Introduction

Ovarian cancer usually does not cause symptoms until it is advanced, and often it is incurable despite recent advances in treatment.  Opportunities for early diagnosis and potentially curative treatment are sometimes missed, and a delay in diagnosis may reduce life expectancy and quality of life. Ovarian cancer is managed by a multidisciplinary team to provide optimal care at all times. It may be possible to prevent ovarian cancer in some women, and opportunities for screening to increase early detection are being developed.

Incidence

Ovarian Cancer was diagnosed in 6490 women in the UK in 2022, and was the cause of death in 4,159, about half of whom were over 75.  The risk of ovarian cancer increases with age, obesity, a family history of ovarian cancer, hormone replacement therapy, endometriosis, and in women who have no children, or who start periods early. or have a late menopause. Women with BRCA1 and BRCA2 gene mutations have a greatly increased risk of ovarian cancer, which develops in around 28-44% with BRCA1 mutation and 13-27% with BRCA2 during their lifetime, compared with about 1.1% incidence in the general population.

Diagnosis

Suspicious symptoms include persistent abdominal bloating, pelvic or abdominal pain, feeling full quickly, the frequent or urgent desire to pass urine, recent weight loss, and fatigue. Examination may reveal a palpable mass in the pelvis or abdomen, and there may be evidence of fluid in the abdomen or chest. An ultrasound scan will usually identify significant abnormalities in the pelvis and abdomen, and CT, MRI  or PET scans can give additional evidence of the extent of the cancer. Ovarian cancer may occasionally be detected incidentally in patients who have no symptoms, but have an examination, scans or an operation for another reason.  Blood tests may show a CA-125 (Cancer Antigen 125) level greater than 35 u/mL, though this can be raised in benign conditions also.  Clinical trials have shown that regular screening of  women by ultrasound and CA-125 tests has not resulted in an improved survival, except in women with a known high risk of ovarian cancer. Algorithms using a combination of indicato, such as the Risk of Malignancy Index (RMI) for Ovarian Cancer and the Risk of Ovarian Malignancy Algorithm (ROCA), show promise in improving the detection of early-stage disease. Additional tumour markers are being analyzed. and AI used to combine clinical features and investigation results  to improve diagnostic specificity in symptomatic women.

The diagnosis is confirmed by examining cells under the microscope, from image-guided biopsy of a tumour, or cytology of abdominal fluid, or at the time of definitive surgery.

The Patient Pathway

The treatment of cancer usually involves several medical specialties and allied professional disciplines, and the majority of women with suspected Gynaecological cancer are cared for by a multidisciplinary team of Gynaecologists, Radiologists, Pathologists, Oncologists, Specialist Nurses, Radiographers, and other supporting staff.  An accurate diagnosis and staging are essential, including detailed histological examination of the tumour tissue to discover its type and likely behaviour. The majority (95 %) of primary ovarian cancers are adenocarcinoma, and classified as high- or low-grade serous, clear cell, endometrioid, or mucinous.  Non-serous tumours may be graded:

GX: Unable to assess grade

G1: Well differentiated

G2: Moderately differentiated

G3: Poorly differentiated.

The extent of the cancer is judged initially from physical examination and imaging, blood tests, and other investigations, which are reviewed by the multidisciplinary team, and the clinical stage and treatment options discussed with the patient and relatives.

Tumours that are considered to be operable are usually treated initially by the removal of both ovaries and fallopian tubes, the uterus, the omentum (a fatty fold of the peritoneum spread over the bowels in the abdomen) and any visible tumour nodules that can be excised safely.  Staging (not to be confused with grading, above) is more accurate after surgery, and is recorded using to the FIGO (International Federation of Obstetrics and Gynaecology) Classification for Ovarian Cancer:

Stage I: Cancer is confined to one or both ovaries or fallopian tubes.

IA: In one ovary/tube.

IB: In both ovaries/tubes.

IC: In one or both, but with surface involvement or cancer cells in fluid.

