Guideline sources The following summarized guidelines for the evaluation and management of ovarian cancer are prepared by our editorial team based on guidelines from the American Society of Clinical Oncology (ASCO 2022; 2021; 2020), the European Society of Medical Oncology (ESMO 2021; 2020; 2018; 2016; 2013), the Society of Obstetricians and Gynaecologists of Canada (SOGC 2020; 2018), the U.S. Preventive Services Task Force (USPSTF 2018; 2017; 2014), the European Society of Gynaecological Oncology (ESGO 2017), the American College of Obstetricians and Gynecologists (ACOG 2017; 2016), the Royal College of Obstetricians and Gynaecologists (RCOG 2016), the Society of Gynecologic Oncology (SGO/ASCO 2016), and the British Society for Gynaecological Endoscopy (BSGE/RCOG 2011). 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 19 20 21 22 https://web.pathway.md/diseases/recrkpHq2HKys01A5 1/15 6/30/23, 1:24 AM Ovarian cancer Pathway Calculator Calculator Calculator Eastern Cooperative Oncology G FIGO staging for ovarian cancer Karnofsky Guidelines 1. Screening and diagnosis Indications for screening, general population: As per SOGC 2020 guidelines, do not obtain CA-125 testing as a screening tool in asymptomatic females without a pelvic or adnexal mass. D As per USPSTF 2018 guidelines, do not obtain screening for ovarian cancer in asymptomatic females. D As per ACOG 2017 guidelines, insufficient evidence to recommend obtaining transvaginal ultrasound and tumor markers, such as CA-125, alone or in combination, for early detection of ovarian cancer in average-risk females. I As per USPSTF 2017 guidelines, insufficient evidence to assess the balance of benefits and harms of performing screening pelvic examinations in asymptomatic, nonpregnant adult females. I Indications for screening, patients at risk: As per ASCO 2020 guidelines, offer individualized genetic risk evaluation, counseling, and genetic testing in first- or second-degree blood relatives of a patient with ovarian cancer with a known germline pathogenic cancer susceptibility gene mutation or variant. A As per ESMO 2016 guidelines, provide counseling outlining options for screening for early detection, as well as risk-reducing measures and issues pertaining to fertility in BRCA mutation carriers. Discuss the issues of quality of life and the psychosocial impact of risk-reducing interventions. B Show 3 more As per USPSTF 2014 guidelines, obtain screening for ovarian cancer in patients with a family history of breast, ovarian, tubal, or peritoneal cancer using a screening tool designed to identify an increased risk for potentially harmful mutations in breast cancer susceptibility genes (BRCA1 or BRCA2). B Show 2 more Monitoring of ovarian cysts: As per ACOG 2016 guidelines, consider obtaining imaging monitoring in patients with simple cysts < 10 cm in diameter on transvaginal ultrasound (obtained by an experienced specialist), even in postmenopausal patients, as these cysts are likely benign. C https://web.pathway.md/diseases/recrkpHq2HKys01A5 2/15 6/30/23, 1:24 AM Ovarian cancer Pathway As per RCOG 2016 guidelines: Recognize that asymptomatic, simple, unilateral, unilocular, < 5 cm ovarian cysts have a low risk of malignancy. Obtain repeat evaluation in 4-6 months in patients with normal serum CA- 125 levels. Consider discontinuing surveillance after 1 year if the cyst remains unchanged or reduces in size, with normal CA-125, taking into consideration the patient's wishes and surgical fitness. B Obtain further surgical evaluation if the patient is symptomatic. B As per RCOG 2011 guidelines, avoid obtaining monitoring in patients with small (< 5 cm diameter) simple ovarian cysts, as these cysts are very likely to be physiological and almost always resolve within 3 menstrual cycles. D Show 2 more Differential diagnosis: obtain laboratory testing to aid in the differential diagnosis of adnexal masses. Test for STI to elicit leukocytosis to help identify tubo-ovarian abscess. Obtain a pregnancy testing can to identify a possible ectopic pregnancies. B 2. Classification and risk stratification Risk assessment: As per ACOG 2017 guidelines: Elicit a detailed personal and family history for breast, gynecologic, and colon cancer to help categorize patients based on their risk (average risk