Ovarian cancer

Last updated: May 5, 2023

Summarytoggle arrow icon

Ovarian cancer is the second most common gynecological cancer and has the highest mortality rate of any gynecological cancer in the United States. Incidence increases with age (peak incidence at 55–64 years of age). Risk factors for ovarian cancer include genetic predisposition (e.g., BRCA1/BRCA2 mutation) and hormonal factors (e.g., early menarche, late menopause). The most common type of ovarian cancer is epithelial cell carcinoma. Symptoms of ovarian cancer are usually nonspecific (e.g., abdominal pain and distension), and over half of those with ovarian cancer have metastatic disease at the time of diagnosis. Transvaginal ultrasound is the imaging test of choice for the evaluation of suspected ovarian cancer; other imaging modalities (e.g., CT scan, MRI) are typically reserved for staging. CA-125 is elevated in ∼ 80% of malignant tumors; the positive predictive value and specificity of CA-125 is higher in postmenopausal women. Surgery is recommended for a definitive diagnosis of ovarian cancer; maximal cytoreduction should be performed to improve long-term outcomes. Most patients with ovarian cancer should receive adjuvant chemotherapy with a platinum-based agent and a taxane. Prognosis is primarily based on the disease stage, with an overall 5-year survival rate of 50%. Routine screening with CA-125 or transvaginal ultrasound is not recommended in individuals with an average risk.

For information about specific ovarian cancer subtypes, see “Overview of ovarian tumors”.

Epidemiologytoggle arrow icon

  • Incidence [1]
  • Prevalence: the lifetime risk of developing malignant ovarian cancer is ∼1% [2]
  • Age
    • Peak incidence: 55–64 years of age [3]
    • Women with genetic mutations are typically diagnosed at a younger age.
  • Mortality: highest mortality rate of any gynecological cancer in the US [1]

Epidemiological data refers to the US, unless otherwise specified.

Etiologytoggle arrow icon

Risk factors [4]

Protective factors [4]

Classificationtoggle arrow icon

Classification of ovarian cancer

Ovarian malignancies can be either primary (i.e., arising from the different types of ovarian tissue) or secondary (i.e., metastases from other primary tumors).

Primary ovarian cancer

High-grade cystadenocarcinoma is the most aggressive ovarian cancer.

Secondary ovarian cancer

Most common primary cancers: gastrointestinal tract (e.g., Krukenberg tumor), breast, and endometrium. [11]

Clinical featurestoggle arrow icon

Symptoms of ovarian cancer are usually nonspecific, which often delays the diagnosis. Early-stage ovarian cancer is usually asymptomatic. [9][13]

Abdominal and pelvic symptoms [9][13]

Advanced disease [9][13]

Over half of those with ovarian cancer have metastatic disease at the time of diagnosis. [13]

Paraneoplastic syndromes [13][17]

Although rare, these syndromes may be seen in patients with ovarian cancer. [17]

Diagnosticstoggle arrow icon


Transvaginal ultrasound (TVUS)

  • Imaging test of choice for evaluation of suspected ovarian cancer [13][18]
  • If TVUS cannot be performed or there are patient-related factors that limit its accuracy (e.g., postsurgical adhesions, masses extending beyond the pelvis), abdominal ultrasound can be performed instead. [18]
Ultrasound workup of ovarian masses [19]
Benign Malignant
Ovarian volume
Internal structure Uniform, thin walls Irregularly thickened septa
Margins Smooth Indistinct borders; papillary projections
Echogenicity Anechoic Hypoechoic, anechoic, and hyperechoic components
Content Cystic Cystic or solid components
Vascularization Unremarkable Possible central vascularization
Pouch of Douglas Unremarkable Possible free fluid (ascites)

Computed tomography (CT) [18]

  • CT scan of the pelvis, abdomen, and chest is useful for staging.
  • Not recommended in the initial evaluation of adnexal masses

Omental caking (thickening) is a radiologic sign that indicates advanced peritoneal ovarian cancer and is due to tumor infiltration of the greater omentum.

