Cancer Care Ontario: Follow-up of patients who are clinically disease-free after primary treatment for fallopian tube, primary peritoneal, and epithelial ovarian cancer

National Guideline Clearinghouse | Follow-up of patients who are clinically disease-free after primary treatment for fallopian tube, primary peritoneal, and epithelial ovarian cancer

Guideline Title

Follow-up of patients who are clinically disease-free after primary treatment for fallopian tube, primary peritoneal, and epithelial ovarian cancer.

Bibliographic Source(s)

Le T, Kennedy EB, Dodge J, Elit L, Ovarian Follow-up Guideline Expert Panel. Follow-up of patients who are clinically disease-free after primary treatment for fallopian tube, primary peritoneal, and epithelial ovarian cancer. Toronto (ON): Cancer Care Ontario (CCO); 2015 Nov 11. 34 p. (Program in Evidence-based Care Guideline; no. 4-22).  [27 references]

Guideline Status

This is the current release of the guideline.
The Program in Evidence-based Care guideline, initially the full original Guideline, over time will expand to contain new information emerging from their reviewing and updating activities.
Please visit the Cancer Care Ontario (CCO) Web site  for details on any new evidence that has emerged and implications to the guidelines.

This guideline meets NGC's 2013 (revised) inclusion criteria.

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Scope Methodology Recommendations Evidence Supporting the Recommendations Benefits/Harms of Implementing the Guideline Recommendations     Note: Disease-free status is determined according to the standard procedure at the unit where treatment was provided and may include negative clinical examinations, negative imaging investigations, and/or negative tumour marker results. Interventions and Practices Considered Discussion of post-treatment follow-up options Patient choice of cancer antigen-125 (CA-125) monitoring Patient education on the limitations and harms of CA-125 measurement Follow-up consultations Timing based on patient risk factors and individual characteristics/need Format to update patient history, assess psychosocial/supportive care needs, undertake physical examination/pelvic examination and symptom assessment Imaging only if clinical or CA-125 evidence of recurrence Models of follow-up care Gynecologic oncologist or a medical oncologist Communication with primary care physician Major Outcomes Considered Anxiety level associated with the time period before and after follow-up visits Overall survival rate Median survival time Quality of life Utility of follow-up methods  Cost Analysis A formal cost analysis was not performed and published cost analyses were not reviewed. Recommendations Major Recommendations Note from the National Guideline Clearinghouse (NGC): The authors of this guideline endorsed recommendations from the Cancer Australia guidance document entitled Follow-up of Women with Epithelial Ovarian Cancer: A Systematic Review. The Working Group members identified key recommendations from that document, which are reproduced verbatim. Recommendations for Follow-up Post-treatment While the optimal method of follow-up is not yet established, possible options for follow-up and the implications and possible consequences of these options should be discussed with the woman at the completion of primary treatment. Consideration should be given as to how anxiety might be lessened, such as scheduling tests before the visit so that test results are available for discussion at the time of the follow-up visit. Recommendations for Cancer Antigen 125 (CA-125) in Follow-up Women should be informed that there is no evidence that monitoring CA-125 improves survival outcome, and that it may worsen quality of life. There should be a time provided for the woman and her clinician to discuss the implications of monitoring progress and initiating treatment based on CA-125 levels. Women can be advised that they have the option to have CA-125 levels tested at agreed intervals, or not at all. Women who choose to have CA-125 levels measured should be informed that CA-125 levels may fluctuate due to individual and laboratory assay variations, and the implications of stable, fluctuating, and rising levels should be discussed. Women should be fully informed of the limitations and potential harms of routine measurement of CA-125 during follow-up and supported to make an informed decision, considering the findings of the randomized controlled trial (RCT) on follow-up after ovarian cancer. The decision to initiate re-treatment requires careful consideration based on the individual woman's situation, and factors including the nature of the recurrence and the wishes of the woman. Recommendations for Timing of Follow-up Consultations Women should be offered the opportunity to have regular follow-up. Discussion with the woman about follow-up could incorporate a schedule of follow-up appointments, including the possibility of no formal follow-up schedule, based on the identified needs and wishes of the individual. There is no recommended frequency of follow-up consultations, but a clear and mutually agreed arrangement should be negotiated with the women, tailored according to risk and to individual patient characteristics, which acknowledges the benefits of an ongoing relationship and the opportunity to deal with issues as they arise. Women residing in rural and regional areas face additional challenges of access to specialist clinicians for follow-up appointments. Individual circumstances should be considered when establishing a follow-up schedule. Recommendations for Format for Follow-up Consultations The basic format of consultation is to update the patient history, assess psychosocial and supportive care needs, and undertake physical examination, which may include pelvic examination. Women should be encouraged to report a range of symptoms, including nausea, vomiting, abdominal distension, cramping, pain, and shortness of breath, and any other concerning symptoms. Radiological imaging should not be done routinely, but should be performed if there is clinical or CA-125 evidence of recurrence. The rationale for not undertaking routine imaging should be discussed with the woman. Recommendation for Models of Follow-up Care A woman may be reviewed by either a gynecologic oncologist or a medical oncologist. Communication with a woman's primary care physician should be maintained throughout follow-up. The use of alternate models of care for women with ovarian cancer, such as primary care physician or nurse-led follow-up, telephone follow-up and patient-initiated care is an area for future research. Some of the issues that would need to be addressed in any future studies include patient and clinician preferences, the effectiveness and cost effectiveness of the alternative models, and the ability of health services to support them.

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