Early Diagnosis of Gynaecological Cancer Rob Gornall Consultant Gynaecology GHNHST

How do we benchmark ourselves? Survival Stage at presentation Audit against agreed referral guidelines Are pathways agreed fit for purpose? What information/resource is there available to quality assure the pathway? What are the expectations of the 2ww referral service and is it achieving its aims?

LUNG CANCER 5 YR R.S. AUS CAN SWE NOR DEN UK COLORECTAL CANCER 5 YR R.S. AUS CAN SWE NOR DEN UK OVARIAN CANCER 5 YR R.S. AUS CAN NOR DEN UK BREAST CANCER 5 YR R.S. AUS CAN SWE NOR DEN UK

Initiatives to reduce cancer and improve early diagnosis Vaccination Programme Screening Public awareness campaigns – early reporting of symptoms 2WW referral guideline Recent NICE guidance on early recognition and initial management of ovarian cancer

Gynaecological cancer Relatively rare cancers Diverse presentation symptoms Large overlap with common conditions IBS/menstrual disorders 2WW Clinics work based around cancer detection of 1 in 10 referrals ‘Best’ services detect only 25% over overall cases What happens to the other 75%

2WW referral guidelines PMB in a women over 55 not on HRT Lesion suspicious for cervical/vulval cancer PCB in a woman over 35 years Pelvic mass not obviously fibroids Suspicious mass on USS

Suspected Endometrial Pathology 2ww referral criteria Significance of endometrial thickening HRT and referral Hysteroscopy or endometrial biopsy? Endometrial hyperplasia

Pathway well established Ultrasound triage Endometrial biopsy/Hysteroscopy if endometrial thickness > 4 mm Outpatient one stop service acceptable for most patient needs Ensure early review for recurrent symptoms Increasing referrals not meeting 2ww criteria put pressure on current service

Moving towards better outcomes from cervical cancer Prevention Vaccination/smoking cessation Gloucestershire screening coverage < 80% Screen detected cancers more likely early stage/managed conservatively Clinical diagnosis sometimes difficult If in doubt refer rather than perform smear Delay in diagnosis particularly in young patients with abnormal bleeding

Suspected Ovarian Pathology Who should I investigate? How should I investigate? CA125 or USS Referral to Secondary Care Criteria Hereditary Ovarian Cancer Indications for risk reducing surgery

2WW All patients with a palpable abdominal or pelvic mass on examination that is not obviously uterine fibroids, nor of gastrointestinal or urological origin Suspicious pelvic mass on imaging

More Usual Presentation Non-specific symptoms may also include: abdominal pain persistent bloating back pain changes in bowel habit urinary and/or pelvic symptoms tiredness difficulty eating and feeling full quickly Shortness of breath

NICE Guidance Early Recognition Patients who have 3 or more symptoms are at increased risk of ovarian cancer Recommendation as initial investigation by primary care CA125 If elevated proceed to USS

Risk of malignancy Menopause score (1,4) USS score (1-3) CA125 RMI > % likelihood malignant in postmenopausal patients Refer to Cancer Centre for Management RMI < 250 Management at cancer unit

Ovarian Cancer Case Discussion CW Age 61 yrs 3 month presentation change in bowel habit/discomfort CA125 normal Referral to secondary care routine GI – CT/endoscopy diverticular disease /indeterminate mass between sigmoid/uterus ?inflammatory 3 month later abdo distension rpt imaging ascites CA Stage 3c ovarian cancer

Ovarian cancer Case Presentation AG Age 67 Presentation recurrent symptoms of UTI multiple course antibiotic therapy over 6 months despite negative MSSU Presentation to another G.P with abdominal distension Examination confirmed large pelvic mass with ascites. CA Referral 2ww – stage 3C ovarian cancer

Ovarian cancer case Discussion DW Age 58 3 month history dyspareunia. Family history of breast/ovary cancer Referral general gynaecology routine 6 week visit OPD 20 week pelvic mass CA CT Ascites Omental Disease Stage 3C ovarian cancer

Moving forward Role of 2WW service – appropriate referrals ?wrong thresholds Availability of endometrial biopsy/USS in primary care Establishing uniformity across Gloucestershire with access to services Earlier investigation for symptoms that could be related to ovarian malignancy – examination/CA125/USS Patient awareness and education key to earlier diagnosis

What are the take home messages? Appreciation of diverse presentation Risk factor awareness Early CA125 Early Pelvic examination USS if strong suspicion of ovarian pathology despite ‘reassuring’ CA125 Review appointment to reassess symptoms and repeat CA125 or USS

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