Dr Anthony Cunliffe, Dr Nicola Harker, and Sophia Nicola share 10 top tips for primary care on the diagnosis of ovarian cancer and supporting patients
Read this article to learn more about:
- the importance of early diagnosis
- persistent and recurrent symptoms to look out for
- investigations for women who may have ovarian cancer, and ongoing management
- supporting women who are undergoing treatment for ovarian cancer.
Ovarian cancer is the sixth most common cancer among females in the UK, more commonly affecting women who are over 65 years of age. Unfortunately, ovarian cancer can be difficult to diagnose, meaning that the majority of patients present with advanced disease.
Late presentation contributes to low survival rates; less than one-half of women with ovarian cancer live for longer than 5 years post diagnosis; however, 5-year survival significantly increases when the disease is diagnosed early, rising to roughly 90% if the condition is diagnosed at an early stage.1 For this reason, Macmillan Cancer Support includes ovarian cancer in all integrated versions of the Cancer Decision Support (CDS)2 tool in an effort to support GPs in diagnosing ovarian cancer earlier.
1 Remember that particular symptoms are significant
One reason why ovarian cancer can be difficult to diagnose is that it may present with a variety of symptoms, many of which are 'vague' and could represent multiple other, more benign conditions. However, some symptoms are particularly significant, including:3
- persistent bloating
- abdominal or pelvic pain
- early satiety and/or loss of appetite
- some urinary symptoms, such as urgency or frequency.
These symptoms are perhaps more likely to have other, more common causes, but in women aged over 50 years it is necessary to at least consider ovarian cancer as a possible cause, especially if symptoms are persistent or recurrent.
2 Be aware of the less obvious symptoms
Some less common but still important symptoms of ovarian cancer include:
- unexplained weight loss
- change in bowel habit
- unexplained fatigue
- loss of appetite.
With vague symptoms it can be difficult for a GP to know which investigations to order, but in women aged over 50 years it is important to consider including investigations for ovarian cancer if a patient presents with these symptoms.3
3 Look out for symptoms that are persistent or recurrent
It is particularly prudent to be alert for individual symptoms or combinations of symptoms that are recurrent, persistent, or unusual for the patient, especially if they occur more than 12 times per month.3 With this in mind, a useful suggestion can be to ask the patient to keep a diary in which they monitor and keep track of the nature and frequency of their symptoms. One such diary can be downloaded as an app or in paper form from Target Ovarian Cancer.4
4 Use safety netting
If a patient consults you about vague symptoms, it is helpful to agree a review date with them so that they understand the importance of coming back for review and know that their symptoms have been taken seriously. If you are arranging tests, ensure that the patient knows when to return to receive their results, and that your practice has a system for ensuring that test results are reviewed and communicated to the patient. The requesting clinician retains responsibility for the test results and so it is important to inform the patient if you want to see them again, even if the tests are normal.5
5 Be cautious of diagnosing irritable bowel syndrome
Some symptoms might suggest a diagnosis of irritable bowel syndrome (IBS); however, as this rarely presents for the first time in women aged over 50 years it is important to investigate and rule out ovarian cancer as a possible diagnosis in any woman aged 50 years or over before treating them for IBS.3
6 Ask about family history
Remember the importance of family history (both maternal and paternal), not only of ovarian cancer but also of breast cancer and prostate cancer as well. Women with known BRCA1 mutation have a 39% chance of developing ovarian cancer by the age of 70 years.6 Women with known BCRA2 gene mutation are also at increased risk, with an 11–13% risk of developing ovarian cancer by the age of 70 years compared with a 1.3% lifetime risk in the general population.6,7 These women are likely to be under specialist care already because of their known family history and may have undergone prophylactic surgery or be under close monitoring; however, they may not recognise bowel symptoms or vague symptoms as any major cause for concern, so may well present to the GP first.
