Healthcare use and clinical investigations before a diagnosis of ovarian cancer: a register-based study in Denmark.

BACKGROUND: Ovarian cancer (OC) is associated with a poor prognosis, which calls for earlier diagnosis. This study aimed to analyse the health care use in primary care and at hospitals among women with OC compared to non-cancerous women to identify a window of opportunity for earlier diagnosis. METHODS: This nationwide register-based observational cohort study included all Danish women aged ≥ 40 years who were diagnosed with a first-time OC or borderline ovarian tumour in 2012-2018 and with no previous cancer diagnosis (n = 4,255). For each case, ten non-cancerous women were identified (n = 42,550). We estimated monthly incidence rate ratios using a negative binomial regression model to assess the use of health care services. We calculated risk ratios of having multiple contacts to general practice before a diagnosis using a binary regression model. RESULTS: Cases had statistically significantly higher contact rates to general practice from five months prior to the diagnosis compared to references. From six to eight months prior to diagnosis, an increased use of transvaginal ultrasound and gynaecologist was seen for cases compared to references. CONCLUSIONS: Increased healthcare use was seen relatively closely to the time of diagnosis for women with OC. This indicates a narrow window of opportunity for a timelier diagnosis. Still, the use of specialised assessment increased at six to eight months before the diagnosis. When women present unspecific symptoms, awareness of potential ovarian malignancies and safety-netting by the general practitioner may be pivotal. TRIAL REGISTRATION: Not relevant.

Characteristics of ovarian cancer patients with first presentation in general practice.

INTRODUCTION: Women with ovarian cancer (OC) have a poor prognosis. An improved prognosis was observed when the pathway to diagnosis begins in general practice. We aimed to investigate patient characteristics among women diagnosed with OC whose diagnostic pathway begins in general practice. METHODS: This was a population-based retrospective cohort study among Danish patients with a first-time OC diagnosis, using questionnaire data and national registers. RESULTS: The GP was involved in the diagnosis in 91.1% of the 313 included women with OC. Women aged 60-74 years had statistically significantly higher odds of having GP involvement than women younger than 60 years (odds ratio (OR) = 2.97 (95% confidence interval (CI): 1.09-8.08)). Women with high comorbidity had statistically significantly lower odds of having GP involvement than women with no comorbidity (OR = 0.25 (95% CI: 0.09-0.66). CONCLUSIONS: This study found higher odds of GP involvement in the diagnosis of OC in women aged 60-74 years and lower odds of GP involvement in women with high comorbidity. The remaining patient characteristics had no significant influence on the first place of presentation for OC patients. Knowledge hereof may potentially inform future initiatives as health campaigns or postgraduate GP training thereby increasing the awareness among women and GPs alike of OC symptoms. However, the study was restricted to a limited number of patients, and future research is warranted to underpin our findings. FUNDING: none. TRIAL REGISTRATION: not relevant.

Variation in the initial assessment and investigation for ovarian cancer in symptomatic women: a systematic review of international guidelines.

BACKGROUND: Women with ovarian cancer can present with a variety of symptoms and signs, and an increasing range of tests are available for their investigation. A number of international guidelines provide advice for the initial assessment of possible ovarian cancer in symptomatic women. We systematically identified and reviewed the consistency and quality of these documents. METHODS: MEDLINE, Embase, guideline-specific databases and professional organisation websites were searched in March 2018 for relevant clinical guidelines, consensus statements and clinical pathways, produced by professional or governmental bodies. Two reviewers independently extracted data and appraised documents using the Appraisal for Guidelines and Research Evaluation 2 (AGREEII) tool. RESULTS: Eighteen documents from 11 countries in six languages met selection criteria. Methodological quality varied with two guidance documents achieving an AGREEII score ≥ 50% in all six domains and 10 documents scoring ≥50% for "Rigour of development" (range: 7-96%). All guidance documents provided advice on possible symptoms of ovarian cancer, although the number of symptoms included in documents ranged from four to 14 with only one symptom (bloating/abdominal distension/increased abdominal size) appearing in all documents. Fourteen documents provided advice on physical examinations but varied in both the examinations they recommended and the physical signs they included. Fifteen documents provided recommendations on initial investigations. Transabdominal/transvaginal ultrasound and the serum biomarker CA125 were the most widely advocated initial tests. Five distinct testing strategies were identified based on the number of tests and the order of testing advocated: 'single test', 'dual testing', 'sequential testing', 'multiple testing options' and 'no testing'. CONCLUSIONS: Recommendations on the initial assessment and investigation for ovarian cancer in symptomatic women vary considerably between international guidance documents. This variation could contribute to differences in the way symptomatic women are assessed and investigated between countries. Greater research is needed to evaluate the assessment and testing approaches advocated by different guidelines and their impact on ovarian cancer detection.