What is the best course of action for a 35-year-old female with a history of ovarian cancer, recent negative Computed Tomography (CT) scan and laboratory results (Cancer Antigen 125 (CA125) and Cancer Antigen 19-9 (CA19-9)), abdominal hernia, and anxiety and depression, seeking referral to a gynecologic oncologist (GYN/ONC) or medical oncologist (MED ONC) for continued monitoring and treatment?

History of Present Illness

35-year-old female with history of ovarian cancer status post tumor resection (July 2024), presenting to establish care and requesting specialist referral for ongoing surveillance. She reports approximately 12 months post-surgical resection with recent negative surveillance imaging (CT scan July 2025) and tumor markers (CA-125, CA 19-9). She has developed a symptomatic incisional hernia limiting work capacity (unable to lift >15 lbs) and has comorbid anxiety/depression with upcoming counseling appointment scheduled.

Assessment and Plan

1. Ovarian Cancer - Surveillance Phase (12 months post-resection)

This patient should be referred to a gynecologic oncologist for ongoing surveillance, as the Society of Gynecologic Oncologists guidelines explicitly state that ovarian cancer patients may be followed by either a generalist or gynecologic oncologist, with specialist care being optimal for comprehensive management 1.

Surveillance Schedule (12-24 Month Window):

• Clinical examination every 3 months with comprehensive review of symptoms and pelvic examination 1
• CA-125 monitoring is optional per Society of Gynecologic Oncologists guidelines, though approximately 80% of epithelial tumors demonstrate elevated CA-125 at diagnosis and levels correlate with disease status, often rising 2-5 months before clinical detection of relapse 1
• Routine interval imaging is not recommended unless recurrence is suspected based on symptoms, examination findings, or rising tumor markers 1

Specialist Referral Options:

• Gynecologic oncologist remains the preferred specialist for ovarian cancer surveillance, as they provide optimal staging, treatment planning, and surveillance expertise 1
• Medical oncologist is an acceptable alternative if gynecologic oncology is geographically inaccessible, though the patient should understand this represents a compromise in specialized care 1
• Facilitate referral to Phoenix-based gynecologic oncologist given the superior outcomes associated with specialist care, particularly for potential secondary cytoreductive surgery if recurrence develops 1

Key Surveillance Principles:

• CT imaging should only be obtained if recurrence is suspected based on rising CA-125, new symptoms (abdominal distention, bloating, pelvic pain, early satiety, urinary symptoms), or abnormal physical examination 1, 2
• Recent negative CT scan (July 2025) and tumor markers provide reassurance but do not eliminate need for ongoing clinical surveillance 1

2. Incisional Hernia - Post-Surgical Complication

Surgical repair should be pursued given functional impairment and work limitations, but timing must be coordinated with oncologic surveillance.

Management Approach:

• Refer to general surgery for hernia evaluation and repair planning [@general medical knowledge@]
• Coordinate timing with gynecologic oncologist to ensure hernia repair does not interfere with surveillance schedule or potential future oncologic interventions [@general medical knowledge@]
• Document functional limitations (unable to lift >15 lbs) for surgical indication and potential work accommodation needs [@general medical knowledge@]

Important Considerations:

• Hernia repair should ideally occur during a stable surveillance period with reassuring tumor markers and imaging [@general medical knowledge@]
• Mesh repair may be preferred given the patient's young age and need to return to full work capacity, though this should be determined by the operating surgeon [@general medical knowledge@]

3. Anxiety and Depression - Psychological Comorbidity

Anxiety and depression are significantly elevated in ovarian cancer patients, with clinical depression rates of 5.9% compared to 3.0% in community norms, and this patient's symptoms warrant active management 3.

Current Management:

• Continue with scheduled counseling appointment through integrative health as planned 3, 4
• Monitor for treatment response at follow-up visits, as higher symptom burden and lower optimism significantly predict both depression and anxiety in ovarian cancer patients 3

Surveillance Considerations:

• Anxiety levels are typically highest prior to surveillance procedures and gradually decrease thereafter, with 74% of ovarian cancer patients experiencing pathological anxiety at some point during treatment 4
• Knowledge about CA-125 levels can paradoxically increase anxiety, with moderate association between high CA-125 and elevated anxiety scores 5
• Consider discussing with patient whether she wants to know CA-125 results at each visit, as some patients prefer selective disclosure to manage anxiety 5

Red Flags Requiring Escalation:

• Persistent high anxiety or depression despite counseling should prompt consideration for psychiatric referral and potential pharmacotherapy 3, 4
• Social support assessment is critical, as lower social support significantly predicts both anxiety and depression in ovarian cancer patients 3

4. Follow-Up Plan

Immediate Actions:

• Initiate referral to gynecologic oncologist (Phoenix-based) or medical oncologist if patient declines travel 1
• Refer to general surgery for hernia evaluation [@general medical knowledge@]
• Ensure counseling appointment occurs as scheduled 3, 4

Next Visit (3 months):

• Review specialist consultation results and establish coordinated surveillance plan 1
• Reassess anxiety/depression symptoms and counseling response 3, 4
• Physical examination including pelvic and rectovaginal exam per surveillance guidelines 1
• CA-125 measurement optional based on shared decision-making with patient and specialist recommendations 1, 2

Common Pitfalls to Avoid:

• Do not order routine surveillance CT scans without clinical indication, as insufficient data supports routine imaging and this increases healthcare costs without proven survival benefit 1
• Do not delay hernia repair indefinitely due to cancer history, as functional impairment affects quality of life and work capacity [@general medical knowledge@]
• Do not underestimate psychological burden of cancer survivorship, as caregivers and patients both experience elevated distress requiring active management 3, 4