7 Give appropriate information if the patient is being referred urgently
The recommendations from NICE Clinical Guideline 122 on Ovarian cancer: recognition and initial management (2011)3 on first symptoms and signs and early investigations for ovarian cancer have been summarised in Macmillan Cancer Support's 2015 Rapid referral guidelines (see Figure 1, below).8 All women should undergo an abdominal and pelvic examination and any suggestion of a suspicious mass or ascites should be followed up with an urgent (i.e. within 2 weeks) suspected cancer referral immediately. In this situation, the patient should be counselled about the referral and offered the appropriate patient information leaflet detailing what to expect when they are seen at the hospital. It is important to check that the patient understands and to use safety netting in case they fail to receive an appointment.8
8 Request appropriate investions
If there is a suspicion of ovarian cancer (in the absence of any pelvic mass), a serum CA125 blood test should be requested urgently and if the level is raised, then an urgent trans-vaginal ultrasound scan (TVUSS) needs to be arranged.3 It is not recommended to refer patients on the 'suspected cancer' pathway9 without an ultrasound scan because serum CA125 can be elevated in benign conditions such as simple ovarian cysts, particularly in younger women. If the ultrasound is suspicious then an urgent suspected cancer referral should be arranged. It is important to counsel the patient regarding the request for an urgent scan, provide them a clear timeline in which they should expect the test to be done, and empower them to follow up with the practice if this does not happen. This is part of good practice safety netting and should go handin-hand with having a practice-based system to alert when urgent requested tests have not been carried out.9
9 Follow up patients with symptoms even after normal investigation results
If a patient has a serum CA125 result that is under 35 UI/ml, she should be followed up to assess for ongoing symptoms with an ultrasound requested or a referral made if symptoms are persistent. Some women with cancer will have a normal serum CA125 and a normal TVUSS, which again highlights the importance of robust safety netting. Negative test results should be clearly explained to the patient so that she is not falsely reassured. If clinical suspicion persists despite normal investigations, then you should still refer urgently for further investigations
10 Support your patient through the effects of cancer treatment
Treatment for ovarian cancer can involve both surgery and chemotherapy. Surgery can be curative; however, a number of patients may undergo surgery with palliative intent even if the tumour is not considered curable. If it is deemed appropriate, then chemotherapy will be given as well and this may occur before or after surgery, depending on the disease stage and the treatment centre. If surgery is not an option, then palliative chemotherapy may be offered.10
As a GP it is important to be aware of the effects of treatment on your patient, so that you can provide them with appropriate support and advice. Many women with ovarian cancer will have concerns about recurrence and this can cause significant distress, particularly where presenting symptoms were vague.
Surgery will usually involve a total abdominal hysterectomy and bilateral salpingo-oophorectomy as well as omentectomy. Women who were premenopausal will experience a sudden early menopause, which can produce intense symptoms of hot flushes, mood changes, vaginal dryness, skin changes, sweats, and anxiety or loss of confidence. The gynaecology team will usually give perioperative advice on hormone replacement therapy, but many women experience ongoing symptoms and may need further advice, or additional treatment for flushes and mood disturbance, such as selective serotonin reuptake inhibitors. Even for women who are post-menopausal, having a hysterectomy can be more upsetting than they anticipate, so asking about this and signposting to appropriate support or counselling is helpful.11
Patients who are of reproductive age are likely to need additional support and conception counselling before and after treatment. Women may experience sexual difficulties as a result of treatment for which support and advice, such as encouraging the use of lubricants to help with vaginal dryness, should be made available.12
The most commonly used drugs in chemotherapy13 are carboplatin14 and paclitaxel.15 During treatment, the patient will be at risk of neutropenia, hair loss, symptoms of peripheral neuropathy (which usually settles but may be permanent), fatigue, mouth soreness, nausea, diarrhoea or constipation, and low blood pressure. Carboplatin may affect the kidneys, and both drugs can affect the lungs (causing breathlessness, wheezing, and a cough). Patients with cancer are at increased risk of thrombosis, and chemotherapy magnifies that risk.
If initial treatment is ineffective, additional drugs may be added to control or shrink the cancer.
Biological drugs act on cellular processes or on the ways that cells communicate with each other.16 Two treatments used in advanced ovarian cancer are bevacizumab17 and olaparib18 (for BRCA1 and BRCA2). These therapies commonly cause problems with fatigue, mouth soreness, gastrointestinal effects, high blood pressure (bevacizumab), neutropenia and pneumonitis (olaparib).17,18
Radiotherapy is not often used for ovarian cancer, but may be used after surgery (for stage 1c or stage 2 cancers) or could be used palliatively to reduce symptoms from a bulky tumour. Radiotherapy to the pelvis carries a risk of early inflammatory side-effects (such as proctitis) as well as long-term gastrointestinal effects and scarring. Radiotherapy may also affect the exocrine function of the pancreas, causing digestive disorders such as steatorrhoea.19 For more information on the possible side-effects or consequences of radiotherapy, please consult Macmillan's Consequences of cancer and treatment toolkit,20 developed in collaboration with the Royal College of General Practitioners.
