Changes

May 2026 — minor update. Changes in management to reflect updated NICE guidance. 

Update

Goals

To support primary health care professionals to:

• Identify women with possible ovarian cancer.
• Refer women with suspected ovarian cancer appropriately.

Outcome measures

Audit criteria

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - Options for local implementation

NICE quality standards

NICE quality standards: Suspected cancer

• Statement 1. GPs have direct access to diagnostic endoscopy, ultrasound, MRI, X-ray and CT for people with suspected cancer.
• Statement 4. People with suspected cancer who are referred to a cancer service are given written information encouraging them to attend.

[NICE, 2017]

What is it?

• Ovarian cancer arises from the ovary.
  • Epithelial carcinomas account for approximately 90% of primary ovarian cancers.
    • Most are thought to arise from the fimbria of the fallopian tube. Primary ovarian-type tumours may also develop within the peritoneum.
    • The World Health Organization (WHO) classification of ovarian tumours recognizes six major histotypes: serous (70–85% of cases), mucinous, endometrioid, clear cell, transitional cell, and other carcinomas.
    • Tumours of each type are further subdivided into benign, malignant, and intermediate (or borderline malignancy).
  • Non-epithelial cancers account for approximately 10% of primary ovarian cancers.
    • They include germ cell tumours, and sex cord/stromal cell tumours.
• Secondary metastatic tumours can occur in the ovary, most notably from cancers of the:
  • Endometrium.
  • Breast.
  • Gastrointestinal tract.
• Ovarian cancer may spread to:
  • Intraperitoneal structures and organs, causing intestinal obstruction and cachexia.
  • The liver.
  • Para-aortic lymph nodes.
  • The lung, causing pleural effusions.

[Ray-Coquard, 2018; Thompson, C; WHO, 2023]

How common is it?

• According to the Cancer Research UK statistics on ovarian cancer [CRUK, 2021]:
  • About 1 in 50 women in the UK will be diagnosed with ovarian cancer during their lifetime.
  • In the UK, ovarian cancer is the sixth most common cancer in women.
    • In 2016–2018, there were approximately 7500 new cases diagnosed, equating to about 21 cases daily. The incidence rates were highest in women aged 75–79 years.
    • In 2016–2018 ovarian cancer accounted for 4% of all new cancer cases in women.
    • In 2017–2019, there were around 4100 deaths from ovarian cancer, and it accounted for 5% of all cancer-related deaths in women.
    • The incidence rates are projected to rise by 5% in the UK between 2023 and 2025, and 2038 and 2040 — projections suggest there could be approximately 9,400 new cases of ovarian cancer every year by 2038 to 2040.
• Ovarian cancer is more common in White women than Asian or Black women, and in the presence of certain risk factors.
• Worldwide in 2020, it was estimated that there were approximately 314,000 new cases of ovarian cancer and 207,250 deaths from ovarian cancer.

What are the risk factors?

• The risk of ovarian cancer is increased by:
  • Increasing age — the incidence of ovarian cancer increases with age and peaks in the eighth decade.
  • Genetic factors, including:
    • Gene mutations — BRCA1 and BRCA2 are tumour suppressor genes involved in DNA (deoxyribonucleic acid) repair, and BRCA-related cancers result from mutation or alteration of these genes. The lifetime risk of developing ovarian cancer is estimated at 28–44% for women with the BRCA1 gene mutation, and 27% for women with the BRCA2 gene mutation.
    • Family history of ovarian cancer — about 3% of ovarian cancer cases occur in women with a family history of ovarian cancer. The risk of ovarian cancer risk is 2.7–3.5 times higher in women whose mother or sister has (or has had) ovarian cancer compared with women with no such family history; the risk may be higher if the affected relative was diagnosed at a younger age. 
    • Family history of cancer — the risk of ovarian cancer is higher in families with a history of breast cancer compared with the general population, at least partly due to BRCA1 or BRCA2 mutations. Ovarian cancer has been associated with genetic syndromes that can also cause bowel, uterine, stomach, liver, pancreatic, prostate, gallbladder, and urinary tract cancers. 
  • Reproductive and hormonal factors, including:
    • Conditions that increase the number of ovulatory cycles, such as nulliparity, early menarche, and late menopause — evidence from epidemiological studies shows that the number of ovulatory cycles a woman has in her lifetime is proportional to her risk of developing ovarian cancer.
    • Use of hormone replacement therapy (HRT) — there appears to be a small increased risk of ovarian cancer associated with the use of HRT (both oestrogen-only and combined HRT).
  • Medical conditions, including:
    • Cancer — a personal history of ovarian, breast, or bowel cancer is associated with an increased risk of ovarian cancer.
    • Endometriosis — endometriosis is sometimes found next to endometrioid or clear cell ovarian cancers, and evidence has shown an increased incidence of ovarian cancer in women with documented endometriosis. 
    • Diabetes — particularly in women who use insulin.
  • Lifestyle factors, including:
    • Tobacco smoking.
    • Being overweight or obese. 
    • Occupational exposure to asbestos. 
• Note: there is conflicting evidence on the perineal use of talc as a risk factor for developing ovarian cancer.
• The risk of ovarian cancer is reduced by:
  • Conditions that decrease the number of ovulatory cycles, including:
    • A higher number of pregnancies.
    • Breastfeeding.
    • Use of the combined oral contraceptive pill.
  • Tubal ligation and hysterectomy.

