Ovarian Cancer: Symptoms, Diagnosis and Treatment

Ovarian Cancer: Symptoms, Diagnosis and Treatment

Ovarian cancer is the fifth leading cause of cancer death in women in developed countries and the most lethal gynaecological malignancy. Approximately 315,000 women are diagnosed with ovarian cancer worldwide each year, and over 200,000 die annually. It is called a "silent killer" because it lacks specific early symptoms and is frequently diagnosed at an advanced stage when curative treatment is difficult.

In China, ovarian cancer incidence has been rising — approximately 55,000 new cases annually — partly due to changing reproductive patterns (decreasing parity and breastfeeding are risk factors). The 5-year survival for all stages combined is approximately 40–50%, but for stage I disease caught early it exceeds 90%.

Types of Ovarian Cancer

The ovary contains multiple cell types, giving rise to different tumour types:

Epithelial Ovarian Cancer (EOC)

Accounts for approximately 90% of all ovarian cancers. Arises from the surface epithelium of the ovary or the fallopian tube (increasingly recognised as the dominant site of origin for high-grade serous carcinoma — the most common subtype).

EOC subtypes:

• High-grade serous carcinoma (HGSC) — the most common (~70% of EOC); highly aggressive; arises predominantly from fallopian tube epithelium; strongly associated with BRCA1/2 mutations; typically advanced at diagnosis; platinum-sensitive but frequently recurs
• Clear cell carcinoma (~10%) — often associated with endometriosis; more common in Asian women; relatively platinum-resistant
• Endometrioid carcinoma (~10%) — frequently associated with endometriosis and Lynch syndrome; better prognosis
• Mucinous carcinoma (~3%) — often confined to ovary at diagnosis; often platinum-resistant; must be distinguished from gastrointestinal primary
• Low-grade serous carcinoma — rare; indolent course; lower sensitivity to platinum than HGSC

Non-Epithelial Ovarian Tumours

• Germ cell tumours (dysgerminoma, yolk sac tumour, immature teratoma) — predominantly in young women; highly chemosensitive; often curable
• Sex cord-stromal tumours (granulosa cell tumour, Sertoli-Leydig) — may produce oestrogen or testosterone; often indolent; lower stage at diagnosis

Causes and Risk Factors

BRCA1 and BRCA2 Mutations

The most important genetic risk factor. Women with a BRCA1 mutation have a lifetime ovarian cancer risk of 40–50%; BRCA2 carriers have a 15–25% lifetime risk. BRCA-mutated cancers are predominantly high-grade serous carcinomas and are exquisitely sensitive to platinum chemotherapy and PARP inhibitors.

Testing: BRCA germline testing is recommended for all women diagnosed with high-grade serous ovarian cancer (prevalence of germline BRCA mutation approximately 15–20%). If a pathogenic germline BRCA variant is identified, adult first- or second-degree blood relatives, including men, should be offered individual genetic risk evaluation, counselling and appropriate testing for that familial variant. Somatic (tumour) BRCA mutations occur in a further 5–7% of EOC.

Lynch Syndrome

Hereditary mismatch repair deficiency (MLH1, MSH2, MSH6, PMS2 mutations) — increases risk of endometrioid and clear cell ovarian cancer, as well as colorectal, endometrial, and gastric cancer.

Reproductive and Hormonal Factors

• Nulliparity — increased lifetime number of ovulatory cycles correlates with risk
• Early menarche / late menopause — more ovulatory cycles
• Oral contraceptive pill — protective; reduces ovarian cancer risk by approximately 50% with 5+ years of use; protection persists for decades after cessation
• Endometriosis — associated with clear cell and endometrioid subtypes (3–4× increased risk); endometriotic cysts (endometriomas) may undergo malignant transformation
• HRT (particularly oestrogen-only, long-term) — modest association with serous tumours

Other Risk Factors

• Age — most cases diagnosed post-menopausally; median age 63
• Family history — first-degree relative with ovarian cancer, even without BRCA mutation, raises risk
• Talcum powder — perineal use historically associated with modest risk increase; mechanism debated; major lawsuits in the US

Protective factors: oral contraceptive use, pregnancy, breastfeeding, tubal ligation, salpingectomy (opportunistic bilateral salpingectomy at hysterectomy is recommended in current ACOG guidance, with preoperative counselling and an individual surgical plan. For carriers of a pathogenic germline BRCA1 or BRCA2 variant, risk-reducing bilateral salpingo-oophorectomy (RRSO) is generally planned after completion of childbearing or when future natural conception is not planned, typically at ages 35–40 for BRCA1 and 40–45 for BRCA2. Timing is individualised to risk and circumstances, with counselling about infertility and, if premenopausal, surgical menopause).

