What is Ovarian Cancer and Who can Suffer from it? 

Ovarian cancer is when abnormal cells in the ovary, fallopian tube or peritoneum begin to grow and divide in an uncontrolled way. They eventually form a growth (tumour). If not caught early, cancer cells gradually grow into the surrounding tissues. And may spread to other areas of the body. Ovarian cancer can affect women, some transgender men and non-binary people assigned female at birth. 

Cancer similar to ovarian cancer can also affect those who were born with ovaries and have had them removed, although the risk is lower after removal of ovaries. This is because the cells in the ovary are also similar to the cells in the peritoneum, which is the surface layer lining the inside of the abdomen and the abdominal organs. The ovary has different types of cells, with cancer forming in these cells that behave differently to each other. 

Incidence: Ovarian cancer is the 6^th  most common cancer in the UK, with approximately 7500 new cases diagnosed annually and approximately 4000 deaths every year.  Ovarian cancer is 4% of all new cancers in women. 

Diagnosing Ovarian Cancer 

Unfortunately, ovarian cancer is usually diagnosed in its advanced stages. This is because of a combination of factors- vague symptoms, women attributing symptoms to getting older or putting on weight, or thinking they are due to food intolerance.  

Healthcare providers must be vigilant about recognising clinical symptoms and signs along with appropriate investigations. Guidelines have been developed for recognising ovarian cancer symptoms and signs by NICE (National Institute for Health and Clinical Excellence), BGCS (British Gynaecological Cancer Society) and the RCOG (Royal College of Obstetricians and Gynaecologists). 

NICE recommends urgent referral to secondary care gynaecology on the suspected cancer pathway if ascites or a pelvic mass (which is not obviously fibroids) is detected. Ovarian cancer can also be associated with several non-specific symptoms - abdominal distension/bloating, early satiety, loss of appetite, pelvic or abdominal pain, increased urinary frequency or urgency, unplanned weight loss, fatigue or changes in bowel habit. 

 Healthcare providers are encouraged to take into consideration symptoms that are not settling with simple measures or multiple attendances with similar complaints. A blood test (CA125) is recommended. CA125 is a marker that is raised in some cases of epithelial cancer. If the result is above the normal range (35 U/mL) then a pelvic ultrasound scan should be requested and/or a referral to secondary care is indicated on the urgent suspected cancer pathway (used to be called a two week wait pathway). 

Based on the blood test and ultrasound findings, risk stratification is performed using various models as locally relevant (based on scan expertise)- ‘Risk of Malignancy Index’ (RMI), IOTA scoring and ORAD scoring. This can help determine if there is suspicion of ovarian cancer.  Often further tests such as CT scan or MRI scan may be requested with more blood tests. These may be discussed at a multidisciplinary meeting (MDT) for a consensus and peer review decision.  

Treating Ovarian Cancer 

A lot of women who are seen on the suspected cancer pathway have a suspicion of ovarian cancer but don’t have a definite diagnosis. They are offered surgery -usually removal of uterus, cervix, both tubes and ovaries along with removal of the omentum (a curtain of fat in the abdomen where ovarian cancer can spread and is helpful for staging) and washings (some fluid is put in the abdomen and removed to look for cancer cells). This should be usually offered by an appropriately subspecialty trained Gynaecological Oncology surgeon.  

If the woman is not willing to undergo this full operation, then she will be offered at least removal of the enlarged ovary for diagnosis. It is important to ensure that this operation is undertaken to ensure that the enlarged tumour does not burst and cause spillage of contents into the abdomen prior to removal. If this happens, it can cause spillage of cancer cells and upstage the cancer. 

For those women who have a very high suspicion of advanced ovarian cancer, treatment is usually with surgery and chemotherapy. The aim of surgery is to remove all disease in the abdomen that is visible to the naked eye, called ‘complete cytoreduction’. However, on many occasions, the cancer is attached to the bowel and other important structures, removal of which would lead to serious complications or not possible. These women are offered chemotherapy first, aiming to shrink the cancer and then offered surgery. This should all happen with MDT advice. If chemotherapy is to be used before surgery, then a biopsy of the tumour to confirm the diagnosis is required. 

Careful follow-up is required after initial treatment, often following local guidance with monitoring of symptoms, CA125 blood test if relevant with open access to  the team via a key worker, usually a clinical nurse specialist, and further investigations based on this assessment. Recurrence of ovarian cancer can be managed with further surgery and/or chemotherapy as relevant.  

Survival from Ovarian Cancer 

Ovarian cancer is not curable. However the aim is to treat it so survival can be improved. Ovarian cancer survival has doubled in the last 50 years in the UK. 81.2% women in England diagnosed with ovarian cancer aged 15-44 years survive for 10 years or more as compared to 21.5% in women aged 75-99 years. 35.3% women diagnosed with ovarian cancer in England survive their disease for ten years or more.  

Survival is improving because of better understanding of the disease and newer targeted therapies being available based on a more aggressive surgical approach, histology type and genetic testing.  

Reducing Risk of Ovarian Cancer 

Screening to reduce risk of ovarian cancer: There is no screening program for ovarian cancer. All major well conducted research has shown that screening the general population for ovarian cancer does not reduce risk of ovarian cancer and therefore does not work like it does for cervical cancer. 

