Intended for healthcare professionals

Rapid response to:

Practice Guidelines

Recognition and initial management of ovarian cancer: summary of NICE guidance

BMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d2073 (Published 21 April 2011) Cite this as: BMJ 2011;342:d2073

Rapid Response:

MR imaging improves management of women with suspected ovarian cancer

The summary of the NICE guidelines for recognition and initial
management of ovarian cancer stated that magnetic resonance (MR) imaging
should not be used routinely [1]. We are concerned that this sends the
wrong message to commissioners of gynaecology services and may result in
denial of MR imaging for women whose care would be improved by its
application.

The summary quite rightly encourages timely investigation with
ultrasound (US) and referral from primary care on the 'two week' pathway.
Our own experience is that a significant proportion of women on this
pathway are discovered to have US 'indeterminate' adnexal masses i.e. it
is unclear whether the mass represents complex benign disease or
malignancy. In the Yorkshire Cancer Network (YCN), for more than a
decade, MR imaging has been routinely used as a problem solving tool for
such indeterminate masses as written in the YCN guidelines [2]. Indeed in
a recent audit it was the commonest cause of referral for gynaecological
MR imaging within the Cancer Centre.

The benefits of using MR imaging for women on this care pathway are
several: provision of a specific diagnosis; a more timely diagnosis;
prevention of unnecessary referral to a Cancer Centre; and, for some,
avoidance of unnecessary surgery. MR imaging has been shown to be
superior to US in determining the nature of adnexal masses [3] and a
valuable adjunct to the risk of malignancy index (RMI) specifically
increasing the proportion of women with cancer referred to the Cancer
Centre [4]. The RMI directs referral on the basis of 'risk'; MR imaging
directs individualised care on the basis of a specific diagnosis. MR
imaging has been shown to be cost effective in the care pathway [5, 6].

We see an increasing number of women referred from other
multidisciplinary teams with such indeterminate masses thought likely to
be early ovarian cancers. The non-specific symptoms of ovarian cancer
described in the NICE guidelines are common to gastrointestinal and
urological disease. Computed tomography, now performed as a first line
investigation for such symptoms, may reveal such indeterminate adnexal
masees [7]. Again the use of MR imaging can effectively minimise the need
for further gynaecological intervention and allay patient anxiety.

Whilst we recognise that the main thrust of the NICE guidelines are
the investigation, referral and treatment of women most likely to have
ovarian cancer they do no service to the many women on this pathway who do
not have ovarian cancer. The summary guidelines regarding use of MR
imaging are contrary to the evidence base and at variance with routine
clinical practice in much of the UK. We are concerned that inappropriate
adherence to the headline comments contained within these will promote
minimum standards of care and result in unnecessary diagnostic uncertainty
and inappropriate referral of and intervention for women with suspected
ovarian cancer.

John A Spencer Consultant Radiologist

Richard J Hutson Consultant Gynaecological Oncologist

Timothy J Perren Consultant Medical Oncologist

Michael J Weston Consultant Radiologist

Sarah E Swift Consultant Radiologist

Timothy J Broadhead Consultant Gynaecological Oncologist

St James's Institute of Oncology, Leeds, LS9 7TF, UK

Corresponding author: johnaspencer50@hotmail.com

References

1. Redman C, Duffy S, Bromham N, Francis K; on behalf of the
Guideline Development Group. Recognition and initial management of
ovarian cancer: summary of NICE guidance. BMJ 2011; 342: d2073. (21
April.)

2. http://www.yorkshire-cancer-
net.org.uk/html/publications/guidelines_gynaecology.php

3. Sohaib SA, Mills TD, Sahdev A et al. The role of magnetic resonance
imaging and ultrasound in patients with adnexal masses. Clin Radiol 2005;
60: 340-8.

4. van Trappen PO, Rufford BD, Mills TD et al. Differential diagnosis of
adnexal masses: risk of malignancy index, ultrasonography, magnetic
resonance imaging, and radioimmunoscintigraphy. Int J Gynecol Cancer 2007;
17: 61-7.

5. Kinkel K, Lu Y, Mehdizade A, Pelte MF, Hricak H. Indeterminate ovarian
mass at US: incremental value of second imaging test for characterization-
-meta-analysis and Bayesian analysis. Radiology 2005; 236: 85-94.

6. Chilla B, Hauser N, Singer G, Trippel M, Froehlich JM, Kubik-Huch RA.
Indeterminate adnexal masses at ultrasound: effect of MRI imaging findings
on diagnostic thinking and therapeutic decisions. Eur Radiol 2011; 21:
1301-10.

7. Spencer JA, Gore RM. The adnexal incidentaloma: a practical approach
to management. Cancer Imaging 2011; 11: 48-51.

Competing interests: No competing interests

10 June 2011
John A Spencer
Consultant Radiologist
Richard J Hutson, Timothy J Perren, Michael J Weston, Sarah E Swift, Timothy J Broadhead
St James's Institute of Oncology, Leeds LS9 7TF