Magnetic resonance imaging (MRI) [18]

  • Useful for assessing disease spread and the feasibility of surgical resection
  • Not routinely recommended for initial evaluation of suspected ovarian cancer

Tumor markers

Tissue diagnosis

  • Needle biopsy
    • Not recommended because of the risk of tumor seeding, which can advance the stage of disease [18]
    • There is an exception for patients with clinical and radiographic findings of advanced ovarian malignancy who are not fit for surgery.
  • Surgical evaluation
    • Recommended for definitive diagnosis of ovarian cancer [9]
    • Should be performed on patients with clinical, radiographic, and/or laboratory findings that suggest ovarian cancer
    • Laparoscopic removal is the preferred surgical procedure.
    • Allows staging and cytoreduction (see “Surgery” in “Treatment” below)

Fine needle aspiration is absolutely contraindicated in ovarian tumors because it can directly spread tumor cells to the peritoneum!

Differential diagnosestoggle arrow icon

Nongynecological [18]

Gynecological [18]

During pregnancy

  • Additional conditions to consider in pregnant individuals:
    • Pregnancy luteoma [20]
      • Definition: rare, benign tumors that arise in response to elevated hormone levels (e.g., β-hCG) during pregnancy
      • Clinical features
        • The majority of patients are asymptomatic.
        • Occasionally, they are functionally active (i.e., cause androgen hypersecretion) and manifest with symptoms of virilization of the mother or the fetus.
      • Diagnostics
      • Treatment
        • Observation
        • Most regress spontaneously post partum.
    • Theca lutein cysts
    • Corpus luteum cyst

If surgical removal of an ovarian tumor is indicated during pregnancy, surgery should, if possible, be scheduled for after the 10th week of gestation, as the secretion of progesterone by the corpus luteum is essential for the maintenance of the pregnancy. The placenta takes over this function from approximately the 10th week of pregnancy onwards.

The differential diagnoses listed here are not exhaustive.

Stagestoggle arrow icon

Staging of epithelial ovarian cancer including fallopian tube cancer and primary peritoneal cancer [21]

Staging is based on the 2017 International Federation of Gynecology and Obstetrics (FIGO) and the Tumor, Node, Metastasis (TNM) classification systems.

Management approach

FIGO Stage


  • Stage IA
  • T1a, N0, M0
  • Stage IB
  • T1b, N0, M0
  • Stage IC
  • T1c, N0, M0
  • Stage IIA
  • T2a, N0, M0
  • Stage IIB
  • T2b, N0, M0
  • Tumor extension to or implants on other pelvic tissues
  • Stage IIIA1
  • T1–T2, N1, M0
  • Stage IIIA2
  • T3a, N0–N1, M0
  • Stage IIIB
  • T3b, N0–N1, M0
  • Stage IIIC
  • T3c, N0–N1, M0
  • Stage IVA
  • T1–T3, N0-N1, M1a
  • Stage IVB
  • T1–T3, N0-N1, M1b

Treatmenttoggle arrow icon

Surgery [22][23]

For the best patient outcomes, surgical staging and debulking should be performed by a gynecological oncologist. [26]

Chemotherapy [9]

Targeted molecular therapy


Prognosistoggle arrow icon

Prognosis is primarily based on the disease stage. [2]

  • Overall 5-year survival rate: 50%
  • 5-year survival rate of metastatic ovarian cancer: ∼ 31%

Preventiontoggle arrow icon

Ovarian cancer screening [31][32]

Strategies to reduce the risk of ovarian cancer

See “Protective factors” in “Etiology” above.

