Intended for healthcare professionals

Rapid response to:

Practice Guidelines

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

BMJ 2011; 342 doi: (Published 21 April 2011) Cite this as: BMJ 2011;342:d2073

Rapid Response:

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

If the purpose of the NICE guidelines (1) on ovarian cancer is to
improve outcome by, among other strategies, allowing earlier diagnosis,
then they are unlikely to succeed.

The recommendations for detection in primary care are flawed. While
the indications for suspecting ovarian cancer are valid, the sequence of
diagnostic tests is illogical. Measuring Ca125 as an initial test 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 sub-types which carry a worse prognosis are not
associated with an elevated serum C125.

An ultrasound scan is recommended only if the Ca125 is abnormal. This
appears to be based on the assumption that women with obvious pelvic
masses would have been detected and referred under the two-week rule. This
does not take into account the fact that General Practitioners and indeed
junior doctors have lost the skill of clinical pelvic assessment and that
an ultrasound in now used as the first test to detect pelvic masses.

In my opinion women with suspicious symptoms should have immediate
access to a high quality ultrasound scan and if this shows a complex
adnexal mass, should be referred to secondary care without delay,
irrespective of serum Ca125 level. This, along with a high index of
suspicion and a low threshold for investigation, is the only way that we
will make a significant impact on early detection and outcome of this


1. National Institute for Health and Clinical Excellence. Recognition and
Initial Management of Ovarian Cancer (Clinical Guideline 122) 2011

2. Woolas RP, Xu FJ, Jacobs IJ, Yu YH, Daly L, Berchuck A, Soper JT,
Clarke-Pearson DL, Oram DH, Bast RC Jr. Elevation of multiple serum
markers in patients with stage I ovarian cancer. J Natl Cancer Inst. 1993
Nov 3;85(21):1748-51.

Competing interests: No competing interests

01 May 2011
Adeola Olaitan
Gynaecological Oncologist