Stage II: Spread to other pelvic organs.

IIA: To uterus, fallopian tubes.

IIB: To other pelvic tissues.

Stage III: Spread to the abdominal lining (peritoneum) or lymph nodes.

IIIA: Microscopically in abdomen or to lymph nodes.

IIIB: Peritoneal spread ≤ 2 cm.

IIIC: Peritoneal spread > 2 cm or to abdominal lymph nodes, possibly surface of liver/spleen.

Stage IV: Spread to distant organs.

IVA: Cancer cells in fluid around the lungs (pleural effusion).

IVB: Spread to distant organs such as the liver, lungs, bones, or groin lymph nodes.

Surgery is often followed by chemotherapy, usually with Carboplatin and Taxol.  Neoadjuvant chemotherapy may be considered before surgery to reduce the extent of the disease prior to an operation in women with a low likelihood of optimal resection, including some with clinically advanced stage IIIC or IV ovarian cancer.

About 80% of women with advanced-stage ovarian cancer develop tumour progression or recurrence, which is incurable, though it may be palliated by further systemic treatment (please see further information about immunotherapy and targeted treatment in “Recent Advances” at the end of this article). After competing the treatment of ovarian cancer, follow-up typically involves regular checks (every 3-6 months initially, becoming less frequent) for about 5 years, to detect any symptom, abnormalities on examination that might be due to recurrence, and if appropriate CA-125 and other blood tests or scans..  The schedule usually depends on the current guidelines used by the Hospital, and the features in individual cases.

Borderline Tumours

About 15% of ovarian tumours are “borderline tumours” which have a low potential for becoming cancer.  Borderline tumours usually affect women aged between 20 and 40 and are often diagnosed at an early stage. They tend to grow slowly and in a more controlled way than cancers, and usually do not invade into the supportive tissue of the ovary. The treatment for borderline tumours is surgery, though occasionally some abnormal cells break away from the tumour and spread elsewhere in the body, usually within the abdomen. Very rarely, these cells start to grow into the underlying tissue. Prognosis of borderline ovarian tumours is generally excellent, though 2 - 24% eventually recur, and malignant transformation develops in 0.5 – 3.8% (reference Baker-Rand 2025), and appropriate follow up is necessary.

Prognosis

Life expectancy with invasive ovarian cancer depends primarily on the stage, and the ability of surgery to remove all the tumour. More than half the women with ovarian cancer have metastastases when first diagnosed, and their life expectancy depends on the sensitivity of the tumour to chemotherapy, and its rate of growth. The average 5-year survival following treatment of stage I ovarian cancer is about 90%, compared with about 30% for advanced-stage disease. The risk of recurrence in stage I ovarian cancer is less than 10%, whereas 90% of women with stage IV ovarian cancer develop recurrence, and only 6% live for 5 years.

Potential Errors in the Management of Ovarian Cancer

Incorrect Diagnosis

Sometimes an ovarian tumour is incorrectly reported to be benign, or the biopsy misses the malignant region of a mass.  Other cancers may metastasize to the ovary, and will need different treatment, appropriate for the type of tumour found.

Delayed Diagnosis

Sadly the diagnosis is often delayed owing to the difficulty interpreting the cause of the symptoms, which may be non-specific and are not considered likely to be due to cancer in the pelvis or abdomen, and their late development. Women have often consulted their GPs several times over a period of months before they are referred for appropriate investigations, and the correct diagnosis eventually made.  Some ovarian cancers grow slowly, and for delays of less than a year it may be difficult to show from the available evidence that earlier diagnosis would have affected the treatment or improved prognosis, though troublesome symptoms such as pain and abdominal distension could probably have been relieved sooner, leading to a better quality of life.

Failure to Obtain Informed Consent

It is difficult to assess accurately the extent of the cancer before surgery, and in most cases the operation will be extensive.  Radical surgery involves removing the ovaries and fallopian tubes, uterus, the omentum, and any tumour spread detected that is operable, sometimes including part of the bladder and bowel, which could require a colostomy.  It is important to discuss the possible extent of the operation needed, especially for women with poor general health. 

