Ovarian Cancer Early Detection, Diagnosis, and Staging

A pelvic exam allows your health care provider to feel the ovaries and uterus for size, shape, and consistency. Pelvic exams may help find other cancers or conditions, but most early ovarian tumors are difficult or impossible to feel. Talk to your doctor about whether you should have regular pelvic exams.

While Pap tests and HPV tests are important to screen for cervical cancer, they only rarely detect ovarian cancer.

Early ovarian cancer often causes no symptoms. More often, by the time ovarian cancer causes symptoms, it has already spread. This can happen rapidly in some types of ovarian cancer. The most common symptoms are:

• Bloating
• Pelvic or abdominal (belly) pain
• Trouble eating or feeling full quickly
• Urinary symptoms such as urgency (always feeling like you have to urinate) or frequency (having to often urinate)

If you have these symptoms on a consistent basis for more than a few weeks, report them right away to your health care provider. Prompt attention to symptoms may improve the odds of early diagnosis and successful treatment.

There are no recommended screening tests for ovarian cancer for women without symptoms or high risk. Studies show that using TVUS and CA-125 to screen average-risk women leads to more testing and surgeries but doesn’t lower ovarian cancer deaths. That’s why no major medical or professional organization recommends these tests for routine screening.

Some organizations state that TVUS and CA-125 may be offered to screen women who have a high risk of ovarian cancer due to an inherited genetic syndrome such as Lynch syndrome, BRCA gene mutations, or a strong family history of breast and ovarian cancer. Even in these women, it has not been proven that using these tests for screening lowers their chances of dying from ovarian cancer.

Transvaginal ultrasound uses sound waves to create images of the ovaries and nearby organs. A small probe is placed in the vagina and a transducer sends out sound waves and picks up the echoes as they bounce off organs. A computer turns these echoes into an image on a screen.

TVUS is often the first test done if an ovarian problem is suspected. It can show whether a mass is solid (a tumor) or fluid-filled (a cyst), and it helps. It can also help the doctor decide which masses or cysts are more worrisome by letting them get a better look at the size and appearance of an ovary.

A CT scan is an x-ray test that makes detailed cross-sectional images of your body. It typically does not show small ovarian tumors well, but it can show larger tumors and whether cancer has spread to nearby structures, lymph nodes, or organs like the liver.

CT scans can be used to guide a biopsy of a suspected metastasis (area of spread). For a CT-guided needle biopsy, CT scans are repeated while a doctor moves a biopsy needle toward the mass, until the scans show that the needle is in the mass. The needle removes a small sample to be examined in the lab.

MRI scans uses strong magnets to create cross-sectional pictures of your insides. A contrast material called gadolinium may be injected into a vein before the scan to see details better.

MRI scans are not used often to look for ovarian cancer, but they are helpful to examine the brain and spinal cord where cancer could spread.

If you have been diagnosed with cancer, a PET scan may be done to see if it has spread to lymph nodes or other parts of the body. For this test, you will be given a small amount of radioactive sugar. Because cancer cells grow quickly, they absorb more of the sugar than normal cells. A special camera creates an image showing areas of radioactivity in the body.

PET scan images are not as detailed as CT or MRI scans. Typically, a PET and CT scan are done at the same time. A PET/CT scan lets the doctor compare areas of higher radioactivity on the PET scan with the more detailed pictures on the CT scan.

Laparoscopy uses a thin, lighted tube with a tiny camera at the end, inserted through a small incision (cut) in the lower abdomen. The camera sends images to a video monitor, allowing the doctor to see the ovaries and nearby organs.

This procedure helps when planning surgery or other treatments, and can help confirm the cancer’s stage (how far it has spread).

The only way to confirm whether a growth is cancer is to remove a sample and examine it in the lab. This is called a biopsy. For ovarian cancer, the biopsy is usually done by removing the tumor during surgery.

If you cannot have surgery because of advanced cancer or another serious medical condition, a biopsy might be done with laparoscopy or by inserting a needle through the skin into the tumor. This approach is not common, because there is a risk that the biopsy could spread the cancer. Ultrasound or a CT scan is usually used to guide the needle.

If you have ascites (fluid buildup in the abdomen), a fluid sample can be taken to check for cancer cells using a procedure called paracentesis. Your skin is numbed, and a needle and syringe are used to collect fluid from the abdominal cavity. Ultrasound may be used to guide the needle.

All tissue or fluid samples are sent to the lab and examined by a pathologist, a doctor who specializes in diagnosing and classifying diseases by studying cells under a microscope and using other lab tests.

Your doctor will order several blood tests to check your overall health and look for signs of cancer:

• Blood counts to make sure you have enough red blood cells, white blood cells and platelets (cells that help stop bleeding).
• Tests to measure your kidney and liver function as well as your general health.
• Tests to measure level(s) of tumor marker(s), for example, the level of CA-125. This information can help support the diagnosis of ovarian cancer, monitor for treatment response, and assess for possible disease recurrence.

If your doctor suspects a germ cell tumor, your blood might be tested for the tumor markers human chorionic gonadotropin (HCG), alpha-fetoprotein (AFP), and/or lactate dehydrogenase (LDH).

If your doctor suspects an ovarian stromal tumor, your blood might be checked for an increase in a substance called inhibin and hormones such as estrogen and testosterone.

If you have an ovarian mass, a test called OVA1 can measure the levels of 5 proteins in the blood to help determine whether the mass should be considered “low risk” or “high risk” for cancer. This NOT a screening test or a tool to decide whether to have surgery. It is used when surgery is already planned, to help decide whether it should be done by a gynecologist or a gynecologic oncologist.

• A "low risk" result means cancer is unlikely.
• A "high risk" result means cancer is more likely and a referral to a gynecologic oncologist is recommended.

BRCA genes are normally involved in DNA repair, and mutations in these genes can cause cells to grow out of control and turn into cancer. Ovarian cancers with BRCA gene mutations are more likely to respond to treatment with targeted drugs called PARP inhibitors.

In many ovarian cancers, the cells have high levels of the FR-alpha protein on their surfaces. Testing for FR-alpha levels can show if the cancer is more likely to respond to treatment with a targeted drug such as mirvetuximab soravtansine (Elahere).

Women who have clear cell, endometrioid, or mucinous ovarian cancer might have their tumor tested for high levels of gene changes called microsatellite instability (MSI) or changes in mismatch repair (MMR) genes such as MLH1, MSH2, MSH6, and PMS2.

Changes in MSI or in MMR genes (or both) are often seen in people with Lynch syndrome (HNPCC). Up to 10% of all ovarian epithelial cancers have changes in these genes.

There are 2 main reasons to test for MSI or for MMR gene changes:

• To check for the possibility of Lynch syndrome. A diagnosis of Lynch syndrome can help determine if a person should have screenings for other types of cancer, such as endometrial or colon cancer. If a person does have Lynch syndrome, their relatives could also have it and may want to be tested for it.
• To determine treatment options. Ovarian cancers that have certain MSI or MMR gene changes might be treated with immunotherapy drugs known as checkpoint inhibitors.

Some ovarian cancers might be tested for changes in one of the NTRK genes. Cells with these gene changes can lead to abnormal cell growth and cancer. Larotrectinib (Vitrakvi) and entrectinib (Rozlytrek) are targeted drugs that stop the proteins made by the abnormal NTRK genes. The number of ovarian cancers that have this mutation is very small, but this may be an option for some women.