Referencestoggle arrow icon

  1. Incidence and Mortality.!/. Updated: January 1, 2023. Accessed: January 31, 2023.
  2. Cancer Stat Facts: Ovarian Cancer. Updated: November 1, 2016. Accessed: November 24, 2022.
  3. Ovarian Cancer Statistics. Updated: June 6, 2022. Accessed: September 27, 2022.
  4. Brett M. R, Brett M. R, Jennifer B. P, Thomas A. S, Jennifer B. P, Thomas A. S. Epidemiology of ovarian cancer: a review. Cancer Biol Med. 2017; 14 (1): p.9-32.doi: 10.20892/j.issn.2095-3941.2016.0084 . | Open in Read by QxMD
  5. Camargo MC, Stayner LT, Straif K, et al. Occupational Exposure to Asbestos and Ovarian Cancer: A Meta-analysis. Environ Health Perspect. 2011; 119 (9): p.1211-1217.doi: 10.1289/ehp.1003283 . | Open in Read by QxMD
  6. Kuchenbaecker KB, Hopper JL, Barnes DR, et al. Risks of Breast, Ovarian, and Contralateral Breast Cancer for BRCA1 and BRCA2 Mutation Carriers. JAMA. 2017; 317 (23): p.2402.doi: 10.1001/jama.2017.7112 . | Open in Read by QxMD
  7. Barrow E, Robinson L, Alduaij W, et al.. Cumulative lifetime incidence of extracolonic cancers in Lynch syndrome: a report of 121 families with proven mutations. Clin Genet. 2009; 75 (2): p.141-149.doi: 10.1111/j.1399-0004.2008.01125.x . | Open in Read by QxMD
  8. Jewish Women and BRCA Gene Mutations. Updated: September 27, 2021. Accessed: September 27, 2022.
  9. Matulonis UA, Sood AK, Fallowfield L, Howitt BE, Sehouli J, Karlan BY. Ovarian cancer.. Nat Rev Dis primers. 2016; 2: p.16061.doi: 10.1038/nrdp.2016.61 . | Open in Read by QxMD
  10. Havrilesky LJ, Moorman PG, Lowery WJ, et al. Oral Contraceptive Pills as Primary Prevention for Ovarian Cancer. Obstet Gynecol. 2013; 122 (1): p.139-147.doi: 10.1097/aog.0b013e318291c235 . | Open in Read by QxMD
  11. de Waal YRP, Thomas CMG, Oei ALM, Sweep FCGJ, Massuger LFAG. Secondary Ovarian Malignancies. International Journal of Gynecological Cancer. 2009; 19 (7): p.1160-1165.doi: 10.1111/igc.0b013e3181b33cce . | Open in Read by QxMD
  12. Kubeček O, Laco J, Špaček J, et al. The pathogenesis, diagnosis, and management of metastatic tumors to the ovary: a comprehensive review. Clin Exp Metastasis. 2017; 34 (5): p.295-307.doi: 10.1007/s10585-017-9856-8 . | Open in Read by QxMD
  13. Doubeni et al.. Diagnosis and Management of Ovarian Cancer. Am Fam Physician. 2016.
  14. Hamilton W, Peters TJ, Bankhead C, Sharp D. Risk of ovarian cancer in women with symptoms in primary care: population based case-control study. BMJ. 2009; 339 (aug25 2): p.b2998-b2998.doi: 10.1136/bmj.b2998 . | Open in Read by QxMD
  15. Lengyel E. Ovarian Cancer Development and Metastasis. Am J Pathol. 2010; 177 (3): p.1053-1064.doi: 10.2353/ajpath.2010.100105 . | Open in Read by QxMD
  16. Deng K, Yang C, Tan Q, Song W, Lu M, Zhao W, Lou G, Li Z, Li K, Hou Y. Sites of distant metastases and overall survival in ovarian cancer: A study of 1481 patients.. Gynecol Oncol. 2018; 150 (3): p.460-465.doi: 10.1016/j.ygyno.2018.06.022 . | Open in Read by QxMD
  17. Shanbhogue AKP, Shanbhogue DKP, Prasad SR, Surabhi VR, Fasih N, Menias CO. Clinical Syndromes Associated with Ovarian Neoplasms: A Comprehensive Review. RadioGraphics. 2010; 30 (4): p.903-919.doi: 10.1148/rg.304095745 . | Open in Read by QxMD
  18. Ovarian Cancer Including Fallopian Tube Cancer and Primary Peritoneal Carcinoma Version 1.2020. Updated: March 11, 2020. Accessed: September 6, 2020.
  19. R Eskander, M Berman, L Keder. Practice Bulletin No. 174. Obstet Gynecol. 2016; 128 (5): p.e210-e226.doi: 10.1097/aog.0000000000001768 . | Open in Read by QxMD
  20. Van Nagell JR, Miller RW. Evaluation and Management of Ultrasonographically Detected Ovarian Tumors in Asymptomatic Women. Obstet Gynecol. 2016; 127 (5): p.848-858.doi: 10.1097/aog.0000000000001384 . | Open in Read by QxMD
  21. Masarie K, Katz V, Balderston K. Pregnancy luteomas. Obstet Gynecol Surv. 2010; 65 (9): p.575-582.doi: 10.1097/ogx.0b013e3181f8c41d . | Open in Read by QxMD
