult eating / feeling full

Of these women, only 0.23% (1 in 500) will turn out to have ovarian cancer. We don’t have a brilliant screening test, so we have to rationalise what we do at the moment. It is recognised that the following process will miss some women, but if all women are advised to return if symptoms become frequent or persistent, then the few who are missed, should re-present

2) Investigate

Organise a CA-125. If it is < 35, review the woman, check if they need investigating for other causes. If not, reassure the woman, but advise her to return if her symptoms persist or worsen, at which point she should be reassessed. Of these women, 6 in 1000 will turn out down the line to have ovarian cancer.

If the CA-125 is ≥ 35, refer for an ultrasound. If this is not suggestive of cancer, again consider other causes, reassure the woman, but advise a return if symptoms persist or worsen. This is likely to miss at most 8 in 1000 women who will turn out to have ovarian cancer. Of women with both a positive CA-125 and a positive ultrasound, 1 in 26 will turn out to have ovarian cancer.

3) Calculate the Risk of Malignancy Score (RMI)

(NB the Quick Reference Guide is a little ambiguous here in that the summary talks about the RMI, but the flow-chart doesn’t mention the RMI – it just advises ‘suggestive of ovarian cancer’)

RMI = U x M x CA125

  • U is ultrasound score. 0 is no points, 1 is 1 point, 3 is 2-5 points. Each of the following features score 1 point: multi-locular cysts, solid areas, metastases, ascites, bilateral lesions.
  • CA-125 is the CA-125 level.
  • M is menopausal status. 1 = pre-menopausal. 3 = post-menopausal (eg no period in a year or a woman over 50 who’s had a hysterectomy).

4) Refer urgently if:

  • Symptoms are suggestive of ovarian CA, positive CA-125 AND USS suggestive of ovarian CA (AND a ‘Risk of Malignancy Score’ > 250) OR
  • Pelvic mass on abdo / pelvic exam which is not obviously fibroids.

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