4 Research recommendations

The Guideline Development Group has made the following recommendations for research, based on its review of evidence, to improve NICE guidance and patient care in the future.

4.1 Relationship between duration of symptoms of ovarian cancer and stage at diagnosis

Further research should be undertaken on the relationship between the duration and frequency of symptoms in women with ovarian cancer before diagnosis, the stage of disease at diagnosis and subsequent survival.

Why this is important

Most women presenting with ovarian cancer have advanced disease and have had symptoms for months. Greater awareness among both women and healthcare professionals might result in women presenting earlier with less advanced disease, leading to better outcomes. There is insufficient understanding of the factors that influence earlier diagnosis in women with ovarian cancer, especially the relationship between duration of symptoms and stage at diagnosis. Data demonstrating benefits from earlier presentation will justify investment in raising awareness among women and healthcare professionals. This is likely to be a population-based study that records both the duration and frequency of symptoms.

4.2 RMI I (risk of malignancy index I) threshold for women with suspected ovarian cancer

Further research should be undertaken to determine the optimum RMI I threshold that should be applied in secondary care to guide the management of women with suspected ovarian cancer.

Why this is important

Variation exists in the current evidence base with regard to the optimum RMI I threshold that should be applied in secondary care. The cut-off levels used will have implications for both the management options considered and the number of women who will be referred for specialist treatment. Therefore it is important to establish the relative sensitivities and specificities at the different levels. The research should be a prospective observational cohort study evaluating women referred with suspected ovarian cancer. Diagnostic accuracy, sensitivity, specificity and cost effectiveness should be examined at the different RMI I thresholds.

4.3 Imaging in the diagnostic pathway for women with ovarian cancer

Large multicentre case–control studies should be conducted to compare the accuracy of CT versus MRI for staging and for predicting optimal cytoreduction in women with ovarian cancer.

Why this is important

Currently most women with ovarian cancer will undergo a CT scan before surgery to assess the extent and resectability of disease. CT and MRI are complementary in their abilities to detect disease, but no adequate studies have been performed that compare their effectiveness in women with suspected ovarian cancer. No comparative studies have been undertaken evaluating surgical outcome. A prospective study in women undergoing primary surgery would be feasible.

4.4 The role of systematic retroperitoneal lymphadenectomy in the surgical treatment of ovarian cancer

A prospective randomised trial should be undertaken to evaluate the therapeutic effect, associated risks and cost effectiveness of systematic retroperitoneal lymphadenectomy in women with ovarian cancer whose disease appears to be confined to the ovaries.

Why this is important

Systematic retroperitoneal lymphadenectomy is an untested procedure but is likely to be more accurate than lymph node sampling, with a potential benefit for the woman of avoiding chemotherapy. However, increased risks are associated with it. Although there may be no overall survival advantage of this procedure, avoidance of chemotherapy and impact on quality of life may make it attractive to some women as a treatment option. In order to counsel women appropriately it is essential to understand fully the risks associated with this surgery as well as the benefits. Researchers should be encouraged to develop a prospective randomised trial with international collaboration to answer this question in a timely manner.

4.5 The value of primary surgery for women with advanced ovarian cancer

Research should be undertaken to determine the effectiveness of primary surgery for women with advanced ovarian cancer whose tumour cannot be fully excised.

Why this is important

Most women with advanced ovarian cancer undergo surgery at some point. Previous studies have shown that surgery after the completion of chemotherapy has no therapeutic value. Studies are being performed to investigate whether the timing of surgery during primary chemotherapy influences outcome. No studies have evaluated whether primary surgery itself has any therapeutic value when compared with chemotherapy alone. The potential advantages of surgery have to be offset against the morbidity, occasional mortality and undoubted costs associated with it. This would be a prospective randomised clinical trial recruiting women who have biopsy-proven advanced ovarian cancer and who are fit enough to receive surgery and chemotherapy. Women would be randomised to either chemotherapy and surgery (conventional arm) or chemotherapy alone (experimental arm). Primary outcome measures would be survival at 1 and 5 years.

  • National Institute for Health and Care Excellence (NICE)