A national clinical audit and the approval of niraparib are two important, recent developments for ovarian cancer.

Government funding for a national ovarian cancer audit (in England) was announced last year. Clinical audits are already performed for other cancers. They are designed to map care pathways, surgery and survival, and address regional variation – information that can be used to drive improvements in clinical practice.  Dr Tate says, “This has come about as a result of a significant piece of work Target Ovarian Cancer has led on and done in collaboration with some other charities and national bodies – which was to carry out a pilot audit.” The aim of the pilot was to provide an evidence base – to find out more about ovarian cancer and the diverse approaches to management and outcomes across England.  The results demonstrated the need for such an audit. “We are really pleased to say that, as a result of the investment in that work we have been able to [provide] evidence that an audit is necessary and now we have secured this government funding for it“, she says.

Niraparib

Another important development was the recent (February 2022) approval of niraparib (Zejula) for recurrent ovarian cancer. Dr Tate explains, “Niraparib is the first ovarian cancer treatment to move from the Cancer Drugs Fund into routine commissioning   so really what this means for us and our community and those healthcare   professionals that are treating women with ovarian cancer is that the future of niraparib as a treatment for recurrent ovarian cancer is now certain.”

Niraparib is a poly-ADP ribose polymerase (PARP) inhibitor – one of a new generation of cancer treatments that is used for maintenance treatment. “What that means is the patient receives this drug once their chemotherapy has completed and the idea is that that drug will prolong the time [to] cancer occurrence and therefore the time between chemotherapy treatments for recurrence, which gives the potential for ….  better quality of life because people can move on with their lives”, says Dr Tate. From a treatment perspective, it probably also increases the number of times that chemotherapy can be used to treat the same patient, she adds.

Call to action

Frontline healthcare practitioners (GPs, nurses and pharmacists) should make sure that their knowledge is absolutely up-to-date. As part of this “they should ensure that they’re not carrying with them any outdated teachings that they may have received during their training”, emphasises Dr Tate.  TOC has a dedicated page for GPs that has links to online e-learning modules, fact sheets and short booklets – all of which are designed to support GPs and primary care professionals to ensure that they are well-informed about current best practice. “We know ovarian cancer diagnosis is never straightforward – it’s extremely challenging – but the first step in supporting an early diagnosis is to get that baseline knowledge”, says Dr Tate. Another useful step could be to perform an audit of a previous case of ovarian cancer in the practice and reviewing the learning points that emerged. Looking at a case from both the practice and the patient perspectives can provide useful learning, Dr Tate suggests.

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Target Ovarian Cancer works hard to stamp out the myth of ‘the silent killer’, says Dr Tate. In fact, research shows that the majority of women experienced symptoms in the months prior to diagnosis. Moreover, “for many years it was taught that only women with advanced stage disease experience symptoms or present with   symptoms and therefore there was nothing that we could do. That’s not the case – women with all stages of ovarian cancer are presenting the symptoms”, she explains. This means that there are opportunities to identify the disease in its early stages.  Part of the problem is that many people are unaware that the symptoms (see the first video in this series) can be associated with something like cancer and so they do not discuss them with their GPs. “From the GP or health care professional perspective the symptoms can be very subtle in presentation. They may also – because of the age group we’re thinking about – present with other comorbidities and so it’s really easy to attribute those to a benign condition like irritable bowel syndrome – it’s a very common misdiagnosis. So, what I would say …. is, please remember that irritable bowel syndrome (IBS) is extremely uncommon as a new diagnosis in women over the age of 50. So, if you are thinking IBS, then please just consider ovarian cancer. Do a CA-125 test, do an ultrasound, get it ruled out before you proceed any further”, says Dr Tate.

CA-125 test

A CA-125 test is a blood test that should be available to all GPs practising in the UK. “It measures the level of CA-125 [protein] in the blood and guidelines tell us that the normal level is 35 [units per millilitre (u/ml)] or below, so anything above 35 we would be maybe starting to think about ovarian cancer, particularly in women over the age of 50”, says Dr Tate.  CA-125 can be raised in other conditions such as   endometriosis, menstruation, ovarian cysts, some inflammatory conditions and other cancers “but at the moment it’s the best tool we have in primary care to start us on the right pathway of diagnosing ovarian cancer”, she adds.

Late diagnosis

Two thirds of UK women with ovarian cancer are diagnosed at an advanced stage when the cancer has already spread beyond the ovary. Dr Tate pinpoints low awareness of symptoms and the fact that NHS systems are not always in place to support GPs as the two main factors that contribute to delayed diagnosis.

“We have a huge problem with awareness of symptoms among the general public, we also have an issue with awareness amongst GPs and therefore them recognising symptomatic patients when they present. Also, the NHS systems are not always in place to support GPs to get that early diagnosis for patients. Target Ovarian Cancer is working across all of these issues. We’re currently calling for a dedicated   symptoms awareness campaign across the UK so that we can finally make some   progress on public awareness”, says Dr Tate.

Target Ovarian Cancer offers a comprehensive range of training and education materials for GPs including e-learning modules with BMJ Learning and the RCGP. There is also a project, currently underway, that is seeking to overcome some of the delays or to address some of the systematic barriers that may be causing delays in   diagnosis.

Self-help and screening

Unlike some other cancers there are no easily-modifiable lifestyle factors for ovarian cancer.  The main risk factors are increasing age and a genetic predisposition. Dr Tate says, “Knowledge is power, so know your own body, know what is normal for you, know the symptoms of ovarian cancer and be aware when they start. If you do get something that you’re concerned about then take that knowledge to your GP as soon as possible and report them. And if you are worried about ovarian cancer then I would advise people to absolutely ask about it. Don’t assume that your GP is going to necessarily think about that initially. I would ask about it if you are worried.”

Screening for ovarian cancer has so far proved to be unsuccessful in reducing mortality.  Dr Tate says, “We would love to have a screening program in our arsenal! No screening program is perfect, it’s part of the approach to addressing early   diagnosis. There have been some major clinical trials undertaken, both in the UK and beyond, to look at screening tools and interventions to see if they have an   impact on diagnosis and the most important outcome, which is mortality”. In some cases, some cancers were diagnosed at an earlier stage, she acknowledges. New research into biomarkers and diagnostic tests might lead to the development of effective screening programmes in future, but “at the moment that isn’t something on   our horizon”, she concludes.

Read and watch the full series on our website or on YouTube.

More than 7000 women, mainly over the age of 50 years, are diagnosed with ovarian cancer every year in the UK. “However, approximately 20 per cent of cases are diagnosed in women under that age and this is often associated with a family history or a known genetic mutation in one of the BRCA1 or BRCA2 genes”, says Dr Tate.  Age is the biggest risk factor for ovarian cancer, followed by family history.

“Unfortunately, at the moment the majority of women are diagnosed with advanced disease – disease that has spread outside of the ovary. But what we do know is that when the disease is diagnosed at the earliest stage, nine in ten women will survive”, she explains. Currently, two-thirds of women are diagnosed late when the cancer is harder to treat and this has a devastating impact upon the long-term outcomes for women. Every day 11 women die from ovarian cancer in the UK.

One of the big challenges at present is an “awareness crisis” about ovarian cancer.  Recent work by TOC showed that four out of five UK women do not know that bloating is a key symptom of ovarian cancer. “We also know …. that, sadly, GP training is woefully inadequate. Knowing the symptoms is the best weapon that we all have against this disease – there is no screening so it’s up to the individual and their GP”, says Dr Tate.

Ovarian cancer symptoms

“The most commonly-reported symptoms are persistent bloating, abdominal pain, feeling full or [having] difficulty eating and needing to wee more urgently or often”, she says. Women can experience marked abdominal distension (bloating) and may even need to buy new clothes to accommodate the increase in size. Early satiety typically appears as, “women who maybe sit down to a meal that they would   normally be able to eat quite easily – suddenly they’re in a situation where they’re taking a couple of mouthfuls or getting through half a meal and they just physically cannot manage anymore”, she says. Another symptom is changes in bowel habit, such as new-onset diarrhoea or constipation. The important point here is that such symptoms are new and are not normal for the individual, emphasises Dr Tate. There may also be the sort of symptoms that are common to many cancers such as extreme fatigue and unexplained weight loss.

Late diagnosis

A number of factors contribute to late diagnosis of ovarian cancer. There is a lack of awareness of symptoms amongst the general public and GPs. In addition, NHS systems are not always in place to support GPs in making early diagnoses for this condition. TOC is working to address all of these issues. “We’re currently calling for a dedicated symptoms awareness campaign across the UK so that we can finally make some progress on public awareness”, says Dr Tate. “As an organization we offer a comprehensive range of training and education materials for GPs including e-learning modules with BMJ Learning and the RCGP, that you can find on our website and we also have a project … that is seeking to overcome some of the delays [and] to address some of those systematic barriers that may be causing delays in diagnosis “, she adds.

Read and watch the full series on our website or on YouTube.