Ovarian Masses and Treatment of Epithelial Ovarian Cancer

• General practitioners should perform a clinical assessment, family history, and where available, aid diagnosis by ultrasound (abdominal and transvaginal ultrasound (TVU), Doppler-enhanced) and/or contrast-enhanced computed tomography (CT) of abdomen and pelvis (with or without thorax).
• In postmenopausal women with symptoms of ovarian cancer, cancer antigen 125 (CA-125) value can assist in diagnosis.
• Ovarian cancer is diagnosed with histologic confirmation in all settings.
• CT-guided biopsy or laparoscopy (with sufficient resources) is preferred instead of laparotomy to obtain histologic confirmation prior to any systemic therapy.

• The purpose of surgery is to diagnose, stage, and/or for treatment.
• Ovarian cancer surgery should be performed by trained gynecologic oncologists or surgeons with oncology surgical expertise. Refer patients to highest-resourced level oncology center with oncology surgical capacity.
• Staging: Where feasible, patients with presumed early-stage ovarian cancer should undergo surgical staging by trained surgeon(s). In basic settings, surgical staging is not feasible, thus NOT recommended.
• Treatment: Women with advanced ovarian cancer (stage III and IV) should receive optimal surgical debulking to remove all visible disease to improve overall survival (OS) by trained surgeon(s).

Access to appropriate evidence-based chemotherapy agents, contraindications to chemotherapy, and potential side effects of chemotherapy should be evaluated and managed in every patient. Basicresource settings that lack the capacity to provide safe administration of chemotherapy should refer patients to a higher-level center for evaluation. Limited settings without skilled capacity should refer patients to settings with access to specialized care.

• Clinicians should document pathology and stage to determine eligibility for adjuvant chemotherapy. If pathology confirmation is not possible due to patient or resource limitation, alternatives can be discussed.
• Clinicians should not administer (systemic treatment) adjuvant chemotherapy to patients with ovarian low malignant potential (LMP) tumors or early-stage micro-invasive borderline tumors, independent of stage.
• Combination chemotherapy with paclitaxel and carboplatin is the standard of care for adjuvant therapy in ovarian cancer.
• Single-agent carboplatin may be used because of resource limitation or patient characteristics.
• Only in enhanced settings, highly selected cases can be assessed for appropriate evidence-based intraperitoneal chemotherapy (IP), following optimal debulking, where there are resources and expertise to manage toxicities.

• For recurrent disease in limited or enhanced settings only, patients with recurrent ovarian cancer should be counseled on treatment options based on a patient’s prior response to platinum-based chemotherapy, that is, platinum-sensitive, platinum-resistant, or platinum-refractory disease status. Platinum rechallenge is only recommended for patients with platinum-sensitive disease.
• In enhanced settings only, clinicians may offer maintenance systemic therapies.
• Treatment is NOT recommended. recommended for patients with tumor marker-positive (CA-125) only recurrent ovarian cancer.
• Early palliative care interventions benefit all patients diagnosed with ovarian cancer.

For women with strong family history of breast and/or ovarian cancer, clinicians should discuss family history and refer to counseling or testing, if available.