Skip to main content

Main menu

  • Home
  • Content
    • Current issue
    • Past issues
    • Early releases
    • Collections
    • Sections
    • Blog
    • Infographics & illustrations
    • Podcasts
    • COVID-19 Articles
  • Authors & Reviewers
    • Overview for authors
    • Submission guidelines
    • Submit a manuscript
    • Forms
    • Editorial process
    • Editorial policies
    • Peer review process
    • Publication fees
    • Reprint requests
    • Open access
    • Patient engagement
  • Members & Subscribers
    • Benefits for CMA Members
    • CPD Credits for Members
    • Subscribe to CMAJ Print
    • Subscription Prices
    • Obituary notices
  • Alerts
    • Email alerts
    • RSS
  • JAMC
    • À propos
    • Numéro en cours
    • Archives
    • Sections
    • Abonnement
    • Alertes
    • Trousse média 2023
  • CMAJ JOURNALS
    • CMAJ Open
    • CJS
    • JAMC
    • JPN

User menu

Search

  • Advanced search
CMAJ
  • CMAJ JOURNALS
    • CMAJ Open
    • CJS
    • JAMC
    • JPN
CMAJ

Advanced Search

  • Home
  • Content
    • Current issue
    • Past issues
    • Early releases
    • Collections
    • Sections
    • Blog
    • Infographics & illustrations
    • Podcasts
    • COVID-19 Articles
  • Authors & Reviewers
    • Overview for authors
    • Submission guidelines
    • Submit a manuscript
    • Forms
    • Editorial process
    • Editorial policies
    • Peer review process
    • Publication fees
    • Reprint requests
    • Open access
    • Patient engagement
  • Members & Subscribers
    • Benefits for CMA Members
    • CPD Credits for Members
    • Subscribe to CMAJ Print
    • Subscription Prices
    • Obituary notices
  • Alerts
    • Email alerts
    • RSS
  • JAMC
    • À propos
    • Numéro en cours
    • Archives
    • Sections
    • Abonnement
    • Alertes
    • Trousse média 2023
  • Visit CMAJ on Facebook
  • Follow CMAJ on Twitter
  • Follow CMAJ on Pinterest
  • Follow CMAJ on Youtube
  • Follow CMAJ on Instagram
Practice

Diagnosing ovarian cancer

Melissa Walker and Mara Sobel
CMAJ October 22, 2018 190 (42) E1259; DOI: https://doi.org/10.1503/cmaj.180499
Melissa Walker
Department of Obstetrics and Gynecology (Walker, Sobel), Faculty of Medicine, University of Toronto; Department of Obstetrics and Gynecology (Walker, Sobel), Mount Sinai Hospital, Toronto, Ont.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Mara Sobel
Department of Obstetrics and Gynecology (Walker, Sobel), Faculty of Medicine, University of Toronto; Department of Obstetrics and Gynecology (Walker, Sobel), Mount Sinai Hospital, Toronto, Ont.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Figures & Tables
  • Related Content
  • Responses
  • Metrics
  • PDF
Loading

Early-stage ovarian cancer is difficult to diagnose because presenting symptoms are vague and nonspecific

Women with persistent abdominal or pelvic pain, bloating, early satiety, urinary urgency or frequency, or constitutional symptoms require further investigation.1 Annual screening in asymptomatic women with a pelvic examination, serum assay for cancer antigen 125 (CA 125) or transvaginal ultrasonography does not improve rates of early diagnosis of ovarian cancer or reduce mortality.2,3

Transvaginal ultrasonography is the initial imaging modality for women with symptoms of ovarian cancer

Small, asymptomatic simple cysts (less than 3 cm) seen on ultrasonography are almost certainly benign and do not require gynecologic consultation.4 Concerning ultrasonography features are outlined in Box 1.

