Key messages
Early chemotherapy for recurrences of ovarian cancer may not prolong life and may reduce quality of life. Note that this trial took place prior to current treatment, so may not apply for women being treated for ovarian cancer today.
Individualised nurse-led follow-up after treatment may improve quality of life more than regular medical follow-up, but may not make much difference for anxiety, depression, or cost.
What did we want to find out?
Ovarian cancer is the eighth most common cancer, and seventh most common cause of cancer death in women worldwide. Traditionally, women were followed up after their treatment in hospital outpatient departments. We wanted to evaluate the evidence for different types of follow-up for women who had completed treatment for the most common type of ovarian cancer.
What did we do?
We searched the medical literature for studies that evaluated different types of follow-up for women who had undergone treatment for ovarian cancer. We assessed their limitations, summarised their results, and assessed how certain we were in the evidence for: overall survival, health-related quality of life, psychological effects (for example, anxiety, depression), and cost-effectiveness.
What did we find?
We found two randomised studies, in which women who had completed their treatment for ovarian cancer were randomly assigned to one of two follow-up groups. Each study examined two different types of follow-up, so we had to examine each study separately, rather than pooling their results.
Limited evidence from one study suggests that regardless of whether women receive chemotherapy immediately after discovering their cancer has recurred (identified by the increase of a tumour marker in the blood, called CA125), or delay treatment until they develop symptoms, there is no real difference in how long they survive. Early treatment of recurrence with chemotherapy may reduce overall quality of life.
Limited evidence from one study suggests that women who receive individualised nurse-led follow-up report better health-related quality of life outcomes compared to those who receive conventional medical follow-up. Psychological effects (anxiety and depression) and costs were similar in both groups of women.
What are the limitations of the evidence?
There is limited evidence from these two trials regarding the appropriate follow-up for women with ovarian cancer. The certainty of the evidence ranges from low to moderate, due to risk of bias and imprecision. Also, these trials pre-date other studies that demonstrate a benefit to maintenance treatment (medicines to reduce tumour growth that are continued after routine chemotherapy is finished), and studies that demonstrate a benefit to further surgery at the time of relapse for some women with low volume disease, who may not be symptomatic. Whether the results of the follow-up studies would apply now, with these new treatment options available at relapse, is uncertain.
How up to date is this evidence?
November 2022
Limited evidence from one trial suggests that routine surveillance with CA125 in asymptomatic women and treatment at CA125-defined relapse does not seem to offer survival advantage when compared to treatment at symptomatic relapse. However, this study pre-dates the use of PARPi maintenance treatment and the increased use of secondary cytoreductive surgery, so the results may be limited in their applicability to current practice.
Limited evidence from one trial suggests that individualised nurse-led follow-up may improve HRQOL in women with ovarian cancer following completion of primary treatment.
Large RCTs are needed to compare different types of follow-up, looking at survival, HRQOL, psychological effects, and cost as outcomes.
This is an update of a previous Cochrane Review, last updated in 2014. Ovarian cancer is the eighth most common cancer and seventh most common cause of death due to cancer in women worldwide. Traditionally, most women who have been treated for cancer undergo long-term follow-up in secondary care. However, it has been suggested that the use of routine review may not be effective in improving survival, or health-related quality of life (HRQOL), or relieving anxiety. In addition, traditional follow-up may not be cost-effective.
To compare the potential effects of different strategies of follow-up in women with epithelial ovarian cancer, following completion of primary treatment.
For this update, we searched the Cochrane Gynaecological Cancer Group Trials Register, CENTRAL 2022, Issue 11, MEDLINE, and Embase from August 2013 to November 2022. We also searched review articles and contacted experts in the field.
All randomised controlled trials (RCTs) that evaluated follow-up strategies for women with epithelial ovarian cancer following completion of primary treatment.
We followed standard Cochrane methodology. Two review authors independently selected potentially relevant trials, extracted data, and assessed risk of bias. They compared results, and resolved disagreements by discussion. We assessed the certainty of evidence, using the GRADE approach, for the outcomes of interest: overall survival (OS), health-related quality of life (HRQOL), psychological effects, and cost analysis.
For this update, we included one new RCT, including 112 women with ovarian, fallopian tube, or peritoneal cancer, who had completed primary treatment by surgery, with or without chemotherapy. This study reported the effect of individualised, i.e. individually tailored, nurse-led follow-up versus conventional medical follow-up on HRQOL, psychological outcomes, and cost-analysis.
Individualised follow-up improved HRQOL in one of the two scales, with a decrease in mean difference (MD) in the QLQ-C30 discomfort scale following 12 months of individualised treatment compared to 12 months of conventional treatment (MD -5.76 points, 95% confidence interval (CI) -10.92 to -0.60; 1 study, 112 participants; low-certainty evidence; minimal important difference 4 to 10 points). There may be little or no difference in the other HRQOL scale (QLQ-Ov28, MD -0.97 points, 95% CI -2.57 to 0.63; 1 study, 112 participants: low-certainty evidence); psychological outcome, measured with the hospital anxiety and depression scale (HADS; MD 0.10 point, 95% CI -0.81 to 1.02; 1 study, 112 participants: low-certainty evidence), or cost analysis (MD -GBP 695.00, 95% CI -1467.23 to 77.23; 1 study, 112 participants: moderate-certainty evidence).
Our previous review included one RCT, with 529 women in a confirmed remission, with normal CA125 concentration and no radiological evidence of disease, after surgery and first-line chemotherapy for ovarian cancer. This study evaluated immediate treatment of ovarian cancer relapse following a rise of serum CA125 levels versus delaying treatment until symptoms developed for OS, and HRQOL.
There was little or no difference in OS between the immediate and delayed arms after a median follow-up of 56.9 months (unadjusted hazard ratio (HR) 0.98, 95% CI 0.80 to 1.20; 1 study, 529 participants; moderate-certainty evidence). Time from randomisation to first deterioration in global health score or death was shorter in the immediate treatment group than in the delayed treatment group (HR 0.71, 95% CI 0.58 to 0.88).