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Ovarian Cancer

Tests and investigations for ovarian cancer

Ian Jacobs, a professor of gynaecological oncology explains the tests used to diagnose ovarian cancer and assess its spread. These tests include an examination of the abdomen both externally and internally (vaginally and sometimes rectally), CA125 blood tests ('Treatment outcomes and follow-up'), and ultrasound scans. These scans use sound waves to make up a picture of the inside of the abdomen. This may be done by spreading a gel on the abdomen and passing a device over it, or by inserting a small device (about the size of a tampon) into the vagina.

 

A Doctor describes the various tests used to diagnose and assess the spread of ovarian cancer.

A Doctor describes the various tests used to diagnose and assess the spread of ovarian cancer.

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If a woman has symptoms suggestive of ovarian cancer, the first thing, of course, would be for her doctor to examine her, and the examination would include an examination of the abdomen, as well as an internal examination to see if there's a mass, a lump, which can be felt in the pelvis. If after the examination there is a real suspicion of the possibility of ovarian cancer the next two straightforward tests would be an ultrasound scan, the same type of scan as performed in pregnancy, which can give a good picture of the size, shape and texture of the ovaries, and a blood test called CA125 which is raised in the majority of women, not all women, but in the majority of women who have ovarian cancer. 

Those tests can either be, sometimes they'd be requested by the general practitioner, in other situations the GP would refer the patient into hospital and may be requested through the hospital. If the ultrasound scan and the CA125 suggest that there is an ovarian cancer present, sometimes no further investigations will be required, and in some instances it will be possible to go on to treatment just on the basis of the examination, the CA125 and the ultrasound. That treatment would normally be surgery in the first instance. In other situations, the CA125 and ultrasound may be uncertain or unclear, or more information may be needed before proceeding to treatment. 

And then more sophisticated investigations may be performed, like a body scan, a CT scan, or an MR scan. They can give more information, not only about the condition of the ovaries, but also about the rest of the abdomen and pelvis, and give information about whether or not the cancer has spread outside the ovary. 

Women may also have one of several other types of scan such as CT or magnetic resonance imaging (MRI). Some have exploratory surgery or biopsies taken. If there is fluid in the abdomen (ascites) it may be drained both to relieve symptoms and to look for cancer cells. 

Some women we interviewed presented with an abdominal lump which their doctor suspected was a cyst or fibroid. Such lumps need further investigation and possibly biopsy and/or surgical removal to show whether they are benign or malignant. One woman had various diagnostic tests that confirmed her doctor's suspicion of an ovarian cyst that would need removal.

 

Went into hospital with a suspected ovarian cyst and describes the tests she had.

Went into hospital with a suspected ovarian cyst and describes the tests she had.

Age at interview: 54
Sex: Female
Age at diagnosis: 53
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Well, I was diagnosed with stage 1A ovarian cancer in April 2002, the day before my 54th birthday. And I'd been to my GP in the March. We were due to go on holiday and I'd been having just a dull ache down the lower left-hand side of my abdomen and I had some tenderness across the pubic bone area. And it wasn't really troublesome but after 4 days I went to see my GP and he examined me and felt my tummy, looked a bit concerned and said he thought he could feel what could be a large ovarian cyst. 

He asked if he could examine me vaginally and rectally to really, just to sort of confirm what he thought. He did do and he was still of the same opinion. He said that I should go straight to our local hospital, be prepared to stay in, they would want to do some tests. And he phoned them so they expected me, and he wrote a covering letter.  

One of my work colleagues took me over to the hospital, tried to contact my husband who was in a meeting so she left a message. Had quite a long wait but I was examined, I was admitted and over the next couple of days I had x-rays, blood tests, ultra-sound scans and they confirmed that yes, there was a large cyst on the left ovary and that it would have to be operated on.  

Where a condition other than ovarian cancer was at first suspected, women had other tests such as colonoscopy, barium enema, urine tests, cervical screening tests and hysteroscopy before or at the same time as having an ultrasound scan that revealed their ovarian cancer.

 

Had a barium enema and blood tests before having an ultrasound scan that showed masses on her...

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Had a barium enema and blood tests before having an ultrasound scan that showed masses on her...

Age at interview: 71
Sex: Female
Age at diagnosis: 66
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The result of the barium enema showed that I had diverticulosis which also runs in my family and on the follow-up I was told that's what I had - thousands of other women in the country had it and I could just go away and get on with life. However there was a lady doctor who suggested I had a blood test before I leave. 

About October time I was feeling a bit down and arranged to go to the theatre - I hadn't been for two years, and had to come out of the performance because I had very painful backache and called in at my doctor's surgery hoping to catch her before she finished in the afternoon and she greeted me with 'Where have you been? We want to do another blood test'. She gave me some painkillers and said that the hospital would like to see me at the weekend and try and cope with the backache as best I could. Anyway it did get worse and we unfortunately had to call a doctor out and I was immediately sent back to the hospital for investigations.

The doctor on duty took my hand in hers and said the result of her blood test showed that there was something wrong with my liver. 

At the weekend I was taken down for an ultrasound and the young lady performed this and sent me back to the ward and nothing else was done or said over the weekend, but on the Monday morning the same porter took me down to the same place and I didn't say 'I've been here before' I thought don't want to be labelled a difficult patient, but I went in and this time was seen by a consultant who, on doing the ultrasound, just looked up said 'you have masses on your ovaries. 

Some women had tests done privately rather than in the NHS to shorten the wait or because they usually used private medical services.

 

Had a scan done privately because of a 6-8 week wait for an NHS scan.

Had a scan done privately because of a 6-8 week wait for an NHS scan.

