Recommendations for detection in primary care are flawed

If the National Institute for Health and Clinical Excellence (NICE) guidelines on ovarian cancer are meant to improve outcome by, among other strategies, allowing earlier diagnosis, then they are unlikely to succeed.1

The recommendations for detection in primary care are flawed. Although the indications for suspecting ovarian cancer are valid, the sequence of diagnostic tests is illogical. Measuring CA125 initially will fail to detect at least 23% of women with non-mucinous stage 1 epithelial ovarian cancer.2 The rarer epithelial ovarian cancers, such as the clear cell and mucinous subtypes, which carry a worse prognosis, are not associated with a raised serum CA125.3

An ultrasound scan is recommended only if CA125 is abnormal. This seems to be based on the assumption that women with obvious pelvic masses would have been detected and referred under the two week rule. But GPs and junior doctors have lost the skill of clinical pelvic assessment and ultrasound in now used as the first test to detect pelvic masses.

Women with suspicious symptoms should have immediate access to a high quality ultrasound scan, and if this shows a complex adnexal mass they should be referred to secondary care without delay, irrespective of serum CA125 value. This, along with a high index of suspicion and a low threshold for investigation, is the only way that we will make a serious impact on early detection and outcome of this disease.