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Ovarian cancer

Key sources
The following summarized guidelines for the evaluation and management of ovarian cancer are prepared by our editorial team based on guidelines from the European Society of Medical Oncology (ESMO 2023; 2018; 2016), the American Academy of Family Physicians (AAFP 2023), the American Society of Clinical Oncology (ASCO 2022; 2021; 2020), the Society of Obstetricians and Gynaecologists of Canada (SOGC 2020; 2018), the U.S. Preventive Services Task Force (USPSTF 2018; 2017; 2014), the American College of Obstetricians and Gynecologists (ACOG 2017; 2016), the European Society of Gynaecological Oncology (ESGO 2017), the Society of Gynecologic Oncology (SGO/ACOG 2017), the Royal College of Obstetricians and Gynaecologists (RCOG 2016), the Society of Gynecologic Oncology (SGO/ASCO 2016), and the British Society for Gynaecological Endoscopy (BSGE/RCOG 2011).
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Guidelines

1.Screening and diagnosis

Indications for screening, general population, AAFP: do not obtain screening for OC in non-high-risk asymptomatic females.
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  • Indications for screening (patients at risk)

  • Monitoring of ovarian cysts (general population)

  • Monitoring of ovarian cysts (pregnant patients)

  • Differential diagnosis

2.Classification and risk stratification

Risk assessment
As per ACOG 2017 guidelines:
Elicit a detailed personal and family history for breast, gynecologic, and colon cancer to help categorize patients based on their risk (average risk or high risk) of developing epithelial OC.
E
Maintain an appropriate level of suspicion when potentially relevant signs and symptoms of OC are present.
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  • Staging

  • Prognosis

3.Diagnostic investigations

History and physical examination: as per ASCO 2021 guidelines, obtain a clinical assessment and elicit a family history in patients with a ovarian mass or suspected OC.
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  • Tumor markers

  • Diagnostic imaging

  • Imaging for staging

  • Genetic testing

4.Diagnostic procedures

Adnexal mass biopsy: as per ASCO 2021 guidelines, perform CT-guided biopsy or laparoscopy (with sufficient resources) instead of laparotomy to obtain histologic confirmation before any systemic therapy.
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  • Histopathology

5.Medical management

Management of early-stage disease, surgical excision: perform total hysterectomy and bilateral salpingo-oophorectomy as the standard of treatment in patients with stage I-II OC. Offer unilateral salpingo-oophorectomy in selected premenopausal patients desiring fertility preservation.
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  • Management of early-stage disease (intraoperative staging)

  • Management of early-stage disease (adjuvant chemotherapy)

  • Management of early-stage disease (PARPi regimens)

  • Management of advanced disease (neoadjuvant therapy)

  • Management of advanced disease (primary cytoreductive surgery)

  • Management of advanced disease (secondary cytoreductive surgery)

  • Management of advanced disease (definitive chemotherapy)

  • Management of advanced disease (maintenance therapy)

  • Management of recurrent disease (general principles)

  • Management of recurrent disease (systemic therapy)

  • Management of recurrent disease (PARPi monotherapy)

6.Therapeutic procedures

Adnexal mass aspiration: consider performing adnexal aspiration for symptom control in patients with advanced malignancy unfit for surgery or further intervention.
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7.Perioperative care

Postoperative care: assess all patients postoperatively at a gynecological oncology multidisciplinary meeting.
E

8.Surgical interventions

Technical considerations for surgery, general principles, ASCO: perform surgery by trained gynecologic oncologists or surgeons with oncology surgical expertise. Refer patients to the highest-resourced level oncology center with oncology surgical capacity.
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  • Technical considerations for surgery (avoidance of intraoperative spillage)

  • Technical considerations for surgery (intraoperative frozen section examination)

9.Specific circumstances

Patients with non-epithelial ovarian cancer, evaluation: obtain pelvic ultrasound, abdominopelvic CT, CXR, and PET in the diagnostic work-up of selected patients with non-epithelial OC (germ cell tumor).
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  • Patients with non-epithelial OC (adjuvant chemotherapy)

  • Patients with non-epithelial OC (hormone therapy)

  • Patients with non-epithelial OC (radiotherapy)

  • Patients with non-epithelial OC (fertility preservation)

  • Patients with non-epithelial OC (surgical resection)

  • Patients with non-epithelial OC (follow-up)

10.Patient education

General counseling: provide counseling in BRCA mutation carriers outlining options for screening for early detection, risk-reducing measures, and issues pertaining to fertility.
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  • Genetic counseling (patients at risk)

  • Genetic counseling (patients with cancer)

11.Preventative measures

Lifestyle modifications: advise exercising regularly, maintaining healthy body weight, limiting alcohol consumption, and avoiding hormone replacement therapy.
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  • Hormone therapy

  • Aspirin

  • Risk-reducing salpingo-oophorectomy

  • Risk-reducing mastectomy

12.Follow-up and surveillance

Indications for referral: as per AAFP 2023 guidelines, refer patients with an adnexal mass and elevated CA-125 levels, high-risk ultrasound findings, or any other concern for ovarian malignancy to a gynecologic oncologist.
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  • Management of treatment-related adverse events

  • Surveillance for recurrence

  • Surveillance for other malignancies (general principles)

  • Surveillance for other malignancies (breast cancer)

  • Surveillance for other malignancies (peritoneal cancer)

  • Surveillance for other malignancies (pancreatic cancer)

  • Surveillance for other malignancies (melanoma)