1.1 The need for a guideline

Ovarian cancer is the fourth most frequently diagnosed cancer in women in Scotland, representing 4.6% of all newly diagnosed cancers, or around 600 new cases per year in Scotland.¹ Ovarian cancer occurs as either an epithelial or a non-epithelial tumour. Epithelial tumours account for over 90% of all ovarian cancers.

The disease is rare in girls and in women under the age of 30 years, with incidence increasing with age, reaching its maximum in the sixth decade.¹ The aetiology of the disease is unknown. It is more common in nulliparous women, and epidemiological studies have shown a significant reduction in ovarian cancer risk in women who have used the oral contraceptive pill.² Most cases of epithelial ovarian cancer are sporadic, occurring in individuals with no family history of the disease. Among women in Scotland with no family history the lifetime risk of developing ovarian cancer is estimated to be 1 in 59.³ In 5 to 10% of women with the disease, an inherited predisposition may be a major contributory cause.⁴

For the majority of women with epithelial ovarian cancer standard therapy consists of surgery followed by chemotherapy. Survival is dependent on the stage of cancer at initial presentation (see Annex 1). Whilst stage I disease has a five year survival rate of 85%, stage IV disease has a five year survival rate of only approximately 10%.⁵

Epithelial ovarian cancer is described as a ‘silent killer’ as in over 60% of cases advanced disease is found at initial presentation.⁶

In Scotland the overall five year survival rate is 30%, and around 400 women die from the disease per year.¹ This rate has not changed significantly in the past 20 years and international comparison of five year survival rates shows that Scotland’s rate lies in the lowest quartile amongst European countries.⁷

Treatment is not usually curative. A typical patient will develop relapsed disease requiring repeated courses of chemotherapy. Relapsed disease is invariably fatal and its diagnosis has a huge impact on patients and their carers. The absence of a recognisable preventable cause and of any effective screening programme means that prospects for improving survival lie with optimal management after initial presentation. The goal for health professionals must be to ensure that where cure is not possible a woman can have a good quality of life with judicious use of surgery and chemotherapy.

1.2 Remit of the guideline

This guideline is concerned with epithelial ovarian cancer only. The management of borderline tumours is not included within this guideline. Management requires a multidisciplinary approach that may include primary care staff, medical and clinical oncologists, gynaecologists, specialist nurses, community nurses, allied health professionals, geneticists, pathologists, specialists in laboratory medicine, pharmacists, radiologists and palliative care specialists. The guideline also highlights areas of controversy as well as recommending good practice where evidence exists.

1.3 Definitions

The International Federation of Gynaecology and Obstetrics (FIGO) staging system used throughout this guideline is given in Annex 1.⁸ The histological classification of ovarian cancer is given in Annex 2.

1.4 Statement of intent

This guideline is not intended to be construed or to serve as a standard of medical care. Standards of care are determined on the basis of all clinical data available for an individual case and are subject to change as scientific knowledge and technology advance and patterns of care evolve. These parameters of practice should be considered guidelines only. Adherence to them will not ensure a successful outcome in every case, nor should they be construed as including all proper methods of care or excluding other acceptable methods of care aimed at the same results. The ultimate judgement regarding a particular clinical procedure or treatment plan must be made by the doctor, following discussion of the options with the patient, in light of the diagnostic and treatment choices available. It is advised however that significant departures from the national guideline or any local guidelines derived from it should be fully documented in the patient’s case notes at the time the relevant decision is taken.

1.5 Review and updating

This guideline was issued in 2003 and will be considered for review when new evidence becomes available. Any updates to the guideline in the interim period will be noted on the SIGN website: www.sign.ac.uk