or high risk) of developing epithelial ovarian cancer. E Maintain an appropriate level of suspicion when potentially relevant signs and symptoms of ovarian cancer are present. E As per RCOG 2016 guidelines, use the RMI I for risk assessment of patients with suspected ovarian cancer. A As per RCOG 2011 guidelines, use a risk stratification tool, such as the RMI I, to assess the risk of malignancy in patients with an ovarian mass. B Show 2 more Prognosis: As per ACOG 2017 guidelines: Recognize that epithelial ovarian cancer is most commonly detected in an advanced stage (65% of cases are stage III-IV) and the cure rate is only 18%. E Recognize that early stage (localized) ovarian cancer is associated with improved survival. E As per ESMO 2013 guidelines: Recognize that the subtype of cancer has prognostic importance. A Recognize that patients with relapsed disease with 2 of 3 of the following criteria have the best survival: complete resection at first surgery https://web.pathway.md/diseases/recrkpHq2HKys01A5 3/15 6/30/23, 1:24 AM Ovarian cancer Pathway good performance status absence of ascites. B 3. Diagnostic investigations History and physical examination: As per ASCO 2021 guidelines, obtain a clinical assessment and elicit a family history in patients with a ovarian mass or suspected ovarian cancer. E As per SOGC 2020 guidelines: Elicit a detailed personal and family history ro guide decisions on further testing and evaluation in patients with adnexal masses. Recognize that the majority of patients with ovarian cancer have symptoms in the year prior to their diagnosis, although these symptoms can be vague. B Perform a physical exmaination including lymph nodes and respiratory system to rule out pleural effusion or consolidation, breast and axillary examination to rule out breast malignancy, and an abdominal examination to assess for ascites, omental caking, and organomegaly as well as a pelvic examination, including a bimanual and rectovaginal examination, to assess for mass size, contour, mobility, and parametrial, bladder, and rectal abnormality. B As per ESGO 2017 guidelines, perform a physical examination, including abdominal, vaginal, and rectal examinations, assessment of the breast, groins, axilla, and supraclavicular areas, and auscultation of the lungs in patients with suspected ovarian cancer. E As per RCOG 2016 guidelines, elicit a thorough medical history with specific attention to risk factors and symptoms suggestive of ovarian malignancy and a family history of ovarian, bowel, or breast cancer in patients with suspected ovarian cancer. B Tumor markers: As per ASCO 2021 guidelines, obtain CA-125 to assist in the diagnosis of postmenopausal patients with symptoms of ovarian cancer. E As per SOGC 2020 guidelines, recognize that CA-125 is a nonspecific glycoprotein that can be elevated in benign and malignant gynecologic conditions and in non-gynecologic conditions. Recognize that only half of all patients with early-stage ovarian cancer and 80% of patients with advanced-stage ovarian cancer show elevated CA-125 levels. B Show 4 more As per ESGO 2017 guidelines: Obtain serum CA-125 as the tumor marker of choice. Recognize that HE4 has also been proposed. E Consider obtaining additional markers, such as AFP, hCG, LDH, CEA, CA 19-9, inhibin B or antimullerian hormone, estradiol, and testosterone, in specific circumstances such as young age or imaging suggesting a mucinous, or nonepithelial, tumor of extra-adnexal origin. E As per RCOG 2016 guidelines, obtain serum CA-125 level measurement in the initial evaluation of ovarian cysts in postmenopausal patients. A https://web.pathway.md/diseases/recrkpHq2HKys01A5 4/15 6/30/23, 1:24 AM Ovarian cancer Pathway Show 3 more As per RCOG 2011 guidelines: Avoid obtaining serum CA-125 in all premenopausal patients with an ultrasound diagnosis of a simple ovarian cyst. D Measure LDH, AFP, and hCG levels in all < 40 years old patients with a complex ovarian mass because of the possibility of a germ cell tumor. B Diagnostic imaging: As per SOGC 2020 guidelines: Use risk prediction models, such as the International Ovarian Tumor Analysis group simple rules, for ultrasound evaluation of adnexal masses to allow operators with varying degrees of expertise to use uniform terminology and