Ovarian cancer, although ranking lower in overall incidence among cancers in the United States, is the most lethal gynecologic malignancy, with a 5-year survival rate of 50.9% despite advances in therapies. Two of the largest challenges in management are the lack of effective screening and the vague symptoms of the disease. Most ovarian cancers are diagnosed after metastasis has occurred. Genetic variants, such as BRCA1 and BRCA2, are strong risk factors, accounting for 10% to 15% of all ovarian cancers. Physicians should consider ovarian cancer in patients with pelvic pain or rapidly increasing abdominal girth. Initial workup includes a bimanual examination palpating for pelvic mass, an abdominal examination for ascites, transvaginal ultrasonography, and a cancer antigen 125 level. Referral to gynecologic oncology is appropriate for patients with findings concerning for malignancy on ultrasonography or with ascites or findings of metastasis. For patients with elevated cancer antigen 125 levels, referral is also warranted. Although there have not been significant advances in early detection, survival rates have improved because of better management and treatment. Family physicians play an important role by providing long-term continuous relationships with patients that may improve recognition of the disease and by providing support during treatment.

Case 3. JN is a 59-year-old cisgender woman who presents with several months of abdominal bloating, early satiety, fatigue, and vague pelvic pain. She has lost approximately 6.8 kg (15 lb) but has been trying to eat healthier and exercise. You palpate a fullness in her right adnexa on bimanual examination and order transvaginal ultrasonography.