STEP 2: Presentation, initial investigations and referral

This step outlines the process for the general practitioner to initiate the right investigations and refer to the appropriate specialist in a timely manner. The types of investigations the general practitioner undertakes will depend on many factors, including access to diagnostic tests, the availability of medical specialists and patient preferences.

Ovarian cancer symptoms are vague and non-specific, but persistent symptoms should be investigated, particularly in older patients or those with family history. The following symptoms should be investigated:

  • abdominal bloating
  • increased abdominal girth
  • abdominal and/or pelvic pain
  • indigestion
  • lack of appetite
  • feeling full after only a small amount of food
  • unexplained weight gain or weight loss
  • change in bowel habits
  • fatigue
  • urinary frequency or incontinence
  • pressure in the abdomen.

The presence of multiple signs and symptoms, particularly in combination with other underlying risk factors, indicates an increased risk of ovarian cancer.

Symptoms that persist for more than four weeks should be investigated.

Symptoms persisting for more than one week after initial treatment initiated by the general practitioner should be further investigated within two weeks.

General practitioner examinations and investigations should include:

  • a general and pelvic examination, including rectal examination
  • pelvic ultrasound (preferably transvaginal) by a practitioner experienced in gynaecological ultrasounds
  • CT scan if appropriate
  • routine blood and tumour marker tests (CA125, CEA and, in younger patients, HCG, AFP, LDH).

Examinations and investigations less frequently undertaken in primary care include:

  • scopes to see inside the gastrointestinal tract
  • biopsy

If ovarian cancer is suspected, initial investigations by the general practitioner should be completed, with the results reviewed by the general practitioner and discussed with the patient within two weeks of the patient initially presenting with symptoms.

If the general practitioner confirms or has a high suspicion of an ovarian cancer diagnosis, they must refer the patient to a specialist (certified gynaecological oncologist who is part of a multidisciplinary team) for further management.

Patients should be enabled to make informed decisions about their choice of specialist and health service. General practitioners should make referrals in consultation with the patient after considering the clinical care needed, cost implications (see referral options and informed financial consent), waiting periods, location and facilities, including discussing the patient’s preference for health care through the public or the private system.

Referral for suspected or diagnosed ovarian cancer should include the following essential information to accurately triage and categorise the level of clinical urgency:

  • important psychosocial history and relevant medical history
  • family history, current symptoms, medications and allergies
  • results of current clinical investigations (imaging and pathology reports)
  • results of all prior relevant investigations
  • notification if an interpreter service is required.

Many services will reject incomplete referrals, so it is important that referrals comply with all relevant health service criteria.

If access is via online referral, a lack of a hard copy should not delay referral.

The specialist should provide timely communication to the general practitioner about the consultation and should notify the general practitioner if the patient does not attend appointments.

Aboriginal and Torres Strait Islander patients will need a culturally appropriate referral. To view the optimal care pathway for Aboriginal and Torres Strait Islander people and the corresponding quick reference guide, visit the Cancer Australia website. Download the consumer resources Checking for cancer and Cancer from the Cancer Australia website.

The specialist appointment should occur within two weeks of a suspected or confirmed diagnosis.

The patient’s general practitioner should consider an individualised supportive care assessment where appropriate to identify the needs of an individual, their carer and family. Refer to appropriate support services as required. See validated screening tools mentioned in Principle 4 ‘Supportive care’.

A number of specific needs may arise for patients at this time:

  • assistance for dealing with the emotional distress and/or anger of dealing with a potential cancer diagnosis, anxiety/depression (particularly in younger patients regarding potential loss of fertility and early menopause), interpersonal problems and adjustment difficulties
  • management of physical symptoms including abdominal distension, constipation, pain and fatigue
  • encouragement and support to increase levels of exercise (Cormie et al. 2018; Hayes et al. 2019).

For more information refer to the National Institute for Health and Care Excellence 2015 guidelines, Suspected cancer: recognition and referral.

For additional information on supportive care and needs that may arise for different population groups, see Appendices A and B, and special population groups.

The general practitioner is responsible for:

  • providing patients with information that clearly describes to whom they are being referred, the reason for referral and the expected timeframes for appointments
  • requesting that patients notify them if the specialist has not been in contact within the expected timeframe
  • considering referral options for patients living rurally or remotely supporting the patient while waiting for the specialist appointment (Cancer Council nurses are available to act as a point of information and reassurance during the anxious period of awaiting further diagnostic information; patients can contact 13 11 20 nationally to speak to a cancer nurse).
More information

Refer to Principle 6 ‘Communication’ for communication skills training programs and resources.