accurately classify these masses as "likely malignant," "benign," or "indeterminate.". B Obtain ultrasound evaluation by an expert operator (if available) or MRI in patients with adnexal masses with indeterminate features. B As per ESGO 2017 guidelines: Obtain routine pelvic (transvaginal and transabdominal) ultrasound as the first-line modality for evaluation of any adnexal mass. B Obtain specialized pelvic, abdominal, and thoracic complementary imaging in case of suspected carcinoma of the ovary or indeterminate or suspicious masses at routine ultrasound examination. B As per RCOG 2016 guidelines, obtain transvaginal pelvic ultrasound in the initial evaluation of ovarian cysts in postmenopausal patients. A Show 12 more As per RCOG 2011 guidelines: Obtain pelvic ultrasound, preferably transvaginal, for the evaluation of an ovarian mass. B Do not obtain routine CT or MRI for the evaluation of ovarian masses to improve ovarian malignancy detection of transvaginal ultrasound. D Imaging for staging: evaluate all patients with suspected stage IIIC or IV invasive epithelial ovarian cancer by a gynecologic oncologist before initiating therapy to determine the candidacy for primary cytoreductive surgery. B Show 3 more Genetic testing: As per ESMO 2021 guidelines: Obtain testing for BRCA1 and BRCA2 mutations (germline/somatic) at diagnosis in all patients with high-grade ovarian cancer. A Obtain testing for genomic instability to identify patients with wild-type BRCA who will derive greater benefit from a poly (ADP-ribose) polymerase inhibitor. A As per ASCO 2020 guidelines, obtain germline genetic testing for BRCA1, BRCA2, and other ovarian cancer susceptibility genes in all patients diagnosed with epithelial ovarian cancer https://web.pathway.md/diseases/recrkpHq2HKys01A5 5/15 6/30/23, 1:24 AM Ovarian cancer Pathway irrespective of their clinical features or family cancer history. Obtain somatic tumor testing for BRCA1 and BRCA2 pathogenic or likely pathogenic variants in patients not carrying a germline pathogenic or likely pathogenic BRCA1/2 variant. B Obtain these tests at the time of diagnosis as this has implications for therapeutic decision-making, A or as soon as possible if the testing is negative at the time of diagnosis. B Show 4 more 4. Diagnostic procedures Adnexal mass biopsy: As per ASCO 2021 guidelines, perform CT-guided biopsy or laparoscopy (with sufficient resources) instead of laparotomy to obtain histologic confirmation before any systemic therapy. E As per SGO 2016 guidelines, obtain histologic confirmation (preferably with core biopsy) of an invasive ovarian, fallopian tube, or peritoneal cancer in all patients before initiating neoadjuvant chemotherapy. Consider obtaining cytologic evaluation combined with a serum CA-125-to-CEA ratio > 25 to confirm the primary diagnosis and exclude non-gynecologic cancers in exceptional cases when a biopsy cannot be performed. B 5. Medical management Neoadjuvant chemotherapy (platinum-based regimens): offer neoadjuvant chemotherapy in patients at high perioperative risk or with a low likelihood of achieving cytoreduction to < 1 cm (ideally to no visible disease). B Show 3 more Neoadjuvant chemotherapy (PARPi regimens): do not offer poly (ADP-ribose) polymerase inhibitors in the initial treatment of early-stage (stage I-II) epithelial ovarian cancer. D Adjuvant chemotherapy: As per ASCO 2021 guidelines, do not offer adjuvant chemotherapy in patients with ovarian low- malignant potential tumors or early-stage micro-invasive borderline tumors, independent of stage. D Show 3 more As per ESMO 2013 guidelines, offer adjuvant chemotherapy in patients with suboptimally staged, early-stage ovarian cancer, and in patients with optimally staged, early-stage disease at higher risk of recurrence. A Definitive chemotherapy: offer a combination of IV paclitaxel 175 mg/m and carboplatin every 3 weeks as standard chemotherapy in patients with stage II-IV ovarian cancer. A Consider offering dose-dense administration of paclitaxel only as an option. B Show 3 more Maintenance therapy: https://web.pathway.md/diseases/recrkpHq2HKys01A5 6/15 6/30/23, 1:24 AM Ovarian cancer Pathway As per ASCO 2022 guidelines, offer poly (ADP-ribose) polymerase inhibitor maintenance therapy in patients with newly diagnosed