Ovarian cancer: recognition and initial management

  • Clinical guideline
  • CG122
  • Published: 
  • Last updated: 
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Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Healthcare professionals should follow our general guidelines for people delivering care:

1.1 Detection in primary care

For recommendations on detecting ovarian cancer in primary care, see the section on ovarian cancer in NICE's guideline on suspected cancer: recognition and referral.

1.2 Establishing the diagnosis in secondary care

1.2.1 Tumour markers: which to use?

1.2.1.1

Measure serum CA125 in secondary care in all women with suspected ovarian cancer, if this has not already been done in primary care.

1.2.1.2

In women under 40 with suspected ovarian cancer, measure levels of alpha fetoprotein (AFP) and beta human chorionic gonadotrophin (beta-hCG) as well as serum CA125, to identify women who may not have epithelial ovarian cancer.

1.2.2 Malignancy indices

1.2.2.1

Calculate a risk of malignancy index I (RMI I) score (after carrying out an ultrasound; see recommendation 1.2.3.1 in the section on imaging in the diagnostic pathway: which procedures?) and refer all women with an RMI I score of 250 or greater to a specialist multidisciplinary team.

See the appendix for details of how to calculate an RMI I score.

1.2.3 Imaging in the diagnostic pathway: which procedures?

1.2.3.1

Carry out an ultrasound of the abdomen and pelvis as the first imaging test in secondary care for women with suspected ovarian cancer, if this has not already been done in primary care.

1.2.3.2

If the ultrasound, serum CA125 and clinical status suggest ovarian cancer, carry out a CT scan of the pelvis and abdomen to establish the extent of the cancer. Include the thorax if clinically indicated.

1.2.3.3

Do not use MRI routinely for assessing women with suspected ovarian cancer.

1.2.4 Tissue diagnosis

Need for tissue diagnosis
1.2.4.1

If offering cytotoxic chemotherapy to women with suspected advanced ovarian cancer, first obtain a confirmed tissue diagnosis by histology (or by cytology if histology is not appropriate) in all but exceptional cases.

1.2.4.2

Offer cytotoxic chemotherapy for suspected advanced ovarian cancer without a tissue diagnosis (histology or cytology) only:

  • in exceptional cases, after discussion with the multidisciplinary team, and

  • after discussing with the woman the possible benefits and risks of starting chemotherapy without a tissue diagnosis.

Methods of tissue diagnosis other than laparotomy
1.2.4.3

If surgery has not been carried out, use histology rather than cytology to obtain a tissue diagnosis. To obtain tissue for histology:

  • use percutaneous image-guided biopsy if this is feasible

  • consider laparoscopic biopsy if percutaneous image-guided biopsy is not feasible or has not produced an adequate sample.

    Use cytology if histology is not appropriate.

1.3 Information and support for women with newly diagnosed ovarian cancer

1.3.1.1

Offer women with newly diagnosed ovarian cancer information about their condition, including psychosocial and psychosexual issues, that:

  • is available at the time they want it

  • includes the amount of detail that they want and are able to deal with

  • is in a suitable format, including written information.

1.3.1.2

Ensure that information is available about:

  • the stage, treatment options and prognosis

  • how to manage the side effects of both the condition and its treatments to maximise wellbeing

  • sexuality and sexual activity

  • fertility and hormone treatment

  • symptoms and signs of cancer recurrence

  • genetics, including the chances of family members developing ovarian cancer (see NICE's guideline on ovarian cancer: identifying and managing familial and genetic risk)

  • self-help strategies to optimise independence and coping

  • where to go for support, including support groups

  • how to deal with emotions such as sadness, depression, anxiety and a feeling of a lack of control over the outcome of the cancer and treatment.

1.4 Managing suspected early (stage 1) ovarian cancer

1.4.1 The role of systematic retroperitoneal lymphadenectomy

1.4.1.1

Carry out retroperitoneal lymph node assessment as part of optimal surgical staging in women with suspected ovarian cancer whose cancer appears to be confined to the ovaries (that is, who appear to have stage 1 ovarian cancer).

Lymph node assessment involves sampling of retroperitoneal lymphatic tissue from the para-aortic area and pelvic side walls if there is a palpable abnormality, or random sampling if there is no palpable abnormality.

