Screening Strategies Are Evolving for Gynecologic Cancers
To improve early disease detection, radiologists need to know how to locate and recognize features of early cancer
In concert with the RadioGraphics monograph, RSNA News shares the latest on the role of medical imaging in disease screening.
Ovarian, endometrial and cervical cancers are the most common cancers of the gynecologic organs and major causes of cancer-related illness and death worldwide. Early detection is critical to improving patient outcomes.
“Imaging plays a limited role in primary screening for the most common gynecologic cancers, but it becomes very important as soon as cancer is detected or suspected on the basis of clinical tests such as Pap smear screening for cervix cancer or symptom-based imaging for endometrial cancer,” said Priyanka Jha, MBBS, associate professor of radiology at Stanford University in California and lead author of the review. “As imagers, we need to understand what early cancer looks like and where to look for disease, because the consequences of lost time can be significant for the patient.”
In a new RadioGraphics article, Dr. Jha and colleagues summarize current and emerging screening strategies and provide practical guidance to help radiologists recognize nuanced signs of early ovarian, endometrial and cervical cancers. They also share insights on disease appearance in patients with elevated genetic risk for gynecologic cancer.
“This review describes screening and imaging within the broader context of gynecologic cancer care,” said senior author Aradhana M. Venkatesan, MD, professor at the University of Texas MD Anderson Cancer Center in Houston. “Understanding how imaging informs clinical decision-making is essential to providing the best care for our patients.”
Imaging is increasingly integrated into staging systems, Dr. Jha said, making it essential to stay informed as gynecologic oncology care evolves. “The role of imaging is variable across the three cancers,” she explained. “But if there’s one diagnosis we never want to miss, it’s cancer.”
Looking Beyond the Ovary
Gynecologic imaging typically enters the workflow after a positive screening test or cancer diagnosis. In ovarian cancer (OC), early detection is difficult because symptoms are often nonspecific. Most patients present with advanced disease.
Incidence of OC is also increasing in the U.S., with roughly 20,890 new cases and 12,730 deaths estimated for 2025. “Right now, there is no single test for OC screening. No labs or blood tests have emerged as an optimal screening test,” Dr. Jha said.
As a result, ovarian imaging is used in patients at high risk for cancer, including those with BRCA mutations and Lynch syndrome, as well as other inherited genetic conditions. Clinical trials for OC screening focused on detecting ovarian lesions have thus far not shown good results, Dr. Jha noted. But she and her colleagues believe a paradigm shift is coming.
“One of the most groundbreaking things we’ve learned in the last five to 10 years is that high-grade serous OC does not start in the ovary. It starts in the fallopian tubes, and those cells are shed onto the ovary,” Dr. Jha said.
Fallopian tubes can be seen on imaging, she emphasized, and it’s a matter of routinely assessing them when OC screening is being performed. Radiologists should pay close attention to subtle changes on US and MRI, involving the tubes in addition to the ovaries. They should also look for mass-like changes and small solid lesions as potential early signs of OC.
“Ovarian cancer remains one of the greatest challenges in early detection,” Dr. Venkatesan said. “For imaging, both the challenge and the opportunity are to detect clinically meaningful disease early enough to make a difference for patients.”
Endometrioid adenocarcinoma (FIGO stage I–II) with superficial myometrial invasion in a 39-year-old woman who presented with abnormal uterine bleeding. (A, B) Sagittal (A) and axial oblique (B) T2-weighted MR images of the uterus show a known endometrial carcinoma (arrowhead) in the lower uterine corpus with intermediate T2 signal intensity and an indistinct interface with the inner myometrium. (C, D) Axial oblique high–b-value diffusion-weighted MR image (C) and corresponding ADC map (D) show the endometrial tumor (black arrowhead) with restricted diffusion and focal irregularity at the tumor–myometrium interface (white arrowhead), consistent with superficial myometrial invasion. (E) Sagittal fat-saturated contrast-enhanced T1-weighted MR image obtained within 60 seconds after administration of intravenous contrast material shows a hypoenhancing endometrial tumor (black arrowhead) with focal disruption of the normally intact subendometrial enhancement and associated peritumoral enhancement (white arrowhead), supporting superficial myometrial invasion. (F) Axial oblique fat-saturated contrast-enhanced T1-weighted MR image obtained approximately 3 minutes after administration of intravenous contrast administration shows the hypoenhancing endometrial tumor (black arrowhead) and focal irregularity at the tumor-myometrium interface (white arrowhead), consistent with superficial myometrial invasion.