  22. Surgery for ovarian cancer. Updated: April 18, 2018. Accessed: September 20, 2020.
  23. Treatment of Invasive Epithelial Ovarian Cancers, by Stage. . Accessed: September 22, 2020.
  24. Chi DS, Eisenhauer EL, Zivanovic O, et al. Improved progression-free and overall survival in advanced ovarian cancer as a result of a change in surgical paradigm. Gynecol Oncol. 2009; 114 (1): p.26-31.doi: 10.1016/j.ygyno.2009.03.018 . | Open in Read by QxMD
  25. Schorge JO, McCann C, Del Carmen MG. Surgical debulking of ovarian cancer: what difference does it make?. Rev Obstet Gynecol. ; 3 (3): p.111-7.
  26. Giede KC, Kieser K, Dodge J, Rosen B. Who should operate on patients with ovarian cancer? An evidence-based review. Gynecol Oncol. 2005; 99 (2): p.447-461.doi: 10.1016/j.ygyno.2005.07.008 . | Open in Read by QxMD
  27. Wright AA, Bohlke K, Armstrong DK, et al. Neoadjuvant Chemotherapy for Newly Diagnosed, Advanced Ovarian Cancer: Society of Gynecologic Oncology and American Society of Clinical Oncology Clinical Practice Guideline.. J Clin Oncol. 2016; 34 (28): p.3460-73.doi: 10.1200/JCO.2016.68.6907 . | Open in Read by QxMD
  28. Konstantinopoulos PA, Norquist B, Lacchetti C, et al. Germline and Somatic Tumor Testing in Epithelial Ovarian Cancer: ASCO Guideline. J Clin Onc. 2020; 38 (11): p.1222-1245.doi: 10.1200/jco.19.02960 . | Open in Read by QxMD
  29. Moore K, Colombo N, Scambia G, et al. Maintenance Olaparib in Patients with Newly Diagnosed Advanced Ovarian Cancer. N Engl J Med. 2018; 379 (26): p.2495-2505.doi: 10.1056/nejmoa1810858 . | Open in Read by QxMD
  30. González-Martín A, Pothuri B, Vergote I, et al. Niraparib in Patients with Newly Diagnosed Advanced Ovarian Cancer. N Engl J Med. 2019; 381 (25): p.2391-2402.doi: 10.1056/nejmoa1910962 . | Open in Read by QxMD
  31. Breast and Ovarian Cancer and Family History Risk Categories. Updated: March 25, 2020. Accessed: April 6, 2021.
  32. BRCA-Related Cancer: Risk Assessment, Genetic Counseling, and Genetic Testing. Updated: August 20, 2019. Accessed: April 6, 2021.
  33. Pinsky PF, Yu K, Kramer BS, et al. Extended mortality results for ovarian cancer screening in the PLCO trial with median 15 years follow-up. Gynecol Oncol. 2016; 143 (2): p.270-275.doi: 10.1016/j.ygyno.2016.08.334 . | Open in Read by QxMD
  34. Jacobs IJ, Menon U, Ryan A, et al. Ovarian cancer screening and mortality in the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS): a randomised controlled trial. Lancet. 2016; 387 (10022): p.945-956.doi: 10.1016/s0140-6736(15)01224-6 . | Open in Read by QxMD
  35. Risk Assessment, Genetic Counseling, and Genetic Testing for BRCA1/2-Related Cancer in Women: A Systematic Review for the U.S. Preventive Services Task Force [Internet]. Updated: August 1, 2019. Accessed: January 13, 2022.
  36. Berek JS, Chalas E, Edelson M, et al. Prophylactic and Risk-Reducing Bilateral Salpingo-oophorectomy. Obstet Gynecol. 2010; 116 (3): p.733-743.doi: 10.1097/aog.0b013e3181ec5fc1 . | Open in Read by QxMD
  37. Smith RA, Manassaram-Baptiste D, Brooks D, et al. Cancer screening in the United States, 2015: A review of current American Cancer Society guidelines and current issues in cancer screening. CA Cancer J Clin. 2015; 65 (1): p.30-54.doi: 10.3322/caac.21261 . | Open in Read by QxMD
  38. Prat J. Staging classification for cancer of the ovary, fallopian tube, and peritoneum. Int J Gynaecol Obstet. 2013; 124 (1): p.1-5.doi: 10.1016/j.ijgo.2013.10.001 . | Open in Read by QxMD
  39. Khosla D, Dimri K, Pandey A, Mahajan R, Trehan R. Ovarian granulosa cell tumor: Clinical features, treatment, outcome, and prognostic factors. North American Journal of Medical Sciences. 2014; 6 (3): p.133.doi: 10.4103/1947-2714.128475 . | Open in Read by QxMD

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