Symptoms

Ovarian cancer symptoms are non-specific and subtle — which is why most women present with advanced disease.

Common symptoms (often dismissed as IBS or menopausal):

• Persistent abdominal bloating — one of the most common early symptoms; often attributed to diet or IBS
• Pelvic or abdominal pain — persistent, not necessarily severe
• Difficulty eating or early satiety — due to ascites or peritoneal deposits compressing the stomach
• Urinary frequency or urgency — bladder compression
• Change in bowel habit — constipation or looser stool; tumour mass effect
• Unexplained weight loss — in advanced disease
• Fatigue

Advanced disease symptoms:

• Ascites — fluid in the abdomen causing gross abdominal distension; the abdomen may appear tight, shiny, and protuberant
• Pleural effusion — breathlessness from fluid around the lungs
• Palpable abdominal mass

Key clinical message: Any woman with persistent unexplained bloating, pelvic pain, early satiety, or urinary urgency lasting >2–3 weeks should be investigated — particularly if postmenopausal. A 2-week-wait referral pathway for suspected ovarian cancer is standard in many countries.

Diagnosis and Staging

Blood Tests

CA125 (cancer antigen 125) — glycoprotein produced by ovarian epithelial cells; elevated (>35 IU/mL) in approximately 80% of advanced ovarian cancers and in 50% of stage I disease. Not sufficiently sensitive or specific for screening (elevated in endometriosis, fibroids, PID, other cancers, and normal menstruation) but essential for monitoring treatment response and recurrence.

HE4 (human epididymis protein 4) — more specific than CA125 for ovarian cancer; ROMA algorithm (CA125 + HE4 + menopausal status) provides better risk stratification than CA125 alone.

AFP, β-hCG, LDH, inhibin — tumour markers for germ cell and sex cord-stromal tumours in younger women.

Imaging

Pelvic ultrasound — first-line imaging; identifies ovarian masses and characterises features (solid vs cystic; septations; papillary projections; vascularity; ascites). The RMI (Risk of Malignancy Index) — combining CA125, menopausal status, and ultrasound morphology score — guides onward referral.

CT chest/abdomen/pelvis with contrast — the primary staging investigation; identifies peritoneal deposits, omental caking, lymph node involvement, pleural effusions, and liver metastases. Essential for surgical planning.

MRI pelvis — superior soft tissue characterisation; used for complex adnexal masses, uterine disease, and delineating local disease extent.

PET-CT — useful for recurrence staging; detects small nodal deposits missed by CT.

Surgical Staging

Ovarian cancer is ultimately surgically staged — the FIGO staging system is determined at laparotomy or laparoscopy:

Stage	Description	5-Year Survival
I	Confined to ovaries/fallopian tubes	~90%
II	Extends to pelvis	~65–70%
III	Peritoneal spread beyond pelvis / retroperitoneal nodes	25–45%
IV	Distant metastasis (IV A: malignant cells confirmed in pleural fluid by cytology; IV B: parenchymal, extra-abdominal)	<20%

Approximately 75% of cases are diagnosed at stage III–IV.

Histological Diagnosis

Tissue diagnosis is required — either via:

• Surgical resection (definitive staging + cytoreduction at laparotomy/laparoscopy)
• CT-guided biopsy of an accessible lesion (peritoneal deposit, omental nodule) — for patients with advanced unresectable disease before neoadjuvant chemotherapy

Molecular profiling: BRCA1/BRCA2 (germline + somatic); MMR/MSI; homologous recombination deficiency (HRD) — guides maintenance therapy with PARP inhibitors.

Treatment

Primary Cytoreductive Surgery (Debulking)

For fit patients with advanced ovarian cancer who are surgical candidates — primary debulking surgery (PDS) aims to remove all visible tumour. The degree of residual disease is the most powerful prognostic factor in ovarian cancer: no residual disease (R0 / complete cytoreduction) confers the best survival.