https://doi.org/10.1148/rg.260031 ©RSNA 2026Visualizing the Entire Endometrium
Like OC, incidence rates of endometrial cancer (EC) are rising. In 2020, about 417,000 new cases and 97,000 deaths were reported globally. “For EC, there is a little bit of good news: patients often present with symptoms that prompt evaluation,” Dr. Jha said.
EC primarily affects postmenopausal women, who often present with abnormal uterine bleeding that prompts imaging assessment with transvaginal US.
Bleeding with endometrial thickness that exceeds 5 mm usually leads to biopsy. However, conventional thresholds have limitations. Dr. Jha noted that the literature shows patients of African American origin have an increased risk of missed cancer diagnoses.
“This applies to any patient who has fibroids or severe adenomyosis,” she said. “They cause shadowing, and we’re not able to see the endometrium very well on US.”
“It’s important for whomever is interpreting the study to ensure the endometrium is seen in its entirety,” Dr. Jha continued, “It’s also important to acknowledge that non-visualized areas may harbor malignancy.”
When US is inadequate or technically limited, MRI can provide further evaluation.
“A measurement is only as useful as the examination behind it. When the endometrium cannot be fully evaluated, communicating that limitation clearly helps the care team determine the next step and avoid false reassurance,” Dr. Venkatesan said.
Understanding Changes in the Cervix
Evaluations for OC and EC are typically symptom driven, whereas cervical cancer (CC) is often found through screening with Pap smears, Dr. Jha said.
CC tends to affect reproductive-aged women, and 90% of cases are caused by persistent human papillomavirus (HPV) infection. Current diagnosis relies on cytology, such as Pap testing, for patients with average risk, and HPV testing for patients at high risk.
After an abnormal result, imaging becomes vital for staging, treatment planning and surveillance. “Accurate staging is important in all patients, particularly those who are pursuing fertility-sparing surgeries,” Dr. Jha said.
For older patients, she stressed that radiologists should be aware of age-related changes in anatomy, such as the shift of the location of the squamocolumnar junction and transformation zone on the cervix after menopause.
“That junction sits deeper in the lumen of the endocervix after menopause, so cancers in older patients tend to occur inside the cervix rather than conventionally on the outside,” Dr. Jha explained.
“Radiologists need to adapt their search patterns, being mindful of these age-related changes,” Dr. Venkatesan said. “Recognizing these patterns can help us avoid overlooking clinically significant disease.”
Looking ahead, this expanded understanding of OC, EC and CC will contribute to more precise, patient-centered imaging.
Personalizing Gynecologic Cancer Care
Genetic abnormalities and risk factors will increasingly dictate who gets imaging and when, Dr. Jha said. Other emerging strategies include liquid biopsy and AI–assisted approaches.
“In the next decade or so, we will likely see a shift in how people are screened, and chances are that disease will be detected earlier,” Dr. Jha emphasized. “As radiologists, we will have to train ourselves to do better at recognizing the early features of malignancy, rather than large masses and distant metastases.”
“As these approaches evolve, our role as radiologists will evolve with them,” Dr. Venkatesan said. “The goal is to integrate clinical risk, molecular information and imaging to guide individualized care and improve outcomes for our patients.”
For More Information
Access the RadioGraphics article, “Screening for Common Gynecologic Malignancies.”
Read previous RSNA News stories on gynecologic imaging: