Ovarian cancer

1. Ovarian cancer Implementing NICE guidance April 2011 NICE clinical guideline 122

2. What this presentation covers • Epidemiology • Background • Scope • Key priorities for implementation • Costs and savings • Discussion • Find out more

3. Epidemiology • Ovarian cancer is the 5th most common cancer in women in the UK • Over 6700 new cases are diagnosed each year, accounting for approximately 1 in 20 cases of cancer in women • Around 4300 women die from ovarian cancer each year in the UK, representing 6% of all cancer deaths in women

4. Background • Ovarian cancer is a challenge to diagnose because of the non-specific nature of symptoms and signs • Most women are diagnosed with advanced disease (stages II– IV) Image reproduced by kind permission of Dr Sue Barter

5. Scope • This guideline is about the recognition and initial management of ovarian cancer • It is relevant to all healthcare professionals who come into contact with women who have or are suspected of having ovarian cancer, and their families and carers

6. Key priorities for implementation

7. Overview of ovarian cancer pathway Women presents to GP GP assesses symptoms Ascites and/or pelvic or abdominal mass Tests in primary care Suspicion of ovarian cancer Urgent referral: assessment in secondary care Support and information Suspicion of ovarian cancer Review by specialist multidisciplinary team (MDT) • Confirmation of diagnosis: • surgical staging or • tissue diagnosis by histology (preferably) or cytology if considering chemotherapy before or instead of surgery for advanced ovarian cancer Management of suspected early ovarian cancer Management of advanced ovarian cancer

8. Detection in primary care

9. Detection in primary care Women presents to GP Ascites and/or pelvic or abdominal mass GP assesses symptoms Support and information Tests in primary care Suspicion of ovarian cancer Urgent referral: assessment in secondary care

10. Awareness of symptoms and signs: 1 • Refer the woman urgently if physical examination identifies ascites and/or a pelvic or abdominal mass (which is not obviously uterine fibroids)

11. Awareness of symptoms and signs: 2 • Carry out tests in primary care 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

12. Awareness of symptoms and signs: 3 • Consider carrying out tests in primary care if a woman reports unexplained weight loss, fatigue or changes in bowel habit • Carry out appropriate tests for ovarian cancer in any woman of 50 or over who has experienced symptoms within the last 12 months that suggest irritable bowel syndrome (IBS) • 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

13. First tests in primary care Measure serum CA125 35 IU/ml or greater Less than 35 IU/ml Assess carefully: are other clinical causes of symptoms apparent? Ultrasound of abdomen and pelvis Normal Suggestive of ovarian cancer Yes No Refer urgently Investigate Advise to return to GP if symptoms become more frequent and/or persistent

14. Diagnosis and management: secondary care

15. Diagnosis and management: secondary care Primary care Suspicion of ovarian cancer Urgent referral: assessment in secondary care Suspicion of ovarian cancer Support and information Review by specialist multidisciplinary team (MDT) • Confirmation of diagnosis: • surgical staging or • tissue diagnosis by histology (preferably) or cytology if considering chemotherapy before or instead of surgery for advanced ovarian cancer Management of suspected early ovarian cancer Management of advanced ovarian cancer

16. Imaging in the diagnostic pathway: which procedures? • Perform an ultrasound of the abdomen and pelvis as the first imaging test in secondary care for women with suspected ovarian cancer • • Do not use MRI routinely for assessing women with suspected ovarian cancer • • 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.

17. Malignancy indices • Perform ultrasound • Calculate a risk of malignancy index I (RMI I) score • Refer all women with an RMI I score of 250 to specialist team Image reproduced by kind permission of Dr Sue Barter

18. 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. Image reproduced by kind permission of Dr Laurence Brown

19. Optimal surgical staging Constitutes: 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 • retroperitoneal lymph node assessment.

20. Role of systematic retroperitoneal lymphadenectomy and lymph node assessment In women with suspected ovarian cancer whose disease appears to be confined to the ovaries (stage I): • perform retroperitoneal lymph node assessment as part of optimal surgical staging • do not include systematic retroperitoneal lymphadenectomy (SRL) as part of standard surgical treatment

21. Adjuvant systemic chemotherapy for stage I disease • Do not offer adjuvant chemotherapy to women who have had optimal surgical stagingand have low-risk stage I disease (grade 1 or 2, stage Ia or Ib)

22. Management of advanced (stage II – IV) ovarian cancer Primary surgery • If performing surgery for women with ovarian cancer, whether before chemotherapy or after neoadjuvant chemotherapy, the objective should be complete resection of all macroscopic disease Intraperitoneal chemotherapy • Do not offer intraperitoneal chemotherapy to women with ovarian cancer, except as part of a clinical trial

23. Support needs of women with newly diagnosed ovarian cancer • Offer all women with newly diagnosed ovarian cancer information about their disease, including psychosocial and psychosexual issues, that: • is available at the time they want it • includes the amount of detail that they want and are able to deal with • is in a suitable format, including written information

24. Costs and savings • The guideline on ovarian cancer is unlikely to have a significant cost impact for the NHS at a national level • However, the guideline may result in additional costs and/or additional savings and benefits, depending on local circumstances • Costs: • Investment in additional tests in primary care • Increase in referrals to secondary care

25. Savings and benefits • Women who display symptoms of ovarian cancer will receive a timely diagnosis • Improved outcomes for women with ovarian cancer as a result of earlier diagnosis and treatment • Women are less likely to present with more advanced ovarian cancer. This potentially reduces secondary care costs in the future • Woman will get access to the correct type of care for ovarian cancer, and incorrect referrals to other cancer specialties should be reduced

26. Discussion • General • How does our current practice need to change to reflect this patient pathway? • How are local referral patterns likely to change? • What training do we need so that we can implement this guidance effectively? • Primary care • How will we manage women with negative CA125 tests or ultrasound? • Secondary or tertiary care • What is our current practice for lymph node assessment and SRL?

27. Find out more • Visit www.nice.org.uk/guidance/CG122 for: • the guideline • the quick reference guide • ‘Understanding NICE guidance’ • costing statement • audit support (primary and secondary care) • baseline assessment tool • clinical case scenarios • podcasts

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