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ovarian cancer charity
WEIGHING UP THE RISK
Consultant
gynaecologist Adam
Rosenthal (left) interprets
the UKCTOCS results for
BRCA-carriers at high risk
of ovarian cancer.
Women who are BRCAcarriers
are still advised
that risk-reducing surgery to remove the fallopian
tubes and ovaries is the only way to prevent ovarian
cancer and is the first option to consider.
It is difficult to extrapolate the results of UKCTOCS
directly to high-risk women, as the trial deliberately
excluded this group. This was because it was
designed to answer the question of whether
screening the general population aged over 50 could
save lives. However, the majority of the ovarian
cancers occurring on UKCTOCS were ‘high grade
serous’, which is by far the commonest type seen in
BRCA-carriers, so it is reasonable to anticipate that
the encouraging results seen in UKCTOCS apply in
the high-risk population.
Impetus for screening
I think the UKCTOCS data strengthens the
argument for screening with the Risk of Ovarian
Cancer Algorithm (ROCA) test used in the trial. This
is the most accurate way of detecting ovarian cancer
in apparently healthy women, and it seems likely to
have saved the lives of some women who develop
the disease (at least in the general population).
Therefore if a high-risk woman wants to undergo
screening until she has surgery, as long as she is fully
informed about its limitations (such as the possibility
of having a false positive result), she should consider
screening with the ROCA test.
Some women delay surgery until completing
their families or until they have gone through the
menopause, in the latter case to avoid the need to
take hormone replacement therapy (HRT) until the
age of natural menopause (around 51 years). HRT
is necessary to alleviate menopausal symptoms
and reduce the increased risks of osteoporosis and
heart disease seen in women who have a premature
menopause. However, there is a real risk that
delaying the surgery until the menopause may be
too late, particularly in BRCA1 carriers who tend to
get ovarian cancer younger. On balance we wouldn’t
advise women to delay surgery until the menopause.
For now, women wanting screening can pay for
it in the private sector. The National Screening
Committee has advised that NHS commissioners
and providers would be unwise to actively pursue or
allow screening of high-risk women before the results
of phase two of the UK Familial Ovarian Cancer
Screening Study (UK FOCSS) of over 4,500 high risk
women are available later this year.
However, there is evidence from the first phase of
UK FOCSS that screening reduces the proportion of
women diagnosed at stage 3b and above. Whilst this
does not prove that screening high-risk women saves
lives, it might have other benefits, such as reducing
the complexity and morbidity of treatment. This first
phase of UK FOCSS used annual screening with
ultrasound scans and CA125 blood tests, but these
were not interpreted using the ROCA test.
In phase two of UK FOCSS, women had an annual
scan and three CA125 tests per year, analysed using
the ROCA test - which we now know detects twice as
many ovarian cancers as CA125 used with a simple
cut-off value - in the hope of detecting cancers earlier.
Women also had an annual scan (sooner if their
ROCA test was not normal).
Phase two of UK FOCSS will therefore provide
some evidence as to whether frequent screening
using these techniques has advantages over annual
screening with scans and CA125 used with a cut-off.
High-risk women wanting screening should follow the
UK FOCSS phase two protocol if the study shows it
has advantages over annual screening.
The introduction of a screening programme for
women at increased risk of ovarian cancer would
probably depend on whether NICE feels it is costeffective
and would probably also take into account
the further mortality analysis from UKCTOCS.
• Disclosure: Adam Rosenthal is clinical lead of UK FOCSS and
has a consultancy agreement with Abcodia.
Ovarian cancer news 5