Oncology · Medical Literature
Determinants and outcomes of ovarian cancer diagnosis following an emergency presentation: a systematic review.
Abstract
This study aimed to identify the clinical and sociodemographic risk factors and compare cancer stage, treatment, and survival outcomes associated with ovarian cancer diagnosed following an emergency presentation versus other routes. A systematic search of Embase and MEDLINE was conducted from January 2000 to August 2025, following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines (PROSPERO: CRD420251111636). Studies were included if they examined risk factors associated with ovarian cancer diagnosis following an emergency presentation. Studies were also included if they compared treatment or survival outcomes between those diagnosed after an emergency presentation and those diagnosed via other routes. The quality of the studies was assessed using the Newcastle-Ottawa scale. Of the 3499 studies identified, 12 met the inclusion criteria and included a total of 127,395 women. All of the studies were conducted in high-income countries. Older age and socioeconomic deprivation were the most common determinants of an ovarian cancer diagnosis following an emergency presentation, although most studies did not adjust for key confounders. This diagnostic route was associated with advanced tumor stage, lower rates of treatment, shorter intervals between diagnosis and treatment initiation, and poorer survival outcomes. While the included studies were at low risk of bias, substantial heterogeneity made cross-study comparison challenging, especially as contradictory findings between larger population-based studies and single-center studies were noted. Women diagnosed with ovarian cancer following an emergency admission have a poor prognosis in many high-income countries. Urgent concerted action is needed to both decrease the number of women diagnosed through this diagnostic pathway and increase their treatment rates to improve survival outcomes.
Clinical relevance
Among women with ovarian cancer, what clinical and sociodemographic factors are associated with diagnosis following an emergency presentation, and how does this route of diagnosis compare to non-emergency routes with respect to cancer stage, treatment receipt, and survival outcomes? __SNAPSHOT__ {"studyDesign":"Systematic review (narrative synthesis; no meta-analysis performed due to substantial heterogeneity); conducted following PRISMA guidelines; pre-registered on PROSPERO (CRD420251111636); study quality assessed using the Newcastle-Ottawa Scale","setting":"Multi-national; all 12 included studies were conducted in high-income countries. Geographic distribution: 8 studies from the United Kingdom, 1 international study spanning 14 regions across 6 countries, 1 from Canada, and at least 1 additional country (full list not reported in abstract; confirmed from full text). Published in the International Journal of Gynecological Cancer, July 7, 2026.","sampleSize":"n = 127,395 women across 12 included studies (screened: 3,499 records; full-text review: 27 studies; 12 met inclusion criteria)","population":"Adult women diagnosed with ovarian cancer who were identified from population-based registries, administrative datasets, and single-center records in high-income countries; studies published January 2000 – August 2025","intervention":"Ovarian cancer diagnosis following an emergency presentation (emergency hospital admission)","comparator":"Ovarian cancer diagnosis via non-emergency routes (e.g., elective referral, two-week-wait urgent cancer referral, outpatient workup)","primaryOutcome":"Risk factors (clinical and sociodemographic) associated with emergency-route diagnosis; and comparison of cancer stage, treatment receipt, and survival outcomes between emergency and non-emergency diagnostic routes","followUp":"Not reported (varied across included studies; dependent on individual study design)","fundingSource":"Not reported in abstract or available full-text excerpt"}
Key findings
Across 12 studies totaling 127,395 women, older age and socioeconomic deprivation were the most consistently identified determinants of ovarian cancer diagnosis following an emergency presentation, although the majority of studies examining risk factors did not adjust for key confounders — only 1 of 8 risk-factor studies controlled for confounding in the Newcastle-Ottawa 'Comparability' domain (receiving 2 stars), while the remaining 7 scored 0 in that domain, indicating high residual confounding risk. Emergency-route diagnosis was consistently associated with advanced tumor stage, lower rates of any treatment, shorter intervals between diagnosis and treatment initiation, and poorer survival. Regarding treatment: in the largest study reported, 43% (2,168/5,012) of women diagnosed via emergency presentation received no treatment, compared with 25% (1,464/9,815) in the overall cohort. One adequately adjusted study (Pickwell-Smith et al.) reported significantly lower odds of receiving surgery (OR 0.39, 95% CI 0.34–0.44) and chemotherapy (OR 0.36, 95% CI 0.32–0.42) among emergency-diagnosed women versus those diagnosed through a two-week-wait referral. A contradictory single-center study (Barakat et al.) found no association between diagnostic route and mode of management, an inconsistency attributed to its smaller, single-center design. No pooled effect sizes (hazard ratios or relative risks for survival) were calculable from the available data due to substantial inter-study heterogeneity; individual study survival estimates are not reported in the abstract. NNT/NNH: not calculable from available data.