Surgical extent: the operation may include total hysterectomy, bilateral salpingo-oophorectomy, omentectomy, peritoneal stripping and resection of involved bowel, bladder, diaphragm or liver-surface deposits as needed for complete cytoreduction. Suspicious or involved lymph nodes are assessed for removal. Systematic removal of clinically normal pelvic and para-aortic nodes is not routine in the advanced-disease setting studied in LION, where all visible tumour had been removed and nodes were normal before and during surgery; it did not improve survival and increased postoperative complications. The specialist team determines the necessary extent for each patient.

Cytoreductive surgery for advanced ovarian cancer is major pelvic and abdominal surgery, sometimes involving bowel resection and stoma; performed by specialist gynaecological oncologists at high-volume cancer centres.

Interval Debulking Surgery (IDS)

For patients not suitable for primary surgery (medically unfit, or disease distribution making upfront complete resection impossible) — neoadjuvant chemotherapy (NACT) is given first (3 cycles), followed by interval debulking surgery, then further chemotherapy. NACT+IDS achieves comparable overall survival to upfront PDS in patients where complete cytoreduction was not achievable upfront.

Chemotherapy

First-line chemotherapy for epithelial ovarian cancer:

• Carboplatin + paclitaxel is a commonly used combination. The treating team individualises the regimen, schedule and number of cycles; this is not a universal prescription for every patient.
• Weekly paclitaxel schedules differ in dose and combinations and are not interchangeable. The weekly dose-dense regimens in ICON8 did not significantly improve progression-free survival over the comparison regimen and increased grade 3 or 4 toxic effects. A weekly schedule should not be assumed to be better tolerated.

Most advanced ovarian cancers initially respond well to platinum chemotherapy (80–90% response rate) — but the majority recur. At recurrence, the time since the last platinum treatment helps estimate the chance of responding again, but a six-month cutoff alone does not determine treatment. The oncology team also considers tumour characteristics, previous treatments and response, residual toxicity or intolerance, general health and patient preferences. Platinum-containing treatment may be considered when clinically appropriate; when platinum is not suitable, non-platinum options are considered as part of an individualised plan.

Bevacizumab (anti-VEGF antibody) — added to chemotherapy and continued as maintenance (ICON7, OCEANS trials): approved for advanced ovarian cancer; improves progression-free survival; used in selected advanced or recurrent ovarian cancer regimens. The intravenous treatment schedule depends on the indication, accompanying chemotherapy and applicable product instructions; it is not universally every three weeks.

PARP Inhibitors — Maintenance Therapy

PARP (poly ADP-ribose polymerase) inhibitors exploit a DNA repair deficiency (homologous recombination deficiency — HRD) present in BRCA-mutated and other HRD-positive ovarian cancers:

• Olaparib (Lynparza) — an option for appropriately selected BRCA-mutated advanced ovarian cancer after a response to first-line platinum-based chemotherapy. In SOLO1, 3-year PFS was 60% versus 27% with placebo. The prespecified descriptive overall-survival analysis at seven years favored olaparib, but did not meet its prespecified threshold for statistical significance; this should not be described as a statistically proven overall-survival benefit.
• Niraparib (Zejula) — eligibility depends on the treatment setting and current local authorization. Under the U.S. label, first-line maintenance is for HRD-positive advanced epithelial ovarian, fallopian-tube or primary peritoneal cancer after a complete or partial response to first-line platinum chemotherapy; recurrent maintenance is restricted to germline BRCA-mutated disease after a complete or partial platinum response.
• Rucaparib (Rubraca) — under the U.S. label, recurrent maintenance is for BRCA-mutated (germline and/or somatic) epithelial ovarian, fallopian-tube or primary peritoneal cancer after a complete or partial response to platinum chemotherapy. This is not an unrestricted second-line indication. Indications and biomarker requirements differ between jurisdictions and treatment settings and can change; the treating team must check current local prescribing information.

PARP inhibitors are oral tablets — a major advance over chemotherapy infusions; principal side effects: fatigue, nausea, anaemia, myelosuppression, risk of myelodysplastic syndrome (rare, long-term).

Targeted Therapy

Bevacizumab: anti-VEGF antibody; given with chemotherapy and as maintenance; improves PFS in advanced and recurrent disease; side effects: hypertension, proteinuria, wound healing impairment, rare bowel perforation.

Mirvetuximab soravtansine (antibody-drug conjugate targeting folate receptor α): the U.S. indication is for adults with FRα-positive, platinum-resistant epithelial ovarian, fallopian tube or primary peritoneal cancer after one to three prior systemic treatment regimens, with selection based on an FDA-approved test. Eligibility elsewhere must be checked against the applicable local product label with the treating team.