Box 1: Risk of malignancy index II scoring system*
CategoryScore
Menopausal scoreM = 1 for premenopausal
M = 4 for postmenopausal
Ultrasonography scoreOne point each for:
• Multilocular cyst
• Presence of solid components
• Evidence of intraabdominal metastases
• Presence of ascites
• Bilaterality of lesions
U = 1 for none or one ultrasonography features
U = 4 for two or more ultrasonography features
CA 125Level in serum (U/mL)
  • Note: CA = cancer antigen, RMI = risk of malignancy index. Adapted from Journal of Obstetrics and Gynaecology Canada, Vol. 40, Tien Le and Christopher Giede, No. 230-Initial evaluation and referral guidelines for management of pelvic/ovarian cysts, e223–29, 2018, with permission from Elsevier.5

  • * RMI II score = M × U × CA 125. A score of 200 or more warrants direct referral to gynecologic oncology.

Serum tumour markers can be helpful when a complex ovarian cyst is identified

Cancer antigen 125 is elevated (greater than 35 U/mL) in most epithelial ovarian cancers and testing should be ordered in all women with concerning findings on ultrasonography. In women who are premenopausal, CA 125 level may be mildly elevated in benign conditions (e.g., endometriosis or fibroids), and this is accounted for in the risk of malignancy index II (RMI II) scoring system (Box 1). In women who are less than 40 years of age, testing for levels of lactate dehydrogenase, α-fetoprotein and β-human chorionic gonadotropin should also be ordered to identify nonepithelial ovarian cancers that are more common in younger women.6

The RMI II can be used in primary care to identify women requiring urgent assessment

Risk of malignancy index II incorporates menopausal score (M), ultrasonography score (U) and CA 125 value (Box 1). A score of 200 or more indicates a substantial risk of epithelial ovarian cancer and warrants direct referral to gynecologic oncology.

Women with a strong family history of breast, ovarian or colon cancer should be referred to a genetic counsellor

A discussion of screening for hereditary syndromes associated with an increased risk of epithelial ovarian cancer is warranted. Compared with the baseline rate of 1.4% in Canadian women, the average lifetime risk of developing ovarian cancer is 45% for women with BRCA1 mutations, 12% for BRCA2 mutations7 and up to 24% for Lynch syndrome.8

Footnotes

  • CMAJ Podcasts: author interview at https://soundcloud.com/cmajpodcasts/180499-five

  • Competing interests: None declared.

  • This article has been peer reviewed.

References

  1. ↵
    1. Goff BA,
    2. Mandel LS,
    3. Melancon CH,
    4. et al
    . Frequency of symptoms of ovarian cancer in women presenting to primary care clinics. JAMA 2004;291:2705–12.
    OpenUrlCrossRefPubMed
  2. ↵
    1. Buys SS,
    2. Partridge E,
    3. Black A,
    4. et al.
    PLCO Project Team. Effect of screening on ovarian cancer mortality: the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Randomized Controlled Trial. JAMA 2011;305:2295–303.
    OpenUrlCrossRefPubMed
  3. ↵
    1. Jacobs IJ,
    2. Menon U,
    3. Ryan A,
    4. et al
    . Ovarian cancer screening and mortality in the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS): a randomised controlled trial. Lancet 2016;387:945–56.
    OpenUrlCrossRefPubMed
  4. ↵
    1. Levine D,
    2. Brown DL,
    3. Andreotti RF,
    4. et al
    . Management of asymptomatic ovarian and other adnexal cysts imaged at US: Society of Radiologists in Ultrasound Consensus Conference Statement. Radiology 2010;256:943–54.
    OpenUrlCrossRefPubMed
    1. Le T,
    2. Giede C
    . No. 230-initial evaluation and referral guidelines for management of pelvic/ovarian masses. J Obstet Gynaecol Can 2018;40:e223–9.
    OpenUrl
  5. ↵
    American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins—Gynecology. Practice Bulletin No. 174: Evaluation and management of adnexal masses. Obstet Gynecol 2016;128:e210–26.
    OpenUrlCrossRefPubMed
  6. ↵
    1. Kuchenbaecker KB,
    2. Hopper JL,
    3. Barnes DR,
    4. et al
    . Risks of breast, ovarian, and contralateral breast cancer for BRCA1 and BRCA2 mutation carriers. JAMA 2017;317:2402–16.
    OpenUrlCrossRefPubMed
  7. ↵
    1. Bonadona V,
    2. Bonaïti B,
    3. Olschwang S,
    4. et al.
    French Cancer Genetics Network. Cancer risks associated with germline mutations in MLH1, MSH2, and MSH6 genes in Lynch syndrome. JAMA 2011;305:2304–10.
    OpenUrlCrossRefPubMed
PreviousNext
Back to top