Age at interview: 44
Sex: Female
Age at diagnosis: 41
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In October of 2000 I actually went to the doctor because I had found a large lump in my pelvic area and I realised that this was probably something more serious than I'd first imagined. The doctor was quite laid back about it, and said it was probably a fibroid or a cyst and then in due course I would need a hysterectomy. My initial reaction then was 'I don't want a general anaesthetic'. If I had known what the future was going to hold, that would have been the least of my worries.

Anyhow, the doctor referred me for an ultra-sound scan on my pelvic area, but I was told that this could probably take six to eight weeks. So discussing it with my husband and my family over that weekend we decided as a family that I should go private.

And on the Monday I rang the local private hospital and got a scan appointment for the Tuesday.

Most women with ovarian cancer already have advanced stage disease when they are diagnosed. This is because early stage ovarian cancer rarely produces symptoms, and because the symptoms of advanced disease are common and are usually caused by less serious conditions (see 'Symptoms'). Over the past decade much research has been done to see if screening well women using ultrasound scans and CA125 blood tests can detect ovarian cancer earlier and save lives. Some evidence already existed that these tests could detect the disease earlier, but our gynaecological oncologist, speaking in 2004, explains why screening has not yet been introduced and why a clinical trial involving many thousands of women was needed. The trial (United Kingdom Collaborative Trial of Ovarian Cancer Screening (UKCTOCS) has now finished and the data analysed but further follow up of the women is needed before “firm conclusions can be reached”* about the benefits of screening.

 

Speaking in 2004, a doctor describes the aims of research into screening for ovarian cancer.

Speaking in 2004, a doctor describes the aims of research into screening for ovarian cancer.

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Because ovarian cancer doesn't cause symptoms until it's reached an advanced stage, a lot of hope has been attached to the possibility of screening for early detection of ovarian cancer, and work on this goes back 20-30 years. The rationale is that if a test can be used which will pick up the cancer when it's confined to the ovary it may be possible to transform the outcome and to successfully treat the patient just by removing the ovaries and the womb without the need for chemotherapy or any other form of treatment. And the survival rates for stage 1 ovarian cancer, that is ovarian cancer which is genuinely confined to one or both ovaries, are over 90% at 5 years after treatment, whereas the overall survival rates for ovarian cancer at present are 30-40%. So if we could pick up the vast majority of women with ovarian cancer with stage 1 disease, it's possible, but not absolutely guaranteed, it's possible that we would transform the outcome for many, many thousands of women.
 
 

Speaking in 2004, a doctor describes why screening has not yet been introduced despite some evidence that it can detect ovarian cancer earlier.

Speaking in 2004, a doctor describes why screening has not yet been introduced despite some evidence that it can detect ovarian cancer earlier.

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Some people will say when they hear that, 'Fantastic. Why don't we screen for ovarian cancer in everyone?' And there are several reasons that we're not introducing this yet as a national screening programme. One is that, although the tests can pick up ovarian cancer, they don't pick it up in everyone. So they will pick up something in the range of 80 - 90% of women who have ovarian cancer; they're not foolproof. The second and more important reason is that the tests are quite often abnormal even in women who do not have ovarian cancer. So there are false positive results associated with these tests.

Ovarian cancer is a relatively uncommon cancer, so that if we're not careful, for every woman picked up with these tests who has cancer, we will end up operating on many, many other women who don't have cancer, and some of those women will have complications, and in fact in some of the studies a small number of women who had false positive screening tests with CA125 or ultrasound have died from complications of surgery even though they did not have ovarian cancer. So we have to be very, very careful about that. 

And the final reason for not offering screening immediately to everyone is that we haven't yet proved that picking the cancer up with the screening test earlier actually saves lives. Now some people say 'If you pick it up earlier surely it saves lives?' Well the answer is not necessarily. We could be picking it up early, but we may not be picking it up early enough to prevent the cancer spreading and to make the disease curable by the treatment that's available. So it's too early to offer this sort of screening to every woman in the population.
 
 

Speaking in 2004, a doctor explains why a clinical trial involving many thousands of women was set up.

Speaking in 2004, a doctor explains why a clinical trial involving many thousands of women was set up.

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What's happening at present is that there is a very big randomised controlled trial in the UK, that is a trial in which half of the women involved are being screened and the other half of the women are not being screened. The study will take 10 years to complete. It will be complete in around about 2010 - 2011. It's already 2-3 years' progress has been made. At the end of that study all of the information needed will be available for the Department of Health and the government to make a decision about whether or not to introduce ovarian cancer screening alongside cervical and breast cancer screening. And the sort of information that's needed is' does ovarian cancer screening save lives? If it does save lives, how much does it cost to do that? And what is the down side of screening' how much anxiety does screening cause, how many false positives are there, how many unnecessary operations result from the false positives, and how many women have serious complications as a result of that unnecessary surgery? So there's quite a fine balance to be reached here in, with the issue of screening. That big study is called the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS). 

The UKCTOCS trial is designed so that recruitment is over 3 years and it's recruitment of 200,000 women, and 160,000 of them are recruited as of now in mid-2004. During the next year the remaining 40,000 will be recruited, so by 2005 all of the women will be participating in the study. The screening will then continue till 2010, and by 2011 or 12 we will have the mortality data, so we'll be able to see for the first time whether ovarian cancer screening really does save lives. 
 


*Jacobs, I J., Menon, U., et al. (2015). Ovarian cancer screening and mortality in the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS): a randomised controlled trial The Lancet : 10.1016/S0140-6736(15)01224-6

Last reviewed June 2016.

Last updated June 2016.


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