stage III-IV high-grade serous or endometrioid ovarian cancer in complete or partial response to first-line platinum-based chemotherapy. Offer olaparib (300 mg every 12 hours for 2 years), niraparib (200-300 mg daily for 3 years), or rucaparib (600 mg BID for 2 years) in patients with germline or somatic pathogenic or likely pathogenic variants in BRCA1 or BRCA2 genes. Consider offering longer durations in selected patients after a discussion of risks. Offer rucaparib or niraparib in homologous recombination deficiency-positive patients. Consider offering niraparib or rucaparib in non-BRCA-mutated/homologous recombination deficiency-negative patients. A Show 3 more As per ESMO 2021 guidelines, offer maintenance treatment with a PARP inhibitor, 2 years for olaparib and 3 years for niraparib, in patients with a BRCA mutation and a partial or complete response to front-line platinum-based chemotherapy. E Offer a combination of olaparib and bevacizumab when bevacizumab is added to front-line chemotherapy. A Show 3 more As per ASCO 2020 guidelines: Consider offering olaparib in addition to bevacizumab maintenance in patients with stage III-IV high-grade serous or endometrioid ovarian cancer and germline or somatic pathogenic or likely pathogenic variants in BRCA1 or BRCA2 genes and/or genomic instability, as determined by the Myriad myChoice CDx, and with partial or complete response to chemotherapy plus bevacizumab combination. B Do not use poly (ADP-ribose) polymerase inhibitors in combination with chemotherapy, other targeted agents, or immune-oncology agents in patients with recurrent disease outside the context of a clinical trial. D As per ESMO 2020 guidelines: Offer maintenance therapy with a poly (ADP-ribose) polymerase inhibitor (olaparib, niraparib, or rucaparib) following a response to platinum-based therapy in patients with recurrent platinum-sensitive high-grade ovarian cancer, irrespective of BRCA status. A Offer rucaparib monotherapy in patients with recurrent platinum-sensitive ovarian cancer and a BRCA mutation unable to receive platinum-based therapy. B Management of progressive/relapsed disease: As per ASCO 2021 guidelines, counsel patients with recurrent ovarian cancer on treatment options based on the patient's prior response to platinum-based chemotherapy (platinum- sensitive, platinum-resistant, or platinum-refractory disease status). Perform platinum rechallenge only in patients with platinum-sensitive disease. E Show 3 more As per ASCO 2016 guidelines, recognize that patients with progressive disease on neoadjuvant chemotherapy have a poor prognosis. Offer alternative chemotherapy regimens, clinical trials, and/or discontinuation of active cancer therapy and initiation of end-of-life care. Do not offer surgery unless for palliation (such as relief of bowel obstruction). B As per ESMO 2013 guidelines: https://web.pathway.md/diseases/recrkpHq2HKys01A5 7/15 6/30/23, 1:24 AM Ovarian cancer Pathway Offer carboplatin-doublet as the treatment of choice in patients with a later relapse, over 6 months and especially over 12 months. A Decide on the choice between different options of platinum-based doublets based on the toxicity profile and convenience of administration. B Consider offering a combination therapy with platinum and pegylated liposomal doxorubicin in patients with a platinum-sensitive relapse. B 6. Therapeutic procedures Adnexal mass aspiration: consider performing adnexal aspiration for symptom control in patients with advanced malignancy unfit for surgery or further intervention. C 7. Perioperative care Postoperative care: assess all patients postoperatively at a gynecological oncology multidisciplinary meeting. E 8. Surgical interventions General principles: As per ASCO 2021 guidelines, perform surgery by trained gynecologic oncologists or surgeons with oncology surgical expertise. Refer patients to the highest-resourced level oncology center with oncology surgical capacity. E As per ESGO 2017 guidelines: Plan treatment preoperatively at a multidisciplinary team meeting, after a workup aimed at ruling out unresectable metastases, and secondary ovarian and peritoneal metastases from other primary malignancies when family history, symptoms, radiological features, or CA-125- CEA ratio is suggestive. B Schedule a second surgical procedure when early carcinoma is incidentally found at surgery for a suspected "benign" condition if the patient has not been comprehensively staged. E Primary cytoreductive surgery: As per ASCO 2021 guidelines, offer optimal surgical debulking to remove all visible disease to improve overall survival by trained surgeons in patients with advanced ovarian cancer (stage III and IV). E As per ESGO 2017 guidelines, offer total hysterectomy and bilateral salpingo-oophorectomy as the standard of treatment in patients with stage I-II ovarian cancer. Offer unilateral salpingo- oophorectomy in selected premenopausal patients desiring fertility preservation. B Show 8 more As per ASCO 2016 guidelines: Consider offering either neoadjuvant chemotherapy or primary cytoreductive surgery in patients with potentially resectable disease, fit for primary cytoreductive surgery. Recognize https://web.pathway.md/diseases/recrkpHq2HKys01A5 8/15 6/30/23, 1:24 AM Ovarian cancer Pathway that neoadjuvant chemotherapy is associated with less peri- and postoperative morbidity and mortality and shorter hospitalizations, while primary cytoreductive surgery shows better survival in selected patients. C Offer primary cytoreductive surgery rather than neoadjuvant chemotherapy in patients with a high likelihood of achieving cytoreduction to < 1 cm (ideally to no visible disease) with acceptable morbidity. B Secondary cytoreductive surgery: As per ESGO 2017 guidelines: Offer interval debulking surgery in patients fit for surgery with a responsive or stable disease compatible with complete resection. A Consider offering delayed debulking surgery after > 3 cycles of neoadjuvant chemotherapy, on an individual basis, if the patient did not have the opportunity of surgery after 3 cycles. E As per ASCO 2016 guidelines, perform interval cytoreductive surgery after 4 cycles of neoadjuvant chemotherapy in patients with a response to chemotherapy or stable disease. Consider offering alternate timing of surgery based on patient-centered factors. B Avoidance of intraoperative spillage: As per ESGO 2017 guidelines: Avoid causing rupture of an intact primary tumor with spillage of tumor cells at the time of dissection and extraction of the specimen. D Avoid causing intraoperative rupture of a yet unruptured adnexal mass. D As per RCOG 2011 guidelines: Avoid spilling cyst contents where possible as preoperative and intraoperative assessment cannot absolutely preclude malignancy. D Consider using a tissue bag to avoid peritoneal spill of cystic contents bearing in mind the likely preoperative diagnosis. C Intraoperative frozen section examination: Consider ensuring the availability of frozen section to allow the necessary surgical assessment to be completed at the time of initial surgery, although definitive pathology is the criterion standard of diagnosis. C Prefer a 2-step procedure in the absence of frozen section or in case of an inconclusive frozen section. E Intraoperarive staging: As per ASCO 2021 guidelines, perform surgical staging by trained surgeons, where feasible, in patients with presumed early-stage ovarian cancer. E As per ESGO 2017 guidelines, perform laparoscopic restaging by a gynecologic oncologist with adequate expertise to obtain a comprehensive assessment. B Show 4 more 9. Specific circumstances https://web.pathway.md/diseases/recrkpHq2HKys01A5 9/15 6/30/23, 1:24 AM Ovarian cancer Pathway Patients with non-epithelial ovarian cancer (evaluation): obtain pelvic ultrasound, abdominopelvic CT, CXR, and positron emission tomography in the diagnostic work-up of selected patients with non-epithelial ovarian cancer (germ cell tumor). B Show 9 more Patients with non-epithelial ovarian cancer (adjuvant chemotherapy): offer adjuvant chemotherapy in patients with germ cell tumors with potential nodal metastasis. B Show 18 more Patients with non-epithelial ovarian cancer (hormone therapy): Consider offering HRT in patients with germ cell tumors. B Do not use HRT in patients with sex cord-stromal tumors. D Patients with non-epithelial ovarian cancer (radiotherapy): consider offering postoperative pelvic radiotherapy, either concurrently or sequentially to high-dose chemotherapy and ASCT. in patients with early or advanced small cell carcinoma of the ovary, hypercalcemic type. C Patients with non-epithelial ovarian cancer (fertility preservation): consider offering oocyte cryopreservation in patients scheduled to receive chemotherapy. C Show 2 more Patients with non-epithelial ovarian cancer (surgical resection): use an open surgical approach or, in selected cases, laparoscopic and robotic approaches, thereby avoiding tumor rupture during surgery. Show 11 more Patients with non-epithelial ovarian cancer (follow-up): recognize that serum tumor markers (hCG, AFP, LDH, cancer antigen 125, and inhibin B) can correlate with tumor response during chemotherapy. B Show 6 more 10. Patient education General counseling: provide counseling in BRCA mutation carriers outlining options for screening for early detection, risk-reducing measures, and issues pertaining to fertility. B Genetic counseling, patients at risk: As per SOGC 2018 guidelines: Provide genetic counseling and assessment in patients at high risk for hereditary breast- ovarian cancer. Provide thorough counseling on the results and implications of testing by an expert in genetics. A Obtain follow-up visits by a geneticist every 5 years in patients with a strong clinical suspicion for hereditary breast-ovarian cancer and uninformative or variant of unknown clinical significance testing. B As per USPSTF 2014 guidelines: https://web.pathway.md/diseases/recrkpHq2HKys01A5 10/15 6/30/23, 1:24 AM Ovarian cancer Pathway Provide genetic counseling in patients with positive screening results and obtain BRCA testing after counseling if indicated. B Do not obtain routine BRCA testing in patients with a family history not associated with an increased risk for potentially harmful mutations in the BRCA1 or BRCA2 genes. D 11. Preventative measures Lifestyle modifications: advise exercising regularly, maintaining healthy body weight, limiting alcohol consumption, and avoiding HRT. B Hormone therapy: As per SOGC 2018 guidelines, recognize that combined hormonal contraceptives are an effective method of chemoprevention for ovarian/tubal/peritoneal cancer in the general population and with BRCA1/2 mutation carriers. A Show 2 more As per ESMO 2016 guidelines, consider offering oral contraceptives as a risk-reducing measure for ovarian cancer. C Aspirin: insufficient evidence to support the use of aspirin for the prevention of ovarian cancer in the BRCA mutation carriers. I Risk-reducing salpingo-oophorectomy: As per SOGC 2018 guidelines, offer risk-reducing surgery to reduce the risk of ovarian cancer in patients with a hereditary predisposition or risk. B Show 12 more As per ESMO 2016 guidelines, offer risk-reducing salpingo-oophorectomy at the age of 35-40 years B for reducing the risk of ovarian cancer in BRCA1/2 carriers. A Show 2 more Risk-reducing mastectomy: as per ESMO 2016 guidelines, offer risk-reducing bilateral mastectomy for reducing breast cancer risk in BRCA1/2 mutation carriers. B Consider offering skin-sparing mastectomy and nipple-sparing mastectomy as alternatives to total mastectomy. B 12. Follow-up and surveillance Indications for referral: As per SOGC 2020 guidelines, refer patients with a personal history of infertility, endometriosis, or cancer, or a family history of cancer, to a gynecologic oncologist for further evaluation, if possible. B Show 3 more As per ESGO 2017 guidelines, refer patients with nonemergency clinical presentation and suspected adnexal/peritoneal malignancy to a specialist in gynecologic oncology. B As per RCOG 2011 guidelines: https://web.pathway.md/diseases/recrkpHq2HKys01A5 11/15 6/30/23, 1:24 AM Ovarian cancer Pathway Refer patients with a suspected malignant disease (based on ultrasound findings and tumor markers) to a gynecologic oncologist. B Refer postmenopausal patients with ovarian cysts with a RMI I score 200 to a gynecological oncologist. B Management of treatment-related adverse events: monitor patients requiring blood transfusion for symptom relief and/or Hgb levels < 8 g/dL. Reduce the dose of poly (ADP-ribose) polymerase inhibitors with evidence of repeated anemia to avoid multiple transfusions. Consider offering growth factor therapy in patients with progressive anemia. B Show 4 more Surveillance for other malignancies (general principles): tailor screening recommendations for BRCA-associated malignancies to an individual's family history of malignancy. B Surveillance for other malignancies (breast cancer): obtain clinical breast examination every 6- 12 months from the age of 25 or 10 years before the youngest breast cancer diagnosis in the family, whichever is earlier, in BRCA mutation carriers. B Show 3 more Surveillance for other malignancies (peritoneal cancer): Insufficient evidence to recommend ovarian/tubal/peritoneal cancer screening in BRCA mutation carriers. Do not obtain surveillance for peritoneal cancer in BRCA mutation carriers following risk- reducing salpingo-oophorectomy. D Surveillance for other malignancies (pancreatic cancer): consider obtaining annual screening for pancreatic cancer with EUS or MRI/MRCP, starting from the age of 50 or 10 years before the earliest diagnosed case in the family, in BRCA2 mutation carriers. C Surveillance for other malignancies (melanoma): consider obtaining annual skin and eye examinations as screening for melanoma in BRCA2 mutation carriers. C Clinical findings Symptoms Past medical history Abdominal pain Endometrial cancer Bloating Endometriosis Constipation Ovarian cyst Diarrhea Past obstetric history Early satiety Fatigue Early menarche Nausea Late menopause Pelvic pain Postmenopause Shortness of breath Abdominal exam Urinary frequency Urinary urgency https://web.pathway.md/diseases/recrkpHq2HKys01A5 12/15 6/30/23, 1:24 AM Ovarian cancer Pathway Vaginal bleeding Abdominal distension Vomiting Ascites Palpable abdominal mass Medication history Palpable pelvic mass Sister Mary Joseph nodule HRT Lymphatic exam Family history Axillary lymphadenopathy Breast cancer Inguinal lymphadenopathy Gynecologic exam Supraclavicular lymphadenopathy Adnexal mass Imaging findings Lab findings Ovarian mass HE4 Pleural effusion serum CA 15-3 serum CA 19-9 serum CEA serum LDH serum antigen 72-4 serum cancer antigen 125 serum -hCG serum alpha fetoprotein Genetic testing Brca1 gene mutation Brca2 gene mutation References 1. 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Assessment of Adult Women With Ovarian Masses and Treatment of Epithelial Ovarian Cancer: ASCO Resource-Stratified Guideline. JCO Glob Oncol. 2021 Jun;7 1032 1066. Open 10. Committee on Practice Bulletins Gynecology, Committee on Genetics, Society of Gynecologic Oncology. Practice Bulletin No 182 Hereditary Breast and Ovarian Cancer Syndrome. Obstet Gynecol. 2017 Sep;130 3):e110-e126. Open 11. Royal College of Obstetricians and Gynaecologists. The Management of Ovarian Cysts in Postmenopausal Women. RCOG. 2016 Jul. Open 12. William P Tew, Christina Lacchetti, Elise C Kohn et al. Poly(ADP Ribose) Polymerase Inhibitors in the Management of Ovarian Cancer: ASCO Guideline Rapid Recommendation Update. J Clin Oncol. 2022 Nov 20;40 33 3878 3881. Open 13. Moyer VA. Risk assessment, genetic counseling, and genetic testing for BRCA-related cancer in women: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014 Feb 18;160 4 271 81. Open 14. 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US Preventive Services Task Force, Bibbins-Domingo K, Grossman DC et al. Screening USPSTF for Gynecologic Conditions With Pelvic Examination US Preventive Services Task Force Recommendation Statement. JAMA. 2017;317 9 947 953. Open 24. David G Mutch, Jaime Prat. 2014 FIGO staging for ovarian, fallopian tube and peritoneal cancer. Gynecol Oncol. 2014 Jun;133 3 401 4. Open 25. Christina Fotopoulou, Fran ois Planchamp, Tugce Aytulu et al. European Society of Gynaecological Oncology guidelines for the peri-operative management of advanced ovarian cancer patients undergoing debulking surgery. Int J Gynecol Cancer. 2021 Sep;31 9 1199 1206. Open 26. William P Tew, Christina Lacchetti, Annie Ellis et al. PARP Inhibitors in the Management of Ovarian Cancer: ASCO Guideline. J Clin Oncol. 2020 Oct 20;38 30 3468 3493. Open 27. Panagiotis A Konstantinopoulos, Barbara Norquist, Christina Lacchetti et al. Germline and Somatic Tumor Testing in Epithelial Ovarian Cancer: ASCO Guideline. J Clin Oncol. 2020 Apr 10;38 11 1222 1245. Open 28. Tarek Motan, Roland Antaki, Jinglan Han et al. Guideline No. 435 Minimally Invasive Surgery in Fertility Therapy. J Obstet Gynaecol Can. 2023 Apr;45 4 273 282.e2. Open https://web.pathway.md/diseases/recrkpHq2HKys01A5 15/15