[Collaborative Group on Epidemiological Studies of Ovarian Cancer, 2015; Sudhar, 2015; CRUK, 2021; Thompson, C; Imyanitov, 2023]

What is the prognosis?

• The survival rate for ovarian cancer is strongly related to the stage of the disease at the time of diagnosis.
  • Women diagnosed with more localised (stage I or II) ovarian cancer have a better one-year survival than those diagnosed with advanced or disseminated (stage IV) cancer.
• A bulletin published by the Office for National Statistics on cancer survival by stage at diagnosis reported that in England in 2013 to 2017:
  • There was a steadily decreasing survival with advancing stages, but survival for women diagnosed at stage I was high: 98% of women diagnosed at stage I survived the disease for at least one year compared with 54% of women diagnosed at stage IV.
  • At least 50% of women diagnosed with ovarian cancer were diagnosed at stages III and IV.
  • The overall one and five year survival rates for women with ovarian cancer were 72% and 43% respectively. 
• Cancer Research UK statistics on ovarian cancer reported that:
  • Five-year survival for ovarian cancer shows a rapid decrease in survival between stages I and IV. 
    • In 2013–2017, the five-year relative survival ranged from almost  95% for women diagnosed at stage I, to 15% for women diagnosed at stage IV.
  • Of women diagnosed with ovarian cancer in England in 2013–2017, 35% survived the disease for ten years or more, almost 45% survived the disease for five years or more, and more than 70% survived the disease for one year or more.
  • Ovarian cancer survival rate in England was highest for women aged under 40 years at the time of diagnosis.
    • In 2013–2017, 81% of women in England diagnosed with ovarian cancer aged 15–39 survived the disease for ten years or more compared with 21.5% of women diagnosed aged 75 years and over.
  • Ovarian cancer survival is improving and has almost doubled in the last 50 years in the UK.
    • In the 1970s, 18% of women diagnosed with ovarian cancer survived the disease beyond ten years, compared with 35% in recent years.
    • Mortality rates for ovarian cancer are projected to fall by 15% in the UK by 2040.

[ONS, 2019; CRUK, 2021] 

When should I suspect ovarian cancer?

• Suspect ovarian cancer and carry out tests:
  • In any woman, or a trans man or non-binary person with female reproductive organs (particularly if over 50 years of age) if any of the following symptoms are persistent or frequent (particularly more than 12 times per month):
    • Abdominal distension (bloating).
    • Feeling full (early satiety) and/or loss of appetite.
    • Pelvic or abdominal pain.
    • Increased urinary urgency and/or frequency.
  • In any woman, or a trans man or non-binary person with female reproductive organs over 50 years of age, if she has had:
    • Symptoms suggestive of irritable bowel syndrome (IBS) within the last 12 months. See the CKS topic on Irritable bowel syndrome for more information.
• Consider the possibility of ovarian cancer and consider carrying out tests in any woman, or a trans man or non-binary person with female reproductive organswho reports any of the following unexplained symptoms:
  • Weight loss.
  • Malaise or fatigue.
  • Change in bowel habit.
• Other symptoms of ovarian cancer that may be present include:
  • Abnormal or postmenopausal bleeding.
  • Gastrointestinal symptoms, such as dyspepsia, nausea, or bowel obstruction.
  • Shortness of breath (due to pleural effusion).

What else might it be?

• Other conditions that could cause symptoms similar to those of ovarian cancer include:
  • Other cancers, including cancer of the cervix, uterus, rectum, and bladder. See the CKS topic on Gynaecological cancers - recognition and referral, Gastrointestinal tract (lower) cancers - recognition and referral, and Urological cancers - recognition and referral for more information.
  • Other causes of abdominal distension or bloating such as:
    • Uterine fibroids. See the CKS topic on Fibroids for more information.
    • Ascites secondary to cirrhosis of the liver, or heart failure. See the CKS topic on Heart failure - chronic for more information.
    • Adenomyosis.
  • Other causes of early satiety, such as gastric cancer. See the CKS topic on Gastrointestinal tract (upper) cancers - recognition and referral for more information.
  • Other causes of urinary frequency or urgency, such as recurrent urinary tract infections (UTIs). See the CKS topic on Urinary tract infection (lower) - women for more information.
  • Other causes of altered bowel habit, such as:
    • Irritable bowel syndrome. See the CKS topic on Irritable bowel syndrome for more information.
    • Constipation (functional or drug-induced). See the CKS topic on Constipation for more information.
    • Coeliac disease. See the CKS topic on Coeliac disease for more information.
    • Inflammatory bowel disease. See the CKS topics on Crohn's disease and Ulcerative colitis for more information.
    • Gastrointestinal infection.
    • Antibiotic-associated diarrhoea. See the CKS topic on Diarrhoea - antibiotic associated for more information.
  • Other causes of abdominal pain or discomfort, such as:
    • Adhesions.
    • Pelvic inflammatory disease (PID). See the CKS topic on Pelvic inflammatory disease for more information.
    • Diverticular disease. See the CKS topic on Diverticular disease for more information.
    • Chronic pancreatitis. See the CKS topic on Pancreatitis - chronic for more information.
    • Gallstones. See the CKS topic on Gallstones for more information.
• Other causes of a raised serum CA125 include:
  • Peritoneal trauma, disease, or irritation.
  • Other cancers, such as primary peritoneal cancer, lung cancer, and pancreatic cancer. See the CKS topics on Lung and pleural cancers - recognition and referral and Gastrointestinal tract (upper) cancers - recognition and referral for more information.
  • Endometriosis. See the CKS topic on Endometriosis for more information.
  • PID. See the CKS topic on Pelvic inflammatory disease for more information.
  • Ovarian cyst torsion, rupture, or haemorrhage.
  • Pregnancy.
  • Heart failure. See the CKS topic on Heart failure - chronic for more information.

