Airedale NHS Foundation Trust Gynaecology MDT Claire Parkinson Macmillan Gynaecology Nurse Specialist The Cancer Alliance is part of West Yorkshire and Harrogate Health and Care Partnership - www.canceralliance.wyhpartnership.co.uk Twitter: @WYHpartnership or @profseanduffy

Approach used Proforma created to standardise information to enable optimal MDT discussions Flow charts of patients’ pathways developed with a SOP for straightforward patients and patients who can be streamlined outside of the MDT

Issues Discussion of non cancer patients No clear questions Delays in pathway waiting for MDT decisions Relevant information not known (Performance status, co-morbidities, patients’ wishes & understanding)

Challenges Time All to be involved Lack of IT skills Embedding the new proforma Making all aware of changes

Outcomes with Proforma Time saved preparing for MDT Optimal MDT discussions Knowing what the question is which needs addressing Saving time in the MDT

Outcomes expected with pathways & SOP Reduction in frequency of patients being discussed Shortening of the patients’ pathway Education of staff of usual investigations & management plan None cancer patients being discussed outside the MDT

Flow chart for management of patients with a suspected or diagnosed endometrial cancer outside the MDT meeting Suspicion of cancer unable to gain access to cavity Atypical hyperplasia Severe atypical cells and or suspicion of cancer Grade 1 or 2 adenocarcinoma of the endometrium High grade Endometrial cancer Discussion with patient re options – Progesterone intrauterine or oral Discussion with patient re most appropriate treatment - hysterectomy Organise urgent MRI & ensure recent U&E’s Organise urgent CT scan Abdo / pelvic & chest ensure U&E’s Discussion with patient re options surgery / monitoring Meet patient & list for local surgery Inform patient Discussion at local MDT Discussion at Local MDT Discuss with central MDT Discuss at local MDT if IB discuss centrally List for Hysterectomy& BSO or request MRI Scan List for surgery or commence other treatment Ensure dated at Leeds & OPD & pre-op booked Commence treatment Register centrally post op All patients on fast track pathway or who have been upgraded should have treatment before day 62

Meet patient & discuss likely plan Flow chart for management of patients with a suspicion of ovarian / Primary peritoneal / tubal cancer outside of MDT meetings Complex cyst with septations Normal CA 125 Risk of Malignancy Index (RMI) < 250 Simple cyst normal CA 125 or Dermoid cyst Complex cyst raised CA 125 RMI >250 Ascites and or omental / peritoneal disease on scan Request an urgent CT scan Repeat CA 125 & request CEA & CA 19.9 Tumour markers (CA 125 CEA CA 19.9) Discuss with radiologists if biopsy possible. Request & organise biopsy There is no need to refer to the MDT. Discuss management with radiologists and or consultant Request an urgent MRI scan. If high concerns of malignancy discuss with radiology Repeat CA 125 (to ensure not rising) request CEA & CA 19.9 Meet patient & explain possible plan Meet patient & discuss likely plan Discuss local & central MDT Meet with patient add to waiting list for surgery Discuss local & central MDT Ensure OPD with surgeon at Leeds or Oncologist Discuss local MDT & central if suspicious of malignancy Organise OPD with Oncologist or Surgeon at Leeds All patients on fast track pathway or who have been upgraded should have treatment before day 62

Flow chart for management of patients with a diagnosis cervical cancer outside the MDT meeting Stage 1A1 completely excised by loop excision Squamous cell carcinoma Any Adenocarcinoma Any cervical cancer greater than 1A1 from LLETZ or cone Request MRI scan ensure U&E’s have been done Organise MRI if disseminated disease suspected CT may also be required Clinic appointment to inform patient Clinic appointment to inform patient Clinic appointment to inform patient Annual cervical cytology test for 10 years Addition to central MDT Addition to Central MDT Book OPD to see relevant consultant – surgery / radiotherapy / chemotherapy PET scan usually organised by Leeds – Inform patient Discuss at local MDT & add to central for registration / information only Book OPD to see relevant consultant – surgery / radiotherapy / chemotherapy

Flow chart for management of patients with a suspected or diagnosis of vulval cancer outside the MDT meeting Suspicion of malignancy & unable to biopsy in OPD Any stage or grade of cancer of the vulva found Patient has an obvious lesion which is less than 2cm & is symptomatic with other comorbidities & not fit for extensive treatment If clinically thought to have nodal involvement or more extensive disease organise appropriate imaging MRI / CT discuss with radiologist if unsure To organise a biopsy in theatre under LA or GA Consider excision of entire lesion. Consider discussion with core member of central MDT. A photograph prior to surgery can be helpful. If no cancer found & no concerns with specimen obtained no need to discuss at MDT Organise OPD to be informed of results Organise OPD to inform patient of diagnosis Referral & discussion at the central MDT Discuss centrally If concerns discuss with core member of MDT & add to MDT if felt appropriate Ensure OPD for appropriate consultant made surgeon . Clinical oncologist or medical oncologist Dependent on outcome of MDT organise appropriate OPD

Flow chart of the management of patients with a suspicion of or diagnosis of vaginal cancer Suspicion of a vaginal cancer on examination Confirmed cancer following biopsy Organise further imaging usually MRI but if disease thought to be more extensive than pelvis both MRI & CT may be required – Ensure U&E’s available If unable to take biopsy in OPD organise GA / theatre urgently Organise OPD to inform patient of diagnosis If benign no need to discuss at MDT unless you remain suspicious that this is a cancer Add to central MDT once confirmed cancer found Organise OPD with appropriate consultant – Surgeon Leeds / Clinical Oncologist / Medical Oncologist

Any questions?