It may be possible to conserve the uterus and one ovary in a young woman, who wishes to retain her fertility, if possible, with a stage IA low grade cancer or borderline tumour, but this cannot be guaranteed in advance, and radical surgery may be needed if the disease is found to be more extensive than expected from pre-operative imaging studies.

Chemotherapy

Chemotherapy is advised for the majority of women with ovarian cancer., and potential side effects should be explained carefully. Cytotoxic (cell-killing) drugs affect mainly the cells that are multiplying rapidly, as are found in most cancers, and are also present in rapidly proliferating normal tissues, such as bone marrow, skin, and intestine. Fortunately, normal cells repopulate rapidly after chemotherapy, whereas malignant cells have less effective compensatory mechanisms, and cancers usually recover more slowly. Cytotoxic chemotherapy is therefore usually scheduled in short cycles every few weeks to kill the maximum number of cancer cells,  with the rest period between pulses enabling normal tissues to recover enough from the inevitable damage, prepared to tolerate another cycle.

Ovarian cancer is moderately sensitive to currently available chemotherapy, and although overt metastases are not curable by chemotherapy alone, the prospects of a cure may be improved when chemotherapy is added to the complete surgical removal of the tumour, probably by the eradicating early microscopic metastases, which are more accessible to the drugs than those in solid tumour masses.

Neoadjuvant chemotherapy may be recommended in locally advanced ovarian cancer to shrink the tumour and metastases prior to surgery, to increase the chance of complete removal of visible cancer.  Adjuvant chemotherapy is often recommended after successful surgery, to kill any residual cancer cells if possible, or at least to delay further recurrence. Chemotherapy may also be offered to women with inoperable ovarian cancer to relieve symptoms and improve their overall quality of life, although this may not increase life expectancy significantly.

Biological Therapies

Research has led to a greater understanding of the differences between cancer cells and normal cells, and has enabled the development of drugs that specifically target the differences in the cancer cell. Genetic analysis has enabled the creation of antibodies against common genetic mutations in cancer cells, which inhibit the growth or enhance the killing of the cancer cells. For example, inhibitors of epidermal growth factor receptor (EGFR) can control the growth of cancers that have the appropriate receptors, although this treatment may cause troublesome side effects in the skin, and general fatigue.

Rapidly growing cancers need to be able to repair damaged DNA, and inhibitors targeted against the repair enzymes can preferentially cause the death of cells in some cancers, although normal cells will also be affected (please see also “Recent Advances” at the end of this article).

Risks Associated With Chemotherapy

Excessive Dose

To achieve the optimum effect on cancers, the maximum dose of a cytotoxic drug that can be tolerated is given, calculated according to the patient’s weight and height (to estimate the volume of fluid which will dilute the drug). Assessing the safe dose also depends on general medical condition, and age, and doses are usually reduced for elderly and frail women. The risk of serious damage to normal tissues is assessed before each cycle of treatment, by the severity of any side effects, general health, and white blood cell count and platelet count, kidney and liver function tests. Some patients are more sensitive than the majority, and doses are reduced or treatment delayed if the blood tests (e.g, the white blood cell and platelet count), or serious side effects have not recovered sufficiently.

Some patients will experience troublesome side effects from the initial dose, even if the correct protocol has been followed, but continuing to receive too high a dose will increase the risk of serious problems and can prove fatal. For example, one patient died after receiving twice the correct dose of chemotherapy due to an incorrect calculation. Another patient, due to a failure in communication, was given several repeat prescriptions by his general practitioner for a drug that should have been taken for no more than 4 days in every 6 weeks. By the time the mistake was recognized, her bone marrow was severely damaged and she did not recover.