Scenario: Managing a woman with suspected ovarian cancer

From age 18 years onwards (Female).

Search strategy

Scope of search

A literature search was conducted for guidelines and systematic reviews on the primary care recognition and management of suspected ovarian cancer. 

Search dates

July 2018 - May 2023

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for EBSCO Medline.

• (MH "Ovarian Neoplasms+") 
• AB ( (ovarian or ovary or ovaries) N2 (cancer* or carcinoma* or neoplasm*) ) OR TI ( (ovarian or ovary or ovaries) N2 (cancer* or carcinoma* or neoplasm*) ) 

Sources of guidelines

• National Institute for Health and Care Excellence (NICE)
• Scottish Intercollegiate Guidelines Network (SIGN)
• Royal College of Physicians
• Royal College of General Practitioners
• Royal College of Nursing
• NICE Evidence
• World Health Organization
• Guidelines International Network
• TRIP database
• Agency for Healthcare Research and Quality
• National Health and Medical Research Council (Australia)
• Royal Australian College of General Practitioners
• British Columbia Medical Association
• Canadian Medical Association
• Alberta Medical Association
• Michigan Quality Improvement Consortium
• Singapore Ministry of Health
• National Resource for Infection Control
• RefHELP NHS Lothian Referral Guidelines
• Medline (with guideline filter)
• Driver and Vehicle Licensing Agency
• NHS Health at Work (occupational health practice)

Sources of systematic reviews and meta-analyses

• The Cochrane Library:
  • Systematic reviews
  • Protocols
  • Database of Abstracts of Reviews of Effects
• Medline (with systematic review filter)
• EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

• NIHR Health Technology Assessment programme
• The Cochrane Library:
  • NHS Economic Evaluations
  • Health Technology Assessments
• Canadian Agency for Drugs and Technologies in Health
• International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

• The Cochrane Library:
  • Central Register of Controlled Trials
• Medline (with randomized controlled trial filter)
• EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

• Drug and Therapeutics Bulletin
• TRIP database
• Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

• Department of Health
• Health Management Information Consortium (HMIC)

Patient experiences

• Healthtalk
• BMJ - Patient Journeys

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

• British National Formulary (BNF)
• electronic Medicines Compendium (eMC)
• European Medicines Agency (EMEA)
• Medicines and Healthcare products Regulatory Agency (MHRA)
• REPROTOX
• Scottish Medicines Consortium
• Stockley's Drug Interactions
• TERIS
• TOXBASE
• Micromedex
• UK Medicines Information

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

• Clinical accuracy.
• Consistency with other providers of clinical knowledge for primary care.
• Accuracy of implementation of national guidance (in particular NICE guidelines).
• Usability.

Principles of the consultation process

• The process is inclusive and any individual may participate.
• To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
• Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
• Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
• External reviewers are not paid for commenting on the draft topics.
• Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
• All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
• All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

• Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
• Stakeholders identified from the following groups are invited to review draft topics:
  • Experts in the topic area.
  • Professional organizations and societies (for example, Royal Colleges).
  • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
  • Guideline development groups where the topic is an implementation of a guideline.
  • The British National Formulary team.
  • The editorial team that develop MeReC Publications.
• Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

• Topic selection
• Scoping of topic
• Selection of clinical scenarios
• First draft internal review
• Second draft internal review
• External review
• Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

• Animal studies
• Original research is not written in English

Possible exclusions for reviewed literature:

• Sample size too small or study underpowered
• Bias evident or promotional literature
• Population not relevant
• Intervention/treatment not relevant
• Outcomes not relevant
• Outcomes have no clear evidence of clinical effectiveness
• Setting not relevant
• Not relevant to UK
• Incorrect study type
• Review article
• Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

• Feasibility
  • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
• Organizational and Financial Impact Analysis
• Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
  • Eligible population
  • Current interventions
  • Likely uptake of new intervention or recommendation
  • Cost of the current or new intervention mix
  • Impact on other costs
  • Condition-related costs
  • In-direct costs and service impacts
  • Time dependencies
• Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

• Personal financial interests
• Personal family interest
• Personal non-financial interest
• Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.