Ovarian Cancer Care in China

China's gynaecological oncology centres offer:

• Ovarian cancer assessment: CA125, HE4, ROMA score, pelvic ultrasound, and CT staging; expert multidisciplinary team review
• Genetic and tumour testing: germline testing can identify inherited BRCA variants, while tumour testing assesses somatic variants and, when indicated, homologous recombination deficiency (HRD). HRD assessment is not itself a germline test. The treating team determines the appropriate tests and genetic-counselling needs.
• Primary cytoreductive surgery planning: confirm the treating centre’s specialist experience and procedural capabilities. Whether complete cytoreduction is feasible depends on the individual disease distribution and clinical assessment; this guide does not provide a verified comparison of centre-level R0 rates.
• PARP inhibitor planning: ask the treating hospital to confirm the specific medicine, its current local approval, biomarker and prior-treatment requirements, and supply. Listing a medicine or a locally developed PARP inhibitor in this guide does not guarantee access or make products interchangeable.
• Bevacizumab planning: the oncology team must confirm whether a specific product is appropriate, locally approved for the intended use and available at the treating hospital.
• Cost: care in China is generally less expensive than UK private treatment, but the hospital prices each case individually — ask us for the written quote before you commit.
• Language and coordination support: confirm the languages, interpretation, report translation and coordination included at each stage with the hospital and PriumCare before travel.

Contact a PriumCare care navigator to arrange an ovarian cancer assessment, second opinion, or treatment consultation.

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Medical content based on MSD Manuals and international ovarian cancer guidelines (ESGO, NCCN, NICE). Evidence reviewed 2025.

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Targeted editorial source check — 26 October 2026: Only the familial germline-testing passage and the positive-cytology requirement for FIGO stage IVA were checked against the original ASCO testing guideline, NCI BRCA information and NCI professional staging definition. This is not a whole-article medical review, adds no named clinical reviewer and retains the original publication date.

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Targeted editorial source check — 26 October 2026: Only the role of systematic lymph-node removal in the LION trial setting, the interpretation of the seven-year SOLO1 survival analysis, and the jurisdiction- and biomarker-dependent PARP maintenance and access wording were checked against NCI discussion of LION, the original SOLO1 report and U.S. prescribing information for niraparib, rucaparib and olaparib. U.S. labeling does not establish local approval or hospital supply elsewhere. This is not a whole-article medical review, adds no named clinical reviewer and retains the original publication date.

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Targeted editorial source check — 26 October 2026: The distinction between germline BRCA testing and tumour BRCA/HRD assessment was checked against NCI genetic-testing information and current U.S. niraparib labeling. Unverified comparisons of surgical outcomes and blanket medicine or English-language availability claims were replaced with hospital-specific confirmation. This is not a whole-article medical review, adds no named clinical reviewer and retains the original publication date.

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Targeted editorial source check — 26 October 2026: Only the preventive-surgery wording within the protective-factors paragraph was checked against the ACOG salpingectomy update, NICE familial ovarian cancer guidance, SGO/ASRM reproductive and hormonal guidance and NCI BRCA information. The choice and timing require individual counselling; this is not a whole-article medical review and retains the original publication date.

Scoped editorial source check — 26 October 2026: The bevacizumab scheduling statement above were checked against the sources below. This limited correction is not a whole-article medical review.

• https://www.avastin.com/patient/ovar/treatment/infusions.html

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Targeted editorial source check — 26 October 2026: Only the mirvetuximab indication was checked against U.S. ELAHERE labeling published by NLM. The prior-treatment and biomarker-testing restrictions are part of that U.S. indication; local authorization, individual suitability and availability require confirmation. This is not a whole-article medical review, does not verify other retained statistics or treatment statements and retains the original publication date.

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Targeted editorial source check — 26 October 2026: Only the first-line chemotherapy wording and weekly-schedule tolerability claim was checked against the primary reference. This is not a whole-article medical review, does not establish local hospital availability and retains the original publication date.

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Targeted editorial source check — 26 October 2026: Only the recurrence-treatment selection wording was checked against ESMO recurrent ovarian cancer guidance, its Express Update and NCI treatment information. The treatment-free interval informs assessment but does not by itself choose a regimen. The retained initial-response statistic was not reassessed. This is not a whole-article medical review and retains the original publication date.