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NICE issues first GP ovarian cancer guidance highlighting four red flags

By Lilian Anekwe

GPs should suspect ovarian cancer in any woman who suffers persistent abdominal distension, difficulty eating, pelvic or abdominal pain or urinary urgency more than 12 times a month, new NICE guidance recommends.

The institute has drafted its first-ever guidelines to help GPs diagnose ovarian cancer earlier and promote more effective management of the disease.

Ovarian cancer is the fifth most common cancer in women, with around 6,800 cases diagnosed in the UK every year. But cases are still relatively rare in general practice and only one GP in five will see a case of ovarian cancer every year.

Despite this, GPs have come under criticism for failing to recognise symptoms of ovarian cancer in older women, and failing to refer them for appropriate diagnostic tests.

The draft NICE guidance, published today, puts the focus on primary care to pick up on women who repeatedly present with one of four red flag symptoms.

Women with palpable abdominal or pelvic masses that can be felt on physical examination should be urgently referred to a specialist.

GPs should always initiate tests in primary care if women, particularly those aged over 50, report any of the following: persistent abdominal distension, difficulty eating and/or early satiety, pelvic or abdominal pain or increased urinary urgency more than 12 times per month.

GPs should also investigate women 50 or over with symptoms that suggest irritable bowel syndrome, ‘because IBS rarely presents for the first time in women of this age', the guidance states.

NICE recommends measuring CA125, a biomarker produced by some ovarian cancers, as the diagnostic tool to rule out ovarian cancer. It is thought that around half of all women with early stage ovarian cancer will have raised CA125 levels in their blood.

If serum levels are greater than 35 IU/ml, GPs should then refer women for an ultrasound of the abdomen and pelvis to confirm the diagnosis. GPs should continue to monitor women with normal serum CA125, or CA125 greater than 35 IU/ml but a normal ultrasound in case their symptoms persist.

Dr Fergus Macbeth, director of the centre for clinical practice at NICE and an oncologist at Velindre hospital in Cardiff, said: 'Overall survival rates for ovarian cancer are low. Only around one in three women will live for at least five years after diagnosis. This is mainly because women who develop ovarian cancer and their GPs often only realise something may be seriously wrong when the cancer is advanced.'

‘Women can also experience delays between visiting their GP, seeing a specialist, getting a diagnosis and receiving treatment. This guideline will seek to overcome these hurdles to ensure women receive a diagnosis and subsequent treatment in a more timely manner.'

Professor William Hamilton, professor of primary diagnostics at the Peninsular Medical School in Exeter, said: 'The real problem with ovarian cancer is steering a course between encouraging investigation of every possible symptom, against waiting for more obvious symptoms to develop.'

'I think this guidance gets this balance right. I'm pleased to see its evidence-based, though I'd love to see the primary care evidence behind CA125 testing. Almost all studies come from secondary care, so while I accept it is a sensible choice, as it's quicker than ultrasound, I'd want to see more research on its exact performance characteristics in primary care diagnosis.'

Detecting ovarian cancer in primary care

• Refer urgently if physical examination identifies a pelvic or abdominal mass and/or ascites.
• Investigate if a woman reports any of the following more than 12 times a month: abdominal distension, difficulty eating and/or feeling full, pelvic or abdominal pain or increased urinary urgency and/or frequency
• Also consider testing woman with abnormal vaginal bleeding, unexplained weight loss, abdominal distension, fatigue or changes in bowel habit.
• Send women with a serum CA125 35 IU/ml for an ultrasound scan and refer with a positive scan urgently for further investigation.
• Advise any woman who has normal serum CA125, or a normal ultrasound, to return to her GP for re-assessment if her symptoms persist or become more frequent.

Source: The recognition and initial management of ovarian cancer, draft NICE guideline, September 2010

Ovarian cancer is the fifth most common cancer in women Ovarian cancer is the fifth most common cancer in women