Management of Postmenopausal Women with Family History of Ovarian Cancer

Guideline-Based Recommendation Against Screening

The US Preventive Services Task Force (USPSTF) gives a Grade D recommendation (harms outweigh benefits) against screening for ovarian cancer in asymptomatic women, even those with a family history, due to no mortality benefit and significant harms through false-positive results and unnecessary surgeries 1, 2, 3
The PLCO trial of 78,216 women (17% with family history) showed no reduction in ovarian cancer deaths with annual CA-125 and transvaginal ultrasound screening, with 118 vs 100 deaths (relative risk 1.18) 4, 5
Approximately 10% of screened women receive false-positive results, with a positive predictive value of only 1-2%, leading to unnecessary surgeries and complications 4, 5
One-third of women with false-positives undergo oophorectomy, resulting in a 20:1 ratio of surgeries to screen-detected cancers 4, 5
Nearly 21 major complications occur per 100 surgical procedures performed for false-positive results 5

The American College of Family Physicians recommends focusing on symptom awareness rather than screening tests, and educating patients about ovarian cancer symptoms, risk-reducing factors, and the fact that early-stage disease is usually asymptomatic 1
Oral contraceptive use reduces the risk of ovarian cancer by ~50%, and other risk-reducing factors include pregnancy, breastfeeding, and bilateral tubal ligation 1, 4

Women with a family history of ovarian cancer should be evaluated for genetic counseling referral based on their family history details, with referral criteria including two or more first- or second-degree relatives with ovarian cancer or a combination of breast and ovarian cancer 1, 3
For Ashkenazi Jewish women, one first-degree relative or two second-degree relatives on the same side of the family with breast or ovarian cancer is sufficient for referral 1, 3
If genetic counseling reveals a BRCA mutation, management changes entirely, and women with known BRCA mutations should be managed differently, potentially including risk-reducing bilateral salpingo-oophorectomy 2, 5

The American College of Radiology confirmed that the PLCO trial found no significant shift in stage distribution and no statistically significant reduction in cancer-specific mortality, with 1,080 women undergoing surgery with oophorectomy and 163 (15%) experiencing major complications 6, 7

Only 5-10% of ovarian cancer patients have a significant family history, but three familial syndromes exist: site-specific ovarian cancer, familial breast-ovarian cancer syndrome, and cancer familial syndrome (Lynch type II) 8
Women with BRCA1 mutations have a cumulative ovarian cancer risk of 56% by age 70 8

The UK Familial Ovarian Cancer Screening Study showed different results for high-risk women (those with ≥10% lifetime risk based on family history or known genetic mutation), with sensitivity of 81.3-87.5% and PPV of 25.5% 9
Screening may be considered for women with confirmed BRCA mutations or very strong family history (multiple affected relatives), using transvaginal ultrasound and CA-125 with the ROCA algorithm 9, 8