Optimal surgical staging constitutes:

  • midline laparotomy to allow thorough assessment of the abdomen and pelvis

  • a total abdominal hysterectomy, bilateral salpingo-oophorectomy and infracolic omentectomy

  • biopsies of any peritoneal deposits

  • random biopsies of the pelvic and abdominal peritoneum

  • retroperitoneal lymph node assessment.

1.4.1.2

Do not include systematic retroperitoneal lymphadenectomy (block dissection of lymph nodes from the pelvic side walls to the level of the renal veins) as part of standard surgical treatment in women with suspected ovarian cancer whose cancer appears to be confined to the ovaries (that is, who appear to have stage 1 ovarian cancer).

1.4.2 Adjuvant systemic chemotherapy for stage 1 ovarian cancer

1.4.2.1

Do not offer adjuvant chemotherapy to women who have had optimal surgical staging and have low-risk stage 1 ovarian cancer (grade 1 or 2, stage 1a or 1b).

1.4.2.2

Offer women with high-risk stage 1 ovarian cancer (grade 3 or stage 1c) adjuvant chemotherapy consisting of 6 cycles of carboplatin.

1.4.2.3

Discuss the possible benefits and side effects of adjuvant chemotherapy with women who have had suboptimal surgical staging and appear to have stage 1 ovarian cancer (see recommendation 1.4.1.1).

1.5 Managing advanced (stage 2 to 4) ovarian cancer

1.5.1 Primary surgery

1.5.1.1

If carrying out surgery for ovarian cancer, whether before chemotherapy or after neoadjuvant chemotherapy, the objective should be complete resection of all macroscopic disease.

1.5.2 Intraperitoneal chemotherapy

1.5.3 First-line systemic anticancer therapy

1.5.3.2

Bevacizumab with paclitaxel and carboplatin is not recommended for the first-line treatment of advanced ovarian cancer. For full details, see NICE's technology appraisal guidance on bevacizumab (TA284, 2013). However, NHS England recommends bevacizumab with paclitaxel and carboplatin as an option for first-line induction treatment for advanced (stage 3 and 4) ovarian cancer at a dose of 7.5 mg/kg or 15 mg/kg. For more information, see the NHS England Cancer Drugs Fund list.

In April 2025, a dose of 7.5 mg/kg was an off-label use of bevacizumab. See NICE's information on prescribing medicines.

1.5.4 Systemic anticancer therapy for maintenance treatment

1.5.4.1

Rucaparib for maintenance treatment is recommended as an option for BRCA mutation-negative, homologous recombination deficiency positive, advanced (stage 3 and 4), high-grade epithelial ovarian cancer after complete or partial response to first-line platinum-based chemotherapy. For full details, see NICE's technology appraisal guidance on rucaparib (TA1055, 2025).

1.5.4.2

Rucaparib for maintenance treatment is recommended as an option for BRCA mutation-negative, advanced (stage 3 and 4), high-grade epithelial ovarian cancer, when homologous recombination deficiency status is negative or unknown and bevacizumab is not a treatment option, after complete or partial response to first-line platinum-based chemotherapy. For full details, see NICE's technology appraisal guidance on rucaparib (TA1055, 2025).

1.5.4.4

Olaparib with bevacizumab for maintenance treatment is recommended as an option for homologous recombination deficiency positive, advanced (stage 3 and 4), high-grade epithelial ovarian cancer after complete or partial response to first-line platinum-based chemotherapy with bevacizumab. For full details, see NICE's technology appraisal guidance on olaparib with bevacizumab (TA946, 2024).

1.5.4.5

Niraparib for maintenance treatment is recommended as an option within the Cancer Drugs Fund for advanced (stage 3 and 4) high-grade epithelial ovarian cancer after response to first-line platinum-based chemotherapy. It is only recommended if the conditions in the managed access agreement are followed. For full details, see NICE's technology appraisal guidance on niraparib (TA673, 2021).

1.6 Systemic anticancer therapy for recurrent or relapsed ovarian cancer

1.6.1 Systemic anticancer therapy options

1.6.2 Systemic anticancer therapy for maintenance treatment

1.6.2.3

Niraparib for maintenance treatment is recommended as an option for treating relapsed, platinum-sensitive, high-grade serous epithelial ovarian cancer in adults when it has responded to the most recent course of platinum-based chemotherapy if:

1.6.3 Neurotrophic tyrosine receptor kinase (NTRK) fusion-positive solid tumours