1. Mr Vivek Nama MD MRCOG Consultant Gynaecological Oncologist
Gynaecological cancers
Mr Vivek Nama MD MRCOG Consultant Gynaecological Oncologist

2. Gynaecological cancers

3. Why do we need 2 week wait ? Early/timely diagnosis of cancer
Possibly less invasive treatment and better QoL
Avoid emergency admissions
Planned delivery of care
Higher standards and job worthwhile
Fewer dissatisfactions, complaints and risk of litigation
16 % of claims at MPS are delayed diagnosis
Assessment and examination of patient

4. Challenges Shift from being always right to being safe
Low diagnostic yield rates – increase referral – inability of services to cope with it
Multiple providers resulting in a complex diagnostic/therapeutic pathway

5. CUH USC performance 20 per week. (Nov 16 to Feb 2017)
62 day treatment – 3 breeches (One each month)
Reasons for delays –
medical reasons for diagnostic delays,
patient choice, other

6. Ovarian Cancer:

7. Ovarian cancer 7029 case in 2012 in the UK and Life time risk 1: 51
Relative 5 year survival rates – 34 %, lower than European average, But stage 1, survival rates of 90 % achieved
Not a silent killer, symptoms present
No effective screening test – UKCTOCS trial, PLCO trial, ROcKets ongoing
Screening history- ovarian cancer – BRCA – Genetic tree

8. Ovarian cancer detection in Primary care

10. Women presenting with symptoms to GP
Examination shows ascites and/or mass (exc. Fibroids)
refer urgently. Perform CA 125 and USS.
any woman of 50 or over who has experienced symptoms within the last 12 months that suggest irritable bowel syndrome (IBS) OR if symptoms are concerning for ovarian cancer but no physical features – Based on Symptom Index
Perform serum CA 125
Unexplained weight loss, Fatigue, Change in bowel habits
Perform CA125

12. Risk of Malignancy index
CA 125 levels in U/ml × menopausal score × ultrasound score
Ultrasound features:
Multi-loccular cyst
Evidence of solid areas
Evidence of metastasis
Presence of ascites
Bilateral lesions
0 – none, 1 – one abnormal feature, 3 – 2 or more abn.
Menopausal score – pre – 1 , post -3
Sensitivity – