Tests for Ovarian Cancer

If your doctor finds something suspicious during a pelvic exam, or if you have symptoms that might be due to ovarian cancer, your doctor will recommend exams and tests to find the cause.

Medical history and physical exam

Your doctor will ask about your medical history to learn about possible risk factors, including your family history. You will also be asked if you’re having any symptoms, when they started, and how long you've had them. Your doctor will likely do a pelvic exam to check for an enlarged ovary or signs of fluid in the abdomen (which is called ascites).

If there is reason to suspect you might have ovarian cancer based on your symptoms and/or physical exam, your doctor will order some tests to check further.

Consultation with a specialist

If the results of your pelvic exam or other tests suggest that you might have ovarian cancer, you will need a doctor or surgeon who specializes in treating women with this type of cancer. A gynecologic oncologist is an obstetrician/gynecologist who is specially trained in treating cancers of the female reproductive system. Treatment by a gynecologic oncologist helps ensure that you get the best kind of surgery for your cancer. It has also been shown to help patients with ovarian cancer live longer. Anyone suspected of having ovarian cancer should see this type of specialist before having surgery.

Imaging tests

Doctors use imaging tests to take pictures of the inside of your body. Imaging tests can show whether a pelvic mass is present, but they cannot confirm that the mass is a cancer. These tests are also useful if your doctor is looking to see if ovarian cancer has spread (metastasized) to other tissues and organs.

Ultrasound

Ultrasound (ultrasonography) uses sound waves to create an image on a video screen. Sound waves are released from a small probe placed in the vagina and a small microphone-like instrument called a transducer gives off sound waves and picks up the echoes as they bounce off organs. A computer turns these echoes into an image on the screen.

Ultrasound is often the first test done if a problem with the ovaries is suspected. It can be used to find an ovarian tumor and to check if it is a solid mass (tumor) or a fluid-filled cyst. It can also be used to get a better look at the ovary to see how big it is and how it looks inside. This helps the doctor decide which masses or cysts are more worrisome.

Computed tomography (CT) scans

The CT scan is an x-ray test that makes detailed cross-sectional images of your body. The test can help tell if ovarian cancer has spread to other organs.

CT scans do not show small ovarian tumors well, but they can see larger tumors, and may be able to see if the tumor is growing into nearby structures. A CT scan may also find enlarged lymph nodes, signs of cancer spread to liver or other organs, or signs that an ovarian tumor is affecting your kidneys or bladder.

CT scans are not usually used to biopsy an ovarian tumor (see biopsy in the section "Other tests"), but they can be used to biopsy a suspected metastasis (area of spread). For this procedure, called a CT-guided needle biopsy, the patient stays on the CT scanning table, while a radiologist moves a biopsy needle toward the mass. CT scans are repeated until the doctors are confident that the needle is in the mass. A fine needle biopsy sample (tiny fragment of tissue) or a core needle biopsy sample (a thin cylinder of tissue about ½ inch long and less than 1/8 inch in diameter) is removed and examined in the lab.

Barium enema x-ray

A barium enema is a test to see if the cancer has invaded the colon (large intestine) or rectum. This test is rarely used for women with ovarian cancer. Colonoscopy may be done instead.

Magnetic resonance imaging (MRI) scans

MRI scans also create cross-section pictures of your insides. But MRI uses strong magnets to make the images – not x-rays. A contrast material called gadolinium may be injected into a vein before the scan to see details better.

MRI scans are not used often to look for ovarian cancer, but they are particularly helpful to examine the brain and spinal cord where cancer could spread.

Chest x-ray

An x-ray might be done to determine whether ovarian cancer has spread (metastasized) to the lungs. This spread may cause one or more tumors in the lungs and more often causes fluid to collect around the lungs. This fluid, called a pleural effusion, can be seen with chest x-rays as well as other types of scans.

Positron emission tomography (PET) scan

For a PET scan, radioactive glucose (sugar) is given to look for the cancer. Body cells take in different amounts of the sugar, depending on how fast they are growing. Cancer cells, which grow quickly, are more likely to take up larger amounts of the sugar than normal cells. A special camera is used to create a picture of areas of radioactivity in the body.

The picture from a PET scan is not as detailed as a CT or MRI scan, but it provides helpful information about whether abnormal areas seen on these other tests are likely to be cancer or not.

If you have already been diagnosed with cancer, your doctor may use this test to see if the cancer has spread to lymph nodes or other parts of the body. A PET scan can also be useful if your doctor thinks the cancer may have spread but doesn’t know where.

PET/CT scan: Some machines can do both a PET and CT scan at the same time. This lets the doctor compare areas of higher radioactivity on the PET scan with the more detailed picture of that area on the CT scan.

PET scans can help find cancer when it has spread, but are not used often to look for ovarian cancer.

Other tests

Laparoscopy

This procedure uses a thin, lighted tube through which a doctor can look at the ovaries and other pelvic organs and tissues in the area. The tube is inserted through a small incision (cut) in the lower abdomen and sends the images of the pelvis or abdomen to a video monitor. Laparoscopy provides a view of organs that can help plan surgery or other treatments and can help doctors confirm the stage (how far the tumor has spread) of the cancer. Also, doctors can manipulate small instruments through the laparoscopic incision(s) to perform biopsies.

Colonoscopy

A colonoscopy is a way to examine the inside of the large intestine (colon). The doctor looks at the entire length of the colon and rectum with a colonoscope, a thin, flexible, lighted tube with a small video camera on the end. It is inserted through the anus and into the rectum and the colon. Any abnormal areas seen can by biopsied. This procedure is more commonly used to look for colorectal cancer.

Biopsy

The only way to determine for certain if a growth is cancer is to remove a piece of it and examine it in the lab. This procedure is called a biopsy. For ovarian cancer, the biopsy is most commonly done by removing the tumor during surgery.