MDT Records and Litigation

Ovarian cancer management is highly dependent on multidisciplinary team (MDT) input. However, in legal claims, MDT notes may lack some details, or be missing, which makes it difficult to verify whether a treatment decision was discussed appropriately  by the relevant membeers, or agreed by the Team.  Any lack of clear recording of MDT decisions - especially concerning whether surgery was appropriate or chemotherapy should be given or delayed - can be a problem from a legal point of view,. If litigation arises, Courts will want to know whether treatment decisions were evidence-based, appropriate for the patient’s individual circumstances, and recorded contemporaneously.

Extravasation

Cytotoxic chemotherapy may be given through a preipheral vein by a short (bolus) injection over 10-15 min or by slow infusion over several hours. If chemotherapy leaks outside the vein, it may cause serious damage to the local tissues. If swelling or pain develops at the infusion site, treatment should be stopped, and the harmful effect of the concentrated chemotherapy on the tissues may be ameliorated by immediate appropriate measures. The resulting tissue destruction may lead to the formation of an ulcer at the site of injection.

Many patients’ receiving regular intravenous chemotherapy for several months will have a catheter inserted into a central vein (peripherally inserted central catheter) for the duration of treatment, which greatly reduces the risk of extravasation, though infection or thrombosis in the line may lead to its early removal.

Failures in Follow-Up 

Another potential area of medico-legal risk arises in follow-up care. Women who have undergone treatment for ovarian cancer should have surveillance for recurrence, including examination, with CA-125 testing and imaging when appropriate. Failure to investigate suspicious symptoms, or rising CA-125 levels, can delay second-line treatment and palliative care - affecting quality of life and possibly life expectancy. The Legal focus will often be on whether follow-up guidelines were followed, and whether a patient’s concerns were acted upon in an appropriate and timely manner.

Recent Advances

Detailed analysis of tumours is making it possible to use drugs designed to target cancer cells to provide personalized treatment for an individual cancer. Antibody-Drug Conjugates (ADCs) (including mirvetuximab soravtansine (Elahere)) are being used for women with tumours that have become resistant to carboplatinum. Immunotherapy, and new combinations such as avutometinib/defactinib are showing promise for low-grade cancers.  PARP inhibitors target cancer cells and block Poly-ADP ribose polymerase (PARP) enzymes, which normally repair damaged DNA, especially in women whose tumours have BRCA mutations.

New imaging systems, such as OVASEEK, are exploring the detection of very early disease through changes in the fallopian tube that are not found during standard investigations.

These advances offer new hope by targeting specific cancer vulnerabilities, reducing toxicity, and personalizing treatment for better quality of life and longer survival.

_Glossary

_{CT Computed tomography     Cross-sectional imaging using X-rays.}

_{MRI Magnetic resonance imaging      Cross-sectional imaging using the disturbance of a magnetic field by molecular vibrations.}

_{PET Positron emission tomography   Cross-sectional imaging using the radiation from a radioactive sugar metabolized by active tissues.}

_{Oncology Textbooks}

_{Cassidy J, Bissett D, Spence RAJ, Payne M, and Morris-Stiff G., 2015, Oxford Handbook of Oncology, fourth ed.  Oxford University Press: Oxford.}

_{DeVita.T., Lawrence T.E. and Rosenberg S.A., 2023, Principles and Practice of Oncology, twelth ed; Lippincott, Walters Kluwer, Philadelphia.}

_{Relevant Publications}

_{Ling Wang, Qun Zhang, Xue Wang, Zixuan Dong, Shanshan Liu, Qi Wang, Zhiqiang Zhang and}

_{Junji Xing, 2025, Therapeutic landscape of ovarian cancer: recent advances and emerging therapies, Biomarker Research (2025) 13:103 https://doi.org/10.1186/s40364-025-00818-7}

_{Baker-Rand H, Bolton J, Morgan RD, Edmondson R. Borderline ovarian tumours. The Obstetrician & Gynaecologist 2025;27:321–31. https://doi.org/10.1111/tog.70007}