Ovarian Cancer: Why We Don’t Screen Everyone and Who We Watch Closely
By Dr. Avinash Deo, Medical Oncologist
September 12, 2025
The Difficult Conversation in Your Clinic
A 45-year-old woman, prompted by a health article she read online, asks you to order a CA-125 blood test and a pelvic ultrasound “just to be safe.” It’s a reasonable request from a concerned patient. Ovarian cancer is often dubbed the “silent killer,” and the desire for an effective screening test is immense.
However, unlike mammography for breast cancer, we currently lack an accurate screening tool for ovarian cancer in the general population. A poorly chosen test can cause more harm than good, leading to a cascade of anxiety, invasive procedures, and complications for a minimal chance of benefit.
Our role as physicians is to move away from indiscriminate testing and towards a strategy of precise risk stratification and education. Here is a framework to guide these crucial patient conversations.
Category 1: The Average-Risk Woman (The Vast Majority)
Who She Is:
- Any woman in the general population without the major genetic or family history risk factors outlined below.
Your Management Plan: Symptom Awareness, Not Screening
- No Routine Screening Recommended: This is the single most important takeaway. Routine screening with transvaginal ultrasound and/or CA-125 in average-risk women is not recommended by any major medical organization. The high rate of false positives leads to unnecessary surgeries and does not improve overall survival.
- Empower with Knowledge: The best tool we have for this group is education. Encourage awareness of the subtle but persistent symptoms that can signal ovarian cancer:
- Persistent bloating (not bloating that comes and goes).
- Nagging pelvic or abdominal pain.
- Difficulty eating or feeling full quickly.
- Urinary symptoms (urgency or frequency).
Clinical Pearl: The key word is persistent. A woman who has new-onset, near-daily bloating for more than a few weeks warrants a clinical evaluation, starting with a physical exam and a pelvic ultrasound. This is a diagnostic workup, not screening.
Category 2: The Woman with Increased / Moderate Risk
Who She Is:
- A woman with a strong family history of ovarian, breast, colon, or endometrial cancer that does not fit the high-risk hereditary patterns described next.
Your Management Plan: Individualised Counseling
- No Consensus on Screening: There is currently no clear evidence to support routine screening in this group either. Management must be highly individualised.
- Focus on Risk Reduction: This is your most impactful intervention.
- Discuss Oral Contraceptives: Use of combination oral contraceptives for five or more years can reduce the risk of ovarian cancer by up to 50%. This is a guideline-supported recommendation, with evidence stemming from large-scale observational studies and meta-analyses. Organizations like the American College of Obstetricians and Gynecologists (ACOG) and the National Comprehensive Cancer Network (NCCN) recognize this benefit. The primary proposed mechanism is the suppression of incessant ovulation, which is thought to reduce the cumulative trauma and subsequent inflammatory repair cycles on the ovarian surface that can contribute to malignant transformation.
- Discuss Prophylactic Surgery: For women in this category who have completed childbearing, a discussion about risk-reducing salpingo-oophorectomy is reasonable, weighing the risks and benefits.
Category 3: The High-Risk Woman (Hereditary Risk)
This is a small but critically important group. Your identification of these women can be life-saving.
Who She Is:
- Has a known BRCA1 or BRCA2 gene mutation.
- Has a known mutation associated with Lynch Syndrome (e.g., MLH1, MSH2, MSH6, PMS2), which increases risk for colon, endometrial, and ovarian cancers.
- Has a very strong family history highly suggestive of one of these syndromes.
Your Management Plan: A Triad of Action
- Genetic Counseling: This is non-negotiable. Any patient you suspect falls into this category should be referred for formal genetic counseling and potential testing.
- Enhanced Screening (with a Major Caveat): Starting between ages 30-35, surveillance with a transvaginal ultrasound and a CA-125 blood test every 6 months may be considered.
- Crucial Counseling Point: You must be clear with the patient that the effectiveness of this screening in saving lives is unproven. It is a surveillance strategy to potentially detect cancer earlier, not a proven mortality-reducing tool.
- Discuss Definitive Risk-Reducing Surgery: This is the most effective intervention.
- Prophylactic Bilateral Salpingo-Oophorectomy (BSO): The removal of both ovaries and fallopian tubes is strongly recommended for these women. This single procedure dramatically reduces their risk.
- Timing: This is typically recommended between the ages of 35 and 45, and always after childbearing is complete.
At-a-Glance Summary
| Risk Category | Key Definition | Key Management Strategy |
| Average Risk | General population | No screening. Educate on persistent symptoms. |
| Increased Risk | Strong family history | No consensus on screening. Discuss oral contraceptives and risk-reducing surgery. |
| High Risk | BRCA, Lynch Syndrome | Refer for genetic counseling. Discuss unproven screening (ultrasound/CA-125). Strongly recommend risk-reducing BSO. |
The Bottom Line
The management of ovarian cancer risk is a paradigm of modern, personalised medicine. For the vast majority of women, our best strategy is to discourage ineffective screening and instead promote symptom awareness. For the small, identifiable group of high-risk women, our most powerful tool isn’t a blood test or a scan—it’s the discussion about prophylactic surgery. Your role in distinguishing between these groups is absolutely vital.