In rare cases, a suspected ovarian cancer may be biopsied during a laparoscopy procedure or with a needle placed directly into the tumor through the skin of the abdomen. Usually the needle will be guided by either ultrasound or CT scan. This is only done if you cannot have surgery because of advanced cancer or some other serious medical condition, because there is concern that a biopsy could spread the cancer.

If you have ascites (fluid buildup inside the abdomen), samples of the fluid can also be used to diagnose the cancer. In this procedure, called paracentesis, the skin of the abdomen is numbed and a needle attached to a syringe is passed through the abdominal wall into the fluid in the abdominal cavity. Ultrasound may be used to guide the needle. The fluid is taken up into the syringe and then sent for analysis to see if it contains cancer cells.

In all these procedures, the tissue or fluid obtained is sent to the lab. There it is examined by a pathologist, a doctor who specialize in diagnosing and classifying diseases by examining cells under a microscope and using other lab tests.

Blood tests

Your doctor will order blood count tests to make sure you have enough red blood cells, white blood cells and platelets (cells that help stop bleeding). There will also be tests to measure your kidney and liver function as well as your general health.

The doctor will also order a CA-125 test. Women who have a high CA-125 level are often referred to a gynecologic oncologist, but any woman with suspected ovarian cancer should see a gynecologic oncologist, as well.

Some germ cell cancers can cause elevated blood levels of the tumor markers human chorionic gonadotropin (HCG), alpha-fetoprotein (AFP), and/or lactate dehydrogenase (LDH). These may be checked if your doctor suspects that your ovarian tumor could be a germ cell tumor.

Some ovarian stromal tumors cause the blood levels of a substance called inhibin and hormones such as estrogen and testosterone to go up. These levels may be checked if your doctor suspects that you have this type of tumor.

Genetic counseling and testing if you have ovarian cancer

If you have been diagnosed with an epithelial ovarian cancer, your doctor will likely recommend that you get genetic counseling and genetic testing for certain inherited gene changes, even if you do not have a family history of cancer. The most common mutations found are in the BRCA1 and BRCA2 genes, but some ovarian cancers are linked to mutations in other genes, such as ATM, BRIP1, RAD51C/RAD51D, MSH2, MLH1, MSH6, or PMS6. 

Genetic testing to look for inherited mutations can be helpful in several ways 

• If you are found to have a gene mutation, you might be more likely to get other types of cancer as well. You might benefit from doing what you can to lower your risk of these cancers, as well as having tests to find them early.
• If you have a gene mutation, your family members (blood relatives) might also have it, so they can decide if they want to be tested to learn more about their cancer risk.
• If you have a BRCA1 or BRCA2 mutation, at some point you might benefit from treatment with targeted drugs called PARP inhibitors.
• Even if you do not have any of the gene mutations listed above, your tumor might be tested for some of these abnormal genes because it might give you more options for treatment.

You may have heard about some home-based genetic tests. There is a concern that these tests are promoted by companies without giving full information. For example, a test for a small number of BRCA1 and BRCA2 gene mutations has been approved by the FDA. However, there are more than 1,000 known BRCA mutations, and the ones included in the approved test are not the most common ones. This means there are many BRCA mutations that would not be detected by this test.

A genetic counselor or other qualified medical professional can help you understand the risks, benefits, and possible limits of what genetic testing can tell you. This can help you decide if testing is right for you, and which testing is best. 

To learn more about genetic testing, see Should I Get Genetic Testing for Cancer Risk?

Lab tests for gene or protein changes

In some ovarian cancers, doctors might look for specific gene or protein changes in the cancer cells that could mean certain targeted or immunotherapy drugs might help treat the cancer. These tests can be done on a piece of the cancer taken during a biopsy or surgery for ovarian cancer.

BRCA1 and BRCA2 gene mutations: BRCA genes are normally involved in DNA repair, and mutations in these genes can cause cells to grow out of control and turn into cancer. Ovarian cancers with BRCA gene mutations are more likely to be helped by treatment with targeted drugs called PARP inhibitors.

Folate receptor-alpha (FR-alpha) testing: In many ovarian cancers, the cells have high levels of the FR-alpha protein on their surfaces. Testing for FR-alpha levels can show if the cancer is more likely to respond to treatment with a targeted drug such as mirvetuximab soravtansine (Elahere).

MSI and MMR gene testing: Women who have clear cell, endometrioid, or mucinous ovarian cancer might have their tumor tested to see if it shows high levels of gene changes called microsatellite instability (MSI). Testing might also be done to see if the cancer cells have changes in any of the mismatch repair (MMR) genes (MLH1, MSH2, MSH6, and PMS2). 

Changes in MSI or in MMR genes (or both) are often seen in people with Lynch syndrome (HNPCC). Up to 10% of all ovarian epithelial cancers have changes in these genes.

There are 2 possible reasons to test ovarian cancers for MSI or for MMR gene changes:

• To identify patients who should be tested for Lynch syndrome. A diagnosis of Lynch syndrome can help determine if a person should have screenings for other types of cancer, such as endometrial or colon cancer. If a person does have Lynch syndrome, their relatives could also have it, and may want to be tested for it.
• To determine treatment options for ovarian cancer. Ovarian cancers that have certain MSI or MMR gene changes might be treated with certain immunotherapy drugs known as checkpoint inhibitors.

NTRK gene mutations: Some ovarian cancers might be tested for changes in one of the NTRK genes. Cells with these gene changes can lead to abnormal cell growth and cancer. Larotrectinib (Vitrakvi) and entrectinib (Rozlytrek) are targeted drugs that stop the proteins made by the abnormal NTRK genes. The number of ovarian cancers that have this mutation is very small, but this may be an option for some women.