Symptom-Triggered Testing Detects Early-Stage Ovarian Cancer in 1 in 4 Women

One in 4 women diagnosed with high-grade serous ovarian cancer through symptom-triggered testing was found to have early-stage disease, according to a study published in the International Journal of Gynecological Cancer.¹

Ovarian cancer is the 6th most common cause of cancer-related deaths in the United Kingdom (UK).² Most (93%) women diagnosed with early-stage ovarian cancer (International Federation of Gynecology and Obstetrics [FIGO] stage I or II) survive after 5 years vs 13% diagnosed in advanced stages (stage III or IV). Although those diagnosed with stages I and II ovarian cancer have better survival rates, early detection is often difficult due to the vague symptoms and low incidence of ovarian cancer.³

However, past research identified a symptom triad associated with ovarian cancer, namely pain, early satiety, and increased abdominal size and/or bloating.⁴ This was then used to develop a symptom index incorporated into national guidelines to raise awareness among clinicians.

Consequently, ovarian cancer symptom-triggered testing was endorsed by cancer organizations in the US and UK; it is considered the fast-track pathway. In this pathway, it is recommended that symptomatic women be prioritized for testing and referred to see a gynecologist within 2 weeks.¹ It also involves testing for cancer antigen (CA)-125; if the CA-125 level is raised, the patient must undergo a transvaginal ultrasound scan.

Despite being endorsed by cancer organizations, the potential value of symptom-triggered testing in detecting early-stage disease or low tumor burden among women with high-grade serous ovarian cancer remains unclear. Therefore, the researchers conducted a study to report on the FIGO stage, disease distribution, and complete cytoreduction rates of women in the fast-track pathway who were diagnosed with high-grade serous ovarian cancer.

They analyzed a dataset from Refining Ovarian Cancer Test accuracy Scores (ROCkeTS), a single-arm prospective diagnostic test accuracy study that recruited patients from 24 UK hospitals. Eligible women between the ages of 16 and 90 had a raised CA-125 level at the primary care level, any abnormal imaging results, or both.

Between June 2015 and July 2022, these women were recruited after a referral to the hospital via the fast-track pathway, routine outpatient referrals, or following emergency admissions. The researchers followed these patients until a histological diagnosis was attained through a biopsy or surgery at 3 months; those who did not undergo biopsy or surgery were followed up at 12 months. Consequently, patients could only be recruited before undergoing surgery or a biopsy.

Of the 2596 patients in ROCkeTS, 1741 (67.0%) were recruited via the fast-track pathway, 692 (26.7%) through outpatient clinics, and 163 (6.3%) following emergency presentations. The researchers found that 119 of 1741 (6.8%) women presenting via the fast-track pathway were diagnosed with high-grade serous ovarian cancer; the median age was 63 years, and 89.9% were post-menopausal.

Out of these 119 patients, 112 (94.1%) had a performance status of 0 and 1, 77 (64.7%) had low-to-moderate disease distribution, and 30 (25.2%) were diagnosed with stages I/II ovarian cancer. Also, 78 (65.5%) patients underwent primary debulking surgery, while 36 (30.3%) received neoadjuvant chemotherapy followed by interval debulking surgery; the remaining patients (4.2%; n = 5) did not undergo surgery. Lastly, 61.3% achieved complete cytoreduction (n = 73), while 15.1% (n = 18) achieved optimal cytoreduction.

“Our figures demonstrate that in a real-world setting, symptom-based testing can potentially lead to a diagnosis of high-grade serous ovarian cancer with low disease spread and results in a high proportion of complete cytoreduction,” the authors wrote.

The researchers acknowledged their limitations, including the modest number of women recruited through the emergency pathway and other outpatient referrals; this limited the ability to draw meaningful conclusions. Despite their limitations, the researchers expressed confidence in their findings.

“Symptom-triggered testing may help identify women with low disease burden, potentially contributing to high complete cytoreduction rates and improving survival outcomes in these patients,” the authors concluded.

References

1. Kwong FLA, Kristunas C, Davenport C, et al. Symptom-triggered testing detects early stage and low volume resectable advanced stage ovarian cancer. Int J Gynecol Cancer. Published online August 13, 2024. doi:10.1136/ijgc-2024-005371
2. Ovarian cancer statistics. Cancer Research UK. Accessed August 29, 2024. https://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/ovarian-cancer
3. Rai N, Nevin J, Downey G, et al. Outcomes following implementation of symptom triggered diagnostic testing for ovarian cancer. Eur J Obstet Gynecol Reprod Biol. 2015;187:64-69. doi:10.1016/j.ejogrb.2015.02.011
4. Ovarian cancer: recognition and initial management. NICE. April 27, 2011. Accessed August 29, 2024. https://www.nice.org.uk/guidance/cg122/