What is the recommended follow‑up schedule and surveillance protocol after completion of primary treatment (surgery with or without adjuvant platinum‑based chemotherapy) for epithelial ovarian cancer?

Ovarian Cancer Follow-Up Protocol

Standard Follow-Up Schedule

After completing primary treatment for epithelial ovarian cancer, patients should undergo clinical surveillance consisting of history and physical examination every 3 months for the first 2 years, every 4 months during year 3, and every 6 months during years 4–5. 1

Clinical Visit Components

• Each visit should include a focused history and pelvic examination to assess for symptoms or physical findings suggestive of recurrence. 2, 1
• CA-125 measurement at each visit is recommended if the level was initially elevated, as it can accurately predict tumor relapse. 2, 1
• Routine complete blood count and chemistry profiles should be obtained only as clinically indicated, not routinely. 1

Role of CA-125 Monitoring: A Critical Controversy

The evidence regarding CA-125 surveillance is mixed, and patients should understand that early treatment based on rising CA-125 alone does not improve survival. 3

• A landmark randomized trial (MRC/EORTC) demonstrated that immediate treatment upon CA-125 rise in asymptomatic patients showed no survival advantage compared to delaying treatment until symptoms developed (HR 0.98,95% CI 0.80–1.20). 3
• Importantly, early treatment based on CA-125 elevation was associated with earlier deterioration in quality of life (HR 0.71,95% CI 0.58–0.88). 3
• Despite these findings, CA-125 monitoring remains recommended at each follow-up visit if initially elevated, as it provides prognostic information and many patients prefer continued monitoring. 2, 1
• The NCCN and SGO acknowledge this trial's limitations and recommend that patients discuss the pros and cons of CA-125 monitoring with their physicians. 2

Imaging Strategy

Routine surveillance imaging (CT, MRI, PET, or PET-CT) is NOT recommended for asymptomatic patients in complete remission. 2, 1

• Imaging should be reserved only for investigation of suspected recurrence based on symptoms, abnormal physical findings, or rising CA-125. 2, 1
• Chest/abdominal/pelvic CT, MRI, or PET-CT may be ordered if clinically indicated by new symptoms or concerning examination findings. 2, 1
• PET-CT (category 2B) may be particularly useful in symptomatic patients where recurrence is suspected but not apparent on conventional imaging. 2, 4

Red-Flag Symptoms Requiring Immediate Evaluation

Patients must be counseled to report any new or worsening symptoms immediately, as these warrant diagnostic work-up:

• Vaginal, bladder, or rectal bleeding 5
• Unexplained weight loss or decreased appetite 5
• Pelvic, abdominal, hip, or back pain 5
• Cough or shortness of breath 5
• Abdominal distension or leg swelling 5

What NOT to Do

Intensive surveillance with routine imaging and laboratory testing has not shown clinical benefit and should be avoided in asymptomatic patients. 2

• Do not perform routine CT scans in asymptomatic patients with normal CA-125 and examination. 2, 1
• Do not order routine vaginal cytology for surveillance, as it is no longer recommended. 5
• Do not use CA-125 alone to make treatment decisions; always combine with radiological and clinical assessment. 6

Maintenance Therapy Considerations

For patients who achieve complete clinical remission after primary treatment, options include:

• Observation alone (standard recommendation). 2
• Clinical trial participation (preferred if maintenance therapy is considered). 2
• Paclitaxel maintenance (135–175 mg/m² every 4 weeks for 12 cycles, category 2B) may be considered, though this should preferably be done within a controlled clinical trial. 2

Note: Complete clinical remission is defined as negative physical examination, normal CA-125 levels, and negative CT with lymph nodes <1 cm. 2

Quality of Life and Practical Considerations

Symptom-directed observation provides reassurance without the burden of unnecessary testing, and there is no demonstrated survival advantage from detecting asymptomatic recurrences early. 5, 3

• The approach balances early detection with quality of life, recognizing that most recurrences will become symptomatic before causing significant morbidity. 3, 4
• Rising CA-125 typically precedes clinical relapse by 2–6 months, but treating at this stage does not improve outcomes. 6, 3

Common Pitfalls to Avoid

• Do not over-investigate asymptomatic patients with normal CA-125 and examination findings, as this increases anxiety without improving outcomes. 2, 3
• Do not delay evaluation of symptomatic patients waiting for scheduled follow-up appointments. 5
• Remember that CA-125 can be elevated in benign conditions (endometriosis, pelvic inflammatory disease, cirrhosis, heart failure, renal failure), so interpret rises in clinical context. 6
• Do not use CA-125 as the sole criterion for initiating treatment in asymptomatic patients, given the lack of survival benefit. 3