‘Let’s get it right - Referral for suspected Cancer’ Dr Banchhita Sahu Consultant O&G Mr Nick Reed MDT lead, Consultant O&G

2 week pathway

Why? Increasing numbers of 2WW referrals No ability to down grade referrals Workload of the Dept and MDT Impact on the management of proven cancer.

2 Week Wait Referrals and confirmed cancers

Audit of 2 WW referrals (2014) 50 PMB 18 PCB/Cervix 11 Pelvic mass 2 Vulva 7 Other Others 2 No information ticked 2 Vague symptoms 1 Incidental raised Ca125 2 Pain

NICE 2015 Endometrial cancer 1.5.10 Refer women using a suspected cancer pathway referral (for an appointment within 2 weeks) for endometrial cancer if they are aged 55 and over with post‑menopausal bleeding (unexplained vaginal bleeding more than 12 months after menstruation has stopped because of the menopause). [new 2015] 1.5.11 Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for endometrial cancer in women aged under 55 with post‑menopausal bleeding. [new 2015]

Post Menopausal Bleed Post Menopausal bleed 40(80%) Appropriate 10(20%) Inappropriate Inappropriate referrals 2 Heavy menstrual bleeding 2 perimenopausal 2 Ring pessaries 2 Hysterectomies 2 Recent HRT

NICE 2015 Cervical cancer 1.5.13 Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for women if, on examination, the appearance of their cervix is consistent with cervical cancer. [new 2015] PCB – Not an indication for referral!

NHSCSP- 10 4.11 Women presenting with symptoms of cervical cancer – such as postcoital bleeding (particularly in women over 40 years), should be referred for gynaecological examination and onward referral for colposcopy if cancer is suspected. Examination should be performed by a gynaecologist experienced in the management of cervical disease (such as a cancer lead gynaecologist). They should be seen urgently, within two weeks of referral.

Cervix  9 Post coital bleed PCB (Inappropriate) IMB 1 Appropriate 4 No smear hx 3 No swabs 4

NICE 2015- Ovary 1.5.1 Refer the woman urgently if physical examination identifies ascites and/or a pelvic or abdominal mass (which is not obviously uterine fibroids). [2011] 1.5.2 Carry out tests in primary care (see recommendations 1.5.6 to 1.5.9) if a woman (especially if 50 or over) reports having any of the following symptoms on a persistent or frequent basis – particularly more than 12 times per month: persistent abdominal distension (women often refer to this as 'bloating') feeling full (early satiety) and/or loss of appetite pelvic or abdominal pain increased urinary urgency and/or frequency. [2011]

NICE 2015- Ovary 1.5.6 Measure serum CA125 in primary care in women with symptoms that suggest ovarian cancer (see recommendations 1.5.1 to 1.5.5). [2011] 1.5.7 If serum CA125 is 35 IU/ml or greater, arrange an ultrasound scan of the abdomen and pelvis. [2011] 1.5.8 If the ultrasound suggests ovarian cancer, refer the woman urgently[1] for further investigation. [2011] 1.5.9 For any woman who has normal serum CA125 (less than 35 IU/ml), or CA125 of 35 IU/ml or greater but a normal ultrasound: assess her carefully for other clinical causes of her symptoms and investigate if appropriate if no other clinical cause is apparent, advise her to return to her GP if her symptoms become more frequent and/or persistent. [2011]

Pelvic Mass(11) Inappropriate referrals Appropriate 3 (28%) USS and Ca125 Inappropriate 8 (72%) Inappropriate referrals −no Ca125/USS (5) −Scan no Ca125 (2) −Simple cyst/N Ca125

‘’45 year old, bloated and pelvic pain, I have arranged ultrasound and CA125’ ‘Incidental finding of ovarian cyst on scan, 54 year old, ‘sizable cyst on scan(26x 30mm), CA125-8, mother had ovarian cancer 81 year old, incidental finding of 3cm ovarian cyst on CT colonoscopy, CA125 5

Others No information (2) Vague symptoms(2) Incidental raised Ca125(1) Pain/discomfort(2)

CONCLUSION 42(48%) Inappropriate referrals via the 2WW pathway 20(48%) Incomplete information on referral These patients need to be seen urgently in the OPD. This will ease pressure on the service; MDT, cancer targets.

Effect on 62 day target

Reasons for breech Workload Poor tracking First Appointment 14+ days Patient delayed investigations Delay in referral to tertiary care

Actions Taken Guidelines and Pathways for – Premenopausal Ovarian Cyst Post menopausal Ovarian cyst Postmenopausal bleeding Suspicious cervix/PCB One stop clinic- PMB PCB/suspicious cervix clinic ?Vulval clinic 80% of endometrial cancer managed laparoscopically TLH /LAVH Improved turnover/bed capacity Weekly meeting to discuss patients on pathways

Patient information leaflets TLH PMB clinic PCB clinic Gynae cancer booklet 2 week wait referral proforma

How can you help? Follow NICE referral guideline GP to inform patient that they are being sent as 2 week wait. Inform on referral when patient is unavailable for review. Patient information leaflets