Ovarian cancer risk is 2.7-3.5 times higher in women whose mother or sister has/had ovarian cancer, compared with women with no such family history. Majority of hereditary ovarian cancer cases are linked to the BRCA1/2 mutations. There are other conditions called Lynch syndrome and Peutz-Jeghers syndrome.  

Women who have a family history or a known hereditary condition, should have risk calculated based on national guidelines and referred to genetics to determine if they have a higher risk of ovarian cancer. If they are, then they are referred to a gynaecologist to discuss risk reducing surgery which is removal of both tubes and ovaries. This then can lead to premature and sudden menopause, which has its associated negative impact on bone health, mental health, cardiovascular health and general wellbeing, which can impact on their work productivity.  

Medico-Legal Implications 

There are a number of areas within ovarian cancer that may give rise to litigation. 

1. Primary Care setting: As previously mentioned, symptoms are vague and primary care providers have to be vigilant for persistent symptoms that do not improve or lead to multiple attendances. NICE guidance is available to guide this. Most GPs therefore will offer investigation including pelvic examination, CA125 blood tests and ultrasound scanning when patients present with symptoms consistent with ovarian disease. A failure to investigate such symptoms leading to a delay in diagnosis may therefore be considered negligent. 

2. Incidental Findings: Sometimes, a scan for any other reason may report an abnormality in the ovary. These are called incidental findings. These may be physiological or pathological. There are local and national evidenced based guidelines for their management, which could be follow up or surgical intervention, which can be determined after discussion with the patient. Failure to refer or act on suspicious imaging results could therefore give rise to negligence claims in primary and secondary care setting. Sometimes, this could also be due to under-reporting or non reporting of an incidental finding on the ovary e.g an ovarian cyst on a MRI spine performed for backache.  

3. Secondary care setting:  

a) managing suspected ovarian cancer: when there is no definitive diagnosis, but risk score suggests risk of cancer, counselling the patient about the options that include surgical and non surgical options along with the pros and cons of each option is essential. Surgical options can be those that are fertility conserving or a full hysterectomy. Non surgical options are monitoring the ovarian cyst. These options should be discussed with the patient to allow them to make their individual decision. Failure to discuss or act on imaging results could therefore give rise to negligence claims 

b) managing high suspicion of ovarian cancer: all such cases should be discussed at a MDT, and management should be directed using MDT consensus.  Recommended options are surgery and chemotherapy. Failure to refer to MDT and/or act on MDT recommendations could therefore give rise to negligence claims. MDT can recommend surgery or chemotherapy. 

c) Surgery: Surgery for high suspicion or diagnosed ovarian cancer should be performed by subspecialty trained gynaecology oncology surgeons. Often they may ask for support from other specialties such as colorectal, hepatobiliary, upper gastrointestinal, urology, vascular and plastic surgeons as indicated.  

Consent: Risks often include prolonged recovery, thromboembolic disease, increased risks of bowel surgery, stoma, urological injuries, discharge to rehabilitation and delay in chemotherapy. Counselling for surgery is also complex, can affect quality of life and should include risks that would agree with the Montgomery ruling. Consent and discussion of the risks/benefits of surgery are important to ensure that fully informed consent is obtained prior to any treatment. 

Documentation: Good and detailed documentation of the consent process as well as of the operative process and postoperative recovery process is essential. Any difficulties during the surgery must be carefully documented to include any potential areas of concern post-operatively and any disease that has not been removed during surgery (and why).  

Failure to obtain appropriate consent with counselling, failure to provide adequate care to prevent complications such as prophylaxis for thromboembolic disease or failure or delay in detecting a complication may give rise to a claim. 

Summary 

Litigation in ovarian cancer cases can arise : 

1. Failure/delay in diagnosis (non compliance with standard guidelines) 
2. Failure/delay in offering individual treatment options with risks and benefits 
3. Failure to refer to a MDT if high suspicion of ovarian cancer 
4. Surgery performed by a non subspecialty trained gynaecology surgeon on someone with high risk of ovarian cancer 
5. Failure in adequate counselling in the consent process 
6. Failure to provide postoperative care to a standard agreed by peers  

Email: s.shanbhag@nhs.net 

Dr Shanbhag is a Consultant Gynaecologist and Gynaecological Oncology surgeon. She works at the University Hospitals of Coventry and Warwickshire. She specialises in all gynaecological cancers, colposcopy, abnormal smears, menstrual disorders and is experienced in complex oncology surgery as well as minimal access surgery. Her consulting rooms are in Birmingham. Dr Shanbhag has been a consultant since Nov 2009. She has been undertaking medicolegal work since 2017 for claimants as well as defendants.  

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References: 

1. Cancer research UK 
2. https://www.nice.org.uk/guidance/NG12/  
3. https://www.bgcs.org.uk/wp-content/uploads/2019/05/BGCS-Guidelines-Ovarian-Guidelines 2017 
4. Management of Suspected Ovarian Masses in Premenopausal Women. RCOG Green top guideline no 62 
5. Ovarian Cysts in Postmenopausal Women. RCOG Green-top Guideline No. 34