Practice implications
This systematic review establishes that emergency presentation as a route to ovarian cancer diagnosis is common across high-income countries and is associated with measurably worse oncologic outcomes: more advanced stage at diagnosis, substantially lower rates of surgery and chemotherapy, and poorer survival. The most vulnerable groups include older women, those with socioeconomic deprivation, frail patients, and — paradoxically — younger women (for whom the disease is less clinically suspected). However, the review does NOT establish causality; the inferior outcomes in the emergency group may reflect the underlying biology (advanced disease prompting emergency symptoms) rather than — or in addition to — a care-pathway effect of the emergency route itself. Critically, most risk-factor studies lacked confounder adjustment, making it impossible to isolate the independent contribution of any single factor. The evidence base is heavily weighted toward the United Kingdom, limiting applicability to health systems with different referral structures, insurance models, or cancer registry practices (e.g., the United States, low- and middle-income countries). Contradictory findings between large population-based studies and single-center studies further caution against universal generalization. Practice should not change based on this review alone, but findings strongly support: (1) proactive clinician vigilance for ovarian cancer symptoms in older, frail, and socioeconomically deprived women presenting to emergency settings; and (2) institutional investment in system-level early detection strategies. NOTE: Only the abstract and selected full-text excerpts were available for this summary; specific survival hazard ratios, p-values, and complete country-level breakdowns could not be independently verified from the abstract alone. __LIMITATIONS__ Narrative synthesis only — no meta-analysis performed; pooled effect estimates for survival or treatment outcomes are not available, precluding quantitative comparison across studies.,Substantial inter-study heterogeneity in definitions of 'emergency presentation,' diagnostic routes, outcome measures, follow-up duration, and patient populations made cross-study comparison challenging.,The majority of risk-factor studies (7 of 8) did not adjust for any confounders (Newcastle-Ottawa Comparability score: 0), introducing high risk of confounding bias; residual confounding is likely even in the 5 outcome studies that did adjust.,All 12 studies were conducted exclusively in high-income countries, most heavily in the United Kingdom (8/12 studies), severely limiting generalizability to lower-income settings or systems without organized referral pathways.,Single-center studies yielded contradictory findings compared to population-based studies, suggesting that site-level case mix, volume, and referral patterns confound results.,Observational study designs across all included studies preclude causal inference — it is unclear whether emergency presentation independently drives worse outcomes or whether advanced underlying disease drives both the emergency presentation and the poor outcomes.,Follow-up duration varied across studies and was not standardized, limiting comparison of survival endpoints.,Frailty, ethnicity, and comorbidity data were inconsistently captured or reported across studies, preventing robust evaluation of these determinants.,Funding sources for the systematic review itself were not reported, and sponsorship of individual included studies was not assessed as a potential bias source.,The review searched only two databases (Embase and MEDLINE), which may have resulted in missed relevant studies indexed elsewhere. __BOTTOM_LINE_CATEGORY__ potentially_practice_informing __BOTTOM_LINE__ Emergency presentation is a common and clinically consequential route to ovarian cancer diagnosis, affecting approximately 40% of women in England and similarly high proportions in other high-income countries, with consistent associations with advanced stage, lower treatment rates, and worse survival. Older age, frailty, and socioeconomic deprivation are the leading identified risk factors, though most contributing studies lacked adequate confounder adjustment. Clinicians — particularly in emergency medicine, primary care, and gynecology — should maintain a heightened index of suspicion for ovarian cancer in these high-risk groups and advocate for system-level interventions to reduce diagnostic delay; however, causally directed practice changes await higher-quality, confounder-adjusted, prospective research.