Primary prevention

There are no proven primary preventative measures for ovarian cancer, but several approaches may reduce the risk of it developing.

The use of oral contraceptives for a period of 5 years is associated with a 50% decrease in the risk of ovarian cancer, which decreases further with longer duration of use.[38][39][40][41][42]

Tubal ligation and hysterectomy are associated with a decreased risk of ovarian cancer.[54][55] However, these procedures should only be performed for valid medical reasons, not for their effect on ovarian cancer risk.

Based on data that implicate the fimbriated end of the fallopian tube as the source of serous ovarian cancer, the American College of Obstetricians and Gynecologists (ACOG) and the Society of Gynecologic Oncology have recommended that physicians discuss opportunistic salpingectomy for all patients at average risk of ovarian cancer who are undergoing hysterectomy.[56][57] However, evidence for opportunistic salpingectomy for ovarian cancer prevention is mostly derived from observational studies.[58]

Risk-reducing surgery for women at high risk

Risk-reducing salpingo-oophorectomy (RRSO) can decrease the risk of ovarian cancer in high-risk patients, such as those with: BRCA1 or BRCA2 mutations; mutations associated with Lynch syndrome; or other ovarian cancer susceptibility gene variants.[16][17][59][60][61][62][63]​​​​​ The decision to undergo RRSO (with or without concurrent hysterectomy) and its timing should be individualised (e.g., based on age, whether childbearing has been completed, menopausal status, comorbidities, specific gene mutation, and family history).[16][17][64]​​​​​​

For women with a BRCA1 mutation, guidelines recommend RRSO at age 35 to 40 years (taking into account childbearing wishes).[17] BRCA2 variants are associated with later ovarian cancer onset, and consideration may be given to delaying RRSO until age 40 to 45 years in these patients (unless there is a family history of early diagnosis). Hysterectomy at the time of RRSO to reduce risk of serous uterine cancer in women with a BRCA mutation may be discussed. Evidence to suggest an increased risk of serous uterine cancer among individuals with BRCA1/2 is limited.[17]​

For women with a BRIP1, RAD51C, or RAD51D mutation, RRSO is recommended at age 45 to 50 years.[17] RRSO may be considered from age 45 to 50 years in women with a PALB2 mutation. Discussions about risk-reducing surgery should start earlier if there is a family history of early-onset disease.[17]

For women with Lynch syndrome, guidelines recommend discussing risk-reducing surgery with women by their early to mid-40s.[20]​​ Evidence supports the use of RRSO in patients with MLH1, MSH2, and EPCAM variants, but is insufficient to recommend risk-reducing surgery for those with MSH6 and PMS2 variants (which are associated with lower risk of ovarian cancer).[16]

In addition to RRSO, hysterectomy should be considered for all patients with Lynch syndrome to reduce the risk of endometrial cancer.[16]

Non-surgical risk reduction for women at high risk

For high-risk women who decline or are unable to have RRSO, routine screening with transvaginal ultrasound and CA-125 is sometimes considered.[18][62][65]​​​​ However, studies do not show a clear benefit and it is not routinely recommended.[16][17]​​​​ The effectiveness of screening women at high risk for ovarian cancer using pelvic examination, CA-125 testing, and transvaginal ultrasound has not been demonstrated; early-stage disease is difficult to detect and may be missed with these approaches.[17][66]

The Risk of Ovarian Cancer Algorithm (ROCA) may have potential utility as a surveillance tool in high-risk women (e.g., with pathogenic germline BRCA1/2 variants) who defer or decline risk-reducing surgery.[67]

In the UK, National Institute of Health and Care Excellence (NICE) guidelines recommend considering surveillance with longitudinal CA125 testing (every 4 months) using an algorithm (such as the ROCA) for patients in the following high-risk groups who defer or decline risk-reducing surgery:[64]

  • BRCA1 pathogenic variant and age over 35 years

  • BRCA2 pathogenic variant and age over 40 years

  • RAD51C, RAD51D, BRIP1, or PALB2 pathogenic variant and age over 45 years.

In addition, an annual review with discussion of risk-reducing surgery is recommended for these patients.

Surveillance of women at high risk of ovarian cancer represents an interim measure and should not be considered as an alternative to risk-reducing surgery.[68]

Consideration of combination oral contraception or a hormonal intrauterine device (IUD) is recommended as a risk-reducing measure among women with a BRCA mutation.[15]​​[17][62]​​​​​​ Use of a combined oestrogen/progestin contraceptive or a levonorgestrel IUD (LNG-IUD) in women with BRCA1 or BRCA2 mutations has been found to reduce ovarian cancer risk to that reported for the general population.[69][70][71][72][73]​​​​​​​ Benefits and harms must be weighed and discussed with high-risk patients, including the increased risk of breast cancer associated with long-term oral contraceptive use.[64][70][73]​​

For women with Lynch syndrome, alternative risk-reduction strategies should be discussed if RRSO is declined or not possible.[16] This should include education about symptoms associated with ovarian cancer.​

Secondary prevention

Early-stage disease is difficult to detect and may be missed with pelvic examination, CA-125 testing, and ultrasound. Therefore, careful discussion between patient and physician is necessary to understand the significant limitations of these tests, even in high-risk populations.[66] 

Preventative measures in women at high risk for developing ovarian cancer are discussed in the primary prevention section.

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