In this issue

Canadian Medical Association Journal: 190 (42)
CMAJ
Vol. 190, Issue 42
22 Oct 2018
  • Table of Contents
  • Index by author

Podcast

Subscribe to podcast
Download MP3

Article tools

Respond to this article
Print
Download PDF
Article Alerts
To sign up for email alerts or to access your current email alerts, enter your email address below:
Email Article

Thank you for your interest in spreading the word on CMAJ.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Diagnosing ovarian cancer
(Your Name) has sent you a message from CMAJ
(Your Name) thought you would like to see the CMAJ web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
Diagnosing ovarian cancer
Melissa Walker, Mara Sobel
CMAJ Oct 2018, 190 (42) E1259; DOI: 10.1503/cmaj.180499

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
‍ Request Permissions
Share
Diagnosing ovarian cancer
Melissa Walker, Mara Sobel
CMAJ Oct 2018, 190 (42) E1259; DOI: 10.1503/cmaj.180499
Digg logo Reddit logo Twitter logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like

Jump to section

  • Article
    • Early-stage ovarian cancer is difficult to diagnose because presenting symptoms are vague and nonspecific
    • Transvaginal ultrasonography is the initial imaging modality for women with symptoms of ovarian cancer
    • Serum tumour markers can be helpful when a complex ovarian cyst is identified
    • The RMI II can be used in primary care to identify women requiring urgent assessment
    • Women with a strong family history of breast, ovarian or colon cancer should be referred to a genetic counsellor
    • Footnotes
    • References
  • Figures & Tables
  • Related Content
  • Responses
  • Metrics
  • PDF

Related Articles

  • PubMed
  • Google Scholar

Cited By...

  • No citing articles found.
  • Google Scholar

More in this TOC Section

  • Pneumopericardium as a complication of pericardiocentesis
  • A blistering variant of phlegmasia cerulea dolens from underlying squamous cell lung cancer
  • Parechovirus infections in infants
Show more Practice

Similar Articles

 

View Latest Classified Ads

Content

  • Current issue
  • Past issues
  • Collections
  • Sections
  • Blog
  • Podcasts
  • Alerts
  • RSS
  • Early releases

Information for

  • Advertisers
  • Authors
  • Reviewers
  • CMA Members
  • CPD credits
  • Media
  • Reprint requests
  • Subscribers

About

  • General Information
  • Journal staff
  • Editorial Board
  • Advisory Panels
  • Governance Council
  • Journal Oversight
  • Careers
  • Contact
  • Copyright and Permissions
  • Accessibiity
  • CMA Civility Standards
CMAJ Group

Copyright 2023, CMA Impact Inc. or its licensors. All rights reserved. ISSN 1488-2329 (e) 0820-3946 (p)

All editorial matter in CMAJ represents the opinions of the authors and not necessarily those of the Canadian Medical Association or its subsidiaries.

To receive any of these resources in an accessible format, please contact us at CMAJ Group, 500-1410 Blair Towers Place, Ottawa ON, K1J 9B9; p: 1-888-855-2555; e: cmajgroup@cmaj.ca

Powered by HighWire