COMMENTARY

Routine Ovarian Cancer Screening: Resist the Temptation -- For Now

Andrew M. Kaunitz, MD

Disclosures

January 12, 2016

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Ovarian cancer continues to be the most lethal gynecologic malignancy. Currently, screening for this disease in average-risk women is not recommended owing to a high rate of false-positive test results that lead to unnecessary surgery.[1]

In an April 2009 commentary, I summarized initial findings from a British trial[2] of ovarian cancer screening in more than 200,000 postmenopausal women. Six years later, these UK investigators have reported their preliminary findings with respect to impact on mortality.[3]

Participants were randomized to no screening, annual transvaginal ultrasound screening, or annual multimodal screening using the investigators' proprietary Risk of Ovarian Cancer Algorithm (ROCA), which takes into account changes over time in serum CA125 levels. Women in the multimodal-screening group assessed to be at normal risk by ROCA were advised to undergo repeat CA125 assessment in 1 year. Women assessed as being at intermediate risk repeated CA125 levels in 3 months, and those determined by ROCA to be at high risk underwent ultrasound in addition to CA125 assessment.

With a median follow-up of 11 years, ovarian cancer (including fallopian tube malignancies) was diagnosed in almost 1300 participants. During the entire study, multimodal screening reduced mortality by 20%. Ultrasound screening alone was less effective in reducing mortality. For each ovarian cancer detected in the multimodal group, an additional two women underwent surgery for what proved to be false-positive screening results. Far more false positives resulted from the primary use of ultrasound for screening.

On the basis of these preliminary findings, some clinicians and women will be tempted to initiate ovarian cancer screening. However, this British trial is being conducted according to a strict protocol, with ultrasound being performed only when specified by the ROCA algorithm. In addition, imaging is performed and interpreted by highly experienced individuals.

In areas where ultrasound is highly accessible, I am concerned that gynecologic imaging will be used as a primary screening tool and that the quality of imaging and its interpretation will be highly variable, resulting in unnecessary surgeries. Accordingly, before implementing population-based screening for ovarian cancer, we should await guidance from professional organizations. Although the road forward continues to be challenging, this trial's findings bring us one step closer to routine screening for ovarian cancer.

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