Ovarian Cancer Diagnosis
Steps, tests and what the results mean
- Most ovarian masses are not cancer, and a referral to a gynecologic oncologist does not mean cancer has been confirmed.
- Ultrasound and the CA-125 test help assess a mass, but on their own they cannot confirm or rule out cancer.
- A mass with concerning features should be assessed by a gynecologic oncologist before surgery.
- Ovarian cancer is confirmed by examining a tissue sample.
- Regular ultrasound scans and blood tests are not recommended to screen for ovarian cancer in people at average risk who have no symptoms.
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Finding a mass or waiting for test results can be worrying. Most ovarian masses (growths on the ovary) are not cancer, and nothing definite can be said about what a mass is until the final results are ready.
What can I do while I wait for my test results?
- How long results take depends on the type of test and where it is done. Ask the lab or your doctor’s office roughly how long it will be.
- Feeling anxious during this time is understandable. Write down your questions and concerns so you can raise them when you talk to your doctor. (Suggested questions for your appointment)
- If you have sudden, severe abdominal or pelvic pain, or pain with fever or vomiting, see a doctor or go to the emergency room (A&E in the UK) right away to be checked, and do not wait for your test results.
A referral to a gynecologic oncologist does not mean cancer has been confirmed. It is part of a careful assessment of the mass.
Screening, diagnosis and staging of ovarian cancer: what is the difference?
1. Screening
Screening means checking people who have no symptoms in order to find a disease early. For the general population, there is no effective screening that reduces deaths from ovarian cancer.
2. Diagnosis
When there are symptoms or a mass, tests are done to find the cause of the symptoms or to work out what the mass is. Cancer is confirmed by examining a tissue sample in the pathology lab.
3. Staging
Once cancer is confirmed, staging shows how far the disease has spread, and it is the basis for choosing treatment. The exact stage is usually determined from the findings at surgery and the pathology results on the samples.
Why can ovarian cancer be diagnosed late?
In the early stages, there may be no clear symptoms. Early symptoms can be vague and look like common digestive or urinary problems, such as bloating, feeling full quickly, pelvic pain or pressure, and sometimes needing to urinate more often. Doctors pay most attention to symptoms that are new and persistent or that keep coming back.
Is yearly screening for ovarian cancer recommended?
For women with no symptoms who are at average risk, ultrasound and the CA-125 test are not recommended as routine screening. These methods have not been proven to reduce deaths, and they may lead to unnecessary tests or surgery.
In one large study of women aged 55 to 74, about 3% of the women in the screening group had surgery during the study because of an abnormal result, even though they did not have cancer.
For women at high risk, the plan for assessment and risk reduction is decided with their doctor. Ultrasound and CA-125 have not been proven to reduce deaths in this group either.
Diagnosing ovarian cancer, step by step
Symptoms or a mass: persistent or recurring symptoms such as bloating, pelvic pain and feeling full quickly, or a mass found during an exam or on ultrasound.
Pelvic exam, ultrasound and blood tests: a first assessment of what the mass might be.
Referral to a gynecologic oncologist: if the mass has concerning features. This referral does not mean cancer has been confirmed.
Tissue examination (pathology): the sample is usually taken during surgery and, in some situations, by a biopsy before treatment. Examining it shows what the mass is and, if there is cancer, what type it is.
Can an ultrasound detect ovarian cancer?
What does an ultrasound show?
It shows whether there is a mass, its size and shape, whether it is solid or cystic (fluid-filled), and whether there is fluid in the abdomen. A Doppler ultrasound also checks blood flow in the mass; abnormal blood flow can be a sign that more tests are needed.
What can an ultrasound not tell you?
On its own, it cannot confirm or rule out for certain whether a mass is cancer, but it helps estimate how likely the mass is to be cancer (malignant). Some small masses may also be missed. Cancer is confirmed by examining a tissue sample. Not every cyst or mass needs a biopsy or surgery.
Abdominal and transvaginal (internal) ultrasound can complement each other. A transvaginal scan usually gives a closer view of the ovaries. If ultrasound does not make clear what the mass is, an MRI may be needed. A CT scan is mainly used to check how far the disease has spread when cancer is suspected.
Not seeing the ovaries on ultrasound does not rule out disease
After menopause, the ovaries become smaller and harder to see. Not seeing an ovary on ultrasound is not, on its own, a sign of disease, but it does not rule out cancer or another condition either. Whether more tests are needed depends on your symptoms, your medical history and the other ultrasound findings.
How benign cysts differ from ovarian masses with concerning features
Usually benign (not cancer)
Functional cysts, which are linked to ovulation and may go away on their own; blood-filled (hemorrhagic) cysts; endometriomas (chocolate cysts); and dermoid cysts
Needs further assessment
These need further assessment: a solid mass or one with prominent solid parts, a large or growing mass, abnormal blood flow on a Doppler ultrasound, or fluid in the abdomen along with the mass.
Can a cyst turn into cancer?
Most cysts are benign and usually do not turn into cancer. Many functional cysts go away on their own within a few weeks to a few months. What matters is following up on a mass that has concerning features or that changes at a later check.
Understanding the tests for ovarian cancer
CA-125
CA-125 is a protein measured in the blood. Its level is raised in many epithelial ovarian cancers, and it is used together with ultrasound to assess a mass.
It is not specific to cancer: endometriosis, pelvic infection (pelvic inflammatory disease), fibroids and menstrual periods can also raise it. A high level on its own does not confirm cancer, and a normal level does not rule it out, especially in the early stages.
HE4 and ROMA
HE4 is a blood marker. The ROMA score (Risk of Ovarian Malignancy Algorithm) combines the HE4 result, the CA-125 result and menopause status to estimate the chance that an ovarian mass is cancer (malignant). For people who are already scheduled for surgery on a mass, this score can help decide whether to refer them to a gynecologic oncologist.
