• Cancer Care Ontario (CCO). Diagnostic imaging in the assessment of metastatic and recurrent ovarian cancer. Toronto (ON): Cancer Care Ontario (CCO); 2006 Apr 7. 14 p. [15 references]

Metastatic and recurrent ovarian cancer

Diagnosis
Evaluation

Obstetrics and Gynecology
Oncology
Radiology

Physicians

• To provide some initial guidance to Ontario health care providers and planners on the use of cross-sectional diagnostic imaging technology for patients with metastatic or recurrent ovarian cancer
• To promote evidence-based practice, provide guidance to clinicians about which imaging techniques are the most appropriate to use in the workup and management of their patients, provide information that is useful to those charged with planning for the number of imaging machines needed for patients with cancer in Ontario, and be used to monitor the use of imaging modalities in patients with cancer

Patients with metastatic and recurrent ovarian cancer

1. Computed tomography (CT)
2. Magnetic resonance imaging (MRI)
3. Ultrasound

• Disease recurrence
• Quality of life
• Survival
• Frequency of true- and false-positive tests
• Sensitivity and specificity of diagnostic tests
• Positive and negative predictive value

Searches of Electronic Databases

Literature Search and Evidence Appraisal Strategies

English language evidence published between 1980 and 2004 was searched through MEDLINE, EMBASE, and the Cochrane Databases of Systematic Reviews and Abstracts of Reviews of Effects. Clinical practice guidelines, meta-analyses, systematic reviews, and trials reporting on sensitivity and specificity were sought. Search strategies were modified for each database and disease site (see Appendix A in the original guideline document).

Eligibility Criteria

Inclusion

Studies were included if they satisfied all of the following criteria:

• Included patients with confirmed ovarian cancer
• Evaluated computed tomography (CT), magnetic resonance imaging (MRI) or ultrasonography
• Described an objective diagnostic standard
• Reported data for disease recurrence, quality of life, survival, frequency of true- and false-positive tests for extent of disease, or sensitivity, specificity, positive predictive value or negative predictive value to detect distant metastases
• Were randomized trials, comparative cohort studies, case series (prospective or retrospective) with more than 12 consecutive patients, meta-analyses (published in English after 1998) of data from randomized trials, comparative cohort studies or case series, or evidence-based clinical practice guidelines

Exclusion

Letters, editorials, and meeting abstracts were not included.

A total of ten papers met the inclusion criteria and were obtained for review.

Expert Consensus (Committee)

Not applicable

Systematic Review with Evidence Tables

Not stated

Expert Consensus

In 2003, Cancer Care Ontario (CCO) established a small working panel, the Diagnostic Imaging Panel, consisting of medical, radiation, and surgical oncologists, diagnostic radiologists, and methodologists, to review guidelines published during the last five years on the use of cross-sectional imaging in oncology. After examining documents from nineteen guideline developers, the panel concluded that the available guidelines did not focus on the particular issues of interest here. Therefore, the panel decided to review the primary research and develop recommendations for Ontario on the use of computed tomography (CT), magnetic resonance imaging (MRI), and ultrasound (US) for any additional staging, assessment of tumour response during active treatment, and follow-up for patients with six types of cancer: lymphoma, breast cancer, colorectal cancer, prostate cancer, lung cancer, and ovarian cancer.

A systematic review of the literature identified few randomized studies to provide guidance on the use of cross-sectional imaging in the management of patients with cancer; therefore, it was decided to also include cohort studies and case series reports in the evidence review and incorporate expert opinion in the development of the recommendations. The initial selection and summary of relevant evidence was completed by methodologists at the Program in Evidence-Based Care in consultation with the clinical experts from the Diagnostic Imaging Panel (see Section IV in the original guideline document).

The reviews served as the evidentiary foundation to inform the deliberation of clinical experts. Formal and informal consultations with radiologists was facilitated by Dr. Anne Keller, diagnostic imaging representative of the CCO Clinical Council, and undertaken with members who participated in the provincial MRI and CT Wait Times Strategy Expert Panel and the CCO Diagnostic Imaging Panel. In addition, consultations with oncologists were undertaken, mainly through the relevant disease site groups of CCO's Program in Evidence-Based Care. Through these consultations emerged the recommendations, which are presented in the format developed by the Canadian Association of Radiologists (see Section VI in the original guideline document).

Not applicable

A formal cost analysis was not performed and published cost analyses were not reviewed.

External Peer Review
Internal Peer Review

Expert Consultation

The draft report, with recommendations developed by a small panel of experts in oncology and radiology, was distributed with a 4-item survey in March 2006 for review as part of an external consultation process to a broader group of Ontario radiologists and oncologists. The external consultation included the 15 members of the provincial Gynecology Cancer Disease Site Group and 23 other Ontario health care providers. Among the eight respondents (21%), which included two Gynecology Cancer Disease Site Group members, two radiologists, two obstetricians, and two other clinicians, seven completed the report survey, and two of these respondents provided written comments. An additional respondent provided written feedback only. Results appear below in Table 2 in the original guideline document.

Report Approval Panel Feedback

The feedback from the Report Approval Panel (RAP) was an acknowledgement that included recommendations are principally based on consensus and that the methods involved in the consensus process is unclear. Also, the role of any diagnostic testing in follow-up is not provided. Adding some information on follow-up would help to make the document more helpful in assisting non-experts, promoting uniformity among experts, and for assisting those responsible for determination of resource needs.

The authors added information concerning follow-up into the document to address this concern.

These recommendations were developed by radiology and oncology experts in Ontario and are informed by research evidence and clinical expertise.

*Band classification of the typical effective doses of ionizing radiation from common imaging procedures

None provided

The recommendations are supported by case series.

Appropriate use of diagnostic imaging in the assessment of metastatic and recurrent ovarian cancer

Not stated

Computed tomography (CT) is contraindicated when the patient has a contrast allergy.

Care has been taken in the preparation of the information contained in this document. Nonetheless, any person seeking to apply or consult the recommendations in this report is expected to use independent medical judgment in the context of individual clinical circumstances or seek out the supervision of a qualified clinician. Cancer Care Ontario makes no representation or guarantees of any kind whatsoever regarding their content or use or application and disclaims any for their application or use in any way.

An implementation strategy was not provided.

Living with Illness

Effectiveness

• Cancer Care Ontario (CCO). Diagnostic imaging in the assessment of metastatic and recurrent ovarian cancer. Toronto (ON): Cancer Care Ontario (CCO); 2006 Apr 7. 14 p. [15 references]

Not applicable: The guideline was not adapted from another source.

2006 Apr 7

Program in Evidence-based Care - State/Local Government Agency [Non-U.S.]

The Program in Evidence-based Care (PEBC) is a Province of Ontario initiative sponsored by Cancer Care Ontario and the Ontario Ministry of Health and Long-Term Care.

Cancer Care Ontario
Ontario Ministry of Health and Long-Term Care

Not stated

Not stated

Not stated

The following is available:

• Browman GP, Levine MN, Mohide EA, Hayward RSA, Pritchard KI, Gafni A, et al. The practice guidelines development cycle: a conceptual tool for practice guidelines development and implementation. J Clin Oncol 1995;13(2):502-12.

None available

This NGC summary was completed by ECRI on October 29, 2006. The information was verified by the guideline developer on November 24, 2006.