In summary, ovarian cancer is difficult to diagnose due to its vague, non-specific presentation. By being aware of key symptoms and investigating proactively, however, practitioners can try to diagnose it at an earlier stage, potentially improving the chances of women's survival and reducing morbidity.
Treatments for ovarian cancer may be lifesaving but can bring significant side-effects and long-term consequences. Patients benefit from GPs and practice nurses asking them directly about long-term effects and specifically asking about quality of life. Even if practitioners do not feel they have the expertise to manage the consequences of a patient's treatment, they can be aware of the services available in their area so they can signpost patients to these; this support could be invaluable in helping each patient live well after treatment.
- Cancer Research UK. Ovarian cancer statistics. www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/ovarian-cancer (accessed 16 February 2017).
- Macmillan Cancer Support. Cancer decision support tool. www.macmillan.org.uk/ecds (accessed 16 February 2017).
- NICE. Ovarian cancer: recognition and initial management. NICE Clinical Guideline 122. NICE, 2011. Available at: www.nice.org.uk/cg122
- Target Ovarian Cancer. Ovarian cancer symptoms diary. www.targetovariancancer.org.uk/information-and-support/what-ovarian-cancer/symptoms/ovarian-cancer-symptoms-diary (accessed 16 February 2017).
- Nicholson B, Mant D, Bankhead C. Can safety-netting improve cancer detection in patients with vague symptoms? BMJ 2016; 355: i5515.
- Chen S, Parmigiani G. Meta-analysis of BRCA1 and BRCA2 penetrance. J Clin Oncol 2007; 25 (11): 1329–1333.
- National Cancer Institute. BRCA1 and BRCA2: cancer risk and genetic testing. www.cancer.gov/about-cancer/causes-prevention/genetics/brca-fact-sheet (accessed 15 February 2017).
- Macmillan Cancer Support. Rapid referral guidelines. 2016 edition. Macmillan Cancer Support, 2015. www.macmillan.org.uk/_images/rapid-referral-toolkit-desktop_tcm9-291864.pdf
- NICE. Suspected cancer: recognition and referral. NICE Guideline 12. NICE, 2015. Available at: nice.org.uk/ng12
- Macmillan Cancer Support. Treatment overview. www.macmillan.org.uk/information-and-support/ovarian-cancer/treating/treatment-decisions/understanding-your-diagnosis/treatment-overview.html (accessed 14 February 2017).
- Macmillan Cancer Support. Information and support for treating ovarian cancer. www.macmillan.org.uk/information-and-support/ovarian-cancer/treating (accessed 15 February 2017).
- Macmillan Cancer Support. Immediate treatment effects of ovarian cancer. www.macmillan.org.uk/information-and-support/ovarian-cancer/treating/after-treatment/managing-treatment-effects/immediate-effects.html (accessed 15 February 2017).
- Cancer Research UK. Cancer drugs. www.cancerresearchuk.org/about-cancer/cancers-in-general/treatment/cancer-drugs/ (accessed 15 February 2017).
- Cancer Research UK. Carboplatin. www.cancerresearchuk.org/about-cancer/cancers-in-general/treatment/cancer-drugs/carboplatin (accessed 15 February 2017).
- Cancer Research UK. Paclitaxel. www.cancerresearchuk.org/about-cancer/cancers-in-general/treatment/cancer-drugs/paclitaxel (accessed 15 February 2017).
- Hornberg J, Bruggeman F, Westerhoff H, Lankelma J. Cancer: a systems biology disease. BioSystems 2006; 83: 81–90.
- Cancer Research UK. Bevacizumab. www.cancerresearchuk.org/about-cancer/cancers-in-general/treatment/cancer-drugs/bevacizumab (accessed 15 February 2017).
- Cancer Research UK. Olaparib. www.cancerresearchuk.org/about-cancer/cancers-in-general/treatment/cancer-drugs/olaparib (accessed 15 February 2017).
- Macmillan Cancer Support. Guidance on long term consequences of treatment for gynaecological cancer: part 1—pelvic radiotherapy. Macmillan Cancer Support, 2014. Available at: www.macmillan.org.uk/documents/aboutus/health_professionals/mac14942_gynae_guide.pdf
- Royal College of General Practitioners, Macmillan Cancer Support. Consequences of cancer and treatment. Consequences of cancer toolkit. www.rcgp.org.uk/clinical-and-research/toolkits/consequences-of-cancer-toolkit.aspx (accessed 15 February 2017) G