Consultant Obstetrician & Gynaecologist Walsall Healthcare NHS Trust Ovarian Cancer Fateh Ghazal Consultant Obstetrician & Gynaecologist 23/3/16

Outline Background Primary care pathway Secondary care pathway ROCkeTS Study & IOTA rules Case presentations 2

Background 1 in 10 women will have surgery for ovarian mass 1 in 10 of suspected ovarian masses are non ovarian Incidence of malignancy in symptomatic ovarian masses is: 1:1000 for premenopausal women 3:1000 for 50 years old 3

Ovarian Cancer Spread lifetime risk 2% Approximately 7000 women diagnosed in the UK each year Frequently diagnosed at Stage 3C/4 Insidious onset with bloating and ascites Treated primarily with surgery and chemotherapy 4

Ovarian cancer Symptoms & Signs: Persistent (>12 times a month) Bloating Feeling full Pelvic pain Urinary urgency / frequency >50 & newly diagnosed IBS 1 in 2 women, aged 45 -70 present to GP each year with symptoms, Sasieini BMC 2014 6

Primary care investigations ≥ 35 IU/ml TA/TV scan Suspected ovarian cancer 2 WW referral Normal < 35 IU/ml Exclude other pathologies 7

Raised CA125 Non-malignant disorders Pelvic-mass associated Multi-visceral tuberculosis Meigs and pseudo-Meigs syndrome Ovarian hyperstimulation syndrome Non-pelvic mass associated Liver cirrhosis Tuberculosis peritonitis Uraemia and renal failure Nephrotic syndrome Fulminant hepatic failure Pancreatitis Malignant disorders Primary pelvic tumour Ovarian cancer Advanced uterine cancer Advanced fallopian-tube cancer Advanced rectal or bladder cancer Secondary pelvic involvement Lymphoma with peritoneal involvement Pancreatic carcinoma Breast cancer with peritoneal metastasis Gastric cancer with peritoneal metastasis/ Advanced hepatocellular ca

Internal audit GP referrals CA125: 3:8 patients (37%) USS: requested in 10:10 patients (100%) USS images uploaded to fusion: 6:10 patients (60%)

Current system Cancer Referral to Treatment start date Date first seen Referral To Treatment (≤ 62 days) Cancer Referral to Treatment start date Date first seen Diagnosis communicated to patient Cancer Treatment Period Start date (Decision To Treat) Treatment Start Date Two week wait (≤ 14 days) First treatment (≤ 31 days)

New system Cancer Referral to Treatment start date Date first seen Diagnosis communicated to patient Cancer Treatment Period Start date (Decision To Treat) Treatment Start Date Two week wait <14 days Four weeks (28 days) First treatment (≤ 31 days) Referral To Treatment (≤ 62 days)

Pre menopausal – Simple cyst Simple ovarian cyst < 5 cm Discharge 5-7 cm Annual scan > 7 cm Consider surgery No Tumour markers Asymptomatic patient 12

Pre menopausal – Complex cyst Complex ovarian cyst < 200 Endometriosis / Fibroids excluded > 200 CA 125 LDH, AFP, BHCG if <40 years Oncology MDT 13

Post menopausal – Ovarian cyst RMI 25-250 Lap BSO >250 Oncology MDT CA 125 TA/TV scan 14

Post menopausal – Ovarian cyst RMI < 25 Simple cyst unilateral < 5 cm CA 125 < 30 TV scan + CA 125 Every 4 months for 1 year No change or resolved Discharge Increased in size / suspicious Recalculate RMI Other cyst Consider surgery 15

RMI = U x M x CA-125 USS features: multilocular solid areas metastases ascites bilateral lesions U = 0 (for an ultrasound score of 0), U = 1 (for an ultrasound score of 1), U = 3 (for an ultrasound score of 2–5). The menopausal status is scored as 1 = premenopausal 3 = postmenopausal 16

ROCkeTS Study & IOTA Rules Multicentre Portfolio Study – NIHR 2 years period Both pre and postmenopausal women with suspected ovarian cancer Exclusion simple ovarian cyst < 5 cm No change in current management Eligible patients will be invited for 3 extra tests Symptoms Questionnaire Blood Test Detailed TA/TV scan IOTA rules 17

Irregular solid tumour B-rules M-rules Unilocular cysts Irregular solid tumour Solid components <7mm Ascites Acoustic shadowing At least four papillary structures Smooth multilocular <100mm Irregular multilocular solid tumour >100mm No blood flow Very strong blood flow 18

In conclusion Ovarian cancer: 80% present at advanced stage All stage 5 years survival <45% The most common cause of gynaecological cancer death Suspect early, Investigate appropriately, Refer promptly 19

Thank you for listening, any questions? 20