They are not screening tests, and on their own they cannot confirm or rule out cancer. ROMA has to be interpreted together with the doctor’s assessment and imaging, and on its own it is not the basis for deciding on surgery.
Germ cell tumor markers: AFP, beta-hCG and LDH
They are helpful in assessing some germ cell tumors, which are more common at younger ages.
They are not used routinely for the most common type of ovarian cancer, epithelial ovarian cancer.
What does a “hypoechoic mass” on an ultrasound report mean?
Hypoechoic means the area looks darker than the tissue around it on the ultrasound image. The term only describes how the mass looks on the image and does not, on its own, mean cancer. This feature can be seen in a blood-filled (hemorrhagic) cyst, an endometrioma or some solid masses. The final interpretation should take into account the whole report, the exam and the tests.
Why does a confirmed diagnosis of ovarian cancer need a tissue sample?
No imaging test or blood test can confirm cancer on its own. Examining a tissue sample under a microscope, which is called pathology, shows what type of mass it is and what it is made of. The sample is usually taken during surgery. If the disease is advanced and the plan is to start chemotherapy before surgery, the diagnosis has to be confirmed before treatment begins; a core needle biopsy (using a thicker needle) is usually the preferred method. The care team decides how and where the biopsy is taken, based on the patient’s situation.
If the pathology result does not match the symptoms or other findings, your doctor may suggest having the sample reviewed again. Ongoing problems after a benign result do not always mean the result was wrong. You have the right to raise your concerns and, if needed, to get a second opinion.
Why a gynecologic oncologist should assess a mass with concerning features
A referral to a gynecologic oncologist means the mass needs a closer look. It does not mean cancer has been confirmed. Many people who are referred turn out to have a benign mass.
Why is assessment before surgery important?
If a mass has concerning features, assessment by a gynecologic oncologist, and surgery by one if needed, can improve the accuracy of the assessment and the quality of staging. The first surgery is usually part of diagnosis, staging and ovarian cancer treatment all at once.
Does a Pap smear show ovarian cancer?
The ovaries, the uterus (womb) and the cervix are three different parts of the body
A Pap test (Pap smear; in the UK, a smear test) checks only the cells of the cervix for precancerous and cancerous changes. It gives no information about the ovaries and cannot rule out or confirm ovarian cancer.
Stages of ovarian cancer
Staging shows how far the disease has spread, and it is the basis for choosing treatment.
In simple terms, in stage I the cancer is limited to the ovary or fallopian tube; in stage II it has reached other tissues or organs in the pelvis; in stage III it has spread to the lining of the abdomen (peritoneum) outside the pelvis or to the lymph nodes at the back of the abdomen (retroperitoneal lymph nodes); and in stage IV it has reached distant areas, such as the lungs or the inside of the liver.
The exact stage is usually determined from the findings at surgery and the pathology results on the samples.
This image is a general overview of staging
The details of the stage and substage are set based on the results of surgery and pathology and each person’s complete medical records.
Does fluid in the abdomen (ascites) mean the end of the road?
No. Ascites means a buildup of fluid in the abdomen. On its own, it does not mean the last stage of cancer or that treatment options have run out, and it needs to be assessed by a specialist. Treatment decisions are based on each person’s complete medical records.
Can young or single women get ovarian cancer?
Family history, BRCA mutations and Lynch syndrome
If you have a family history of ovarian or breast cancer, or a harmful inherited variant (mutation) in the BRCA1 or BRCA2 gene or Lynch syndrome has been found in your family, genetic counseling can help assess your personal risk and choose ways to lower it.
I'm single or a virgin. Could I get ovarian cancer?
Yes. Being single or never having had sex does not protect you from ovarian cancer.
The disease can occur at different ages, although it becomes more common with age. Having no family history does not rule out the possibility either.
For family and friends: coping with stress and supporting your loved one
While you are waiting, listening without judging, writing down questions and going with her to appointments, if she wants you to, can all help. Looking after your own mental health matters too. Feeling worn out as a caregiver is understandable and is not a sign of weakness. Ask others for help so you can rest and share the responsibilities.
Questions to ask at your appointment:
- Does this mass look benign, or does it need more tests? What is the next step?
- What exactly do the CA-125 and ultrasound results mean?
- Do I need to see a gynecologic oncologist?
- What is needed for a final diagnosis, and when will the results be ready?
Frequently asked questions about ovarian cancer diagnosis
My abdominal ultrasound showed nothing. Is a transvaginal ultrasound better?
A transvaginal ultrasound usually shows the ovaries in more detail and can complement an abdominal ultrasound. If your symptoms continue or the ovaries were not seen clearly on the abdominal scan, your doctor will decide whether you need a transvaginal ultrasound or other tests. Not everyone needs a CT scan or an MRI.
My CA-125 is high. Does that mean I have cancer?
Not necessarily. Endometriosis, pelvic infection (pelvic inflammatory disease), fibroids and menstrual periods can also raise CA-125. The result has to be interpreted together with ultrasound and an exam.
My ultrasound report says “hypoechoic mass.” Does that mean cancer?
No. The term only describes how the mass looks on the image, and it can be seen in a blood-filled (hemorrhagic) cyst, an endometrioma or some solid masses.
Does a Pap smear show ovarian cancer?
No. A Pap test checks only the cells of the cervix and does not rule out or confirm ovarian cancer.
I'm single or a virgin. Can I still get ovarian cancer?
Yes. This disease has nothing to do with marriage or sex. Family history and genetic factors matter more.
Does fluid in the abdomen mean the disease is in its final stage?
No. Ascites on its own does not determine the stage of the disease and has to be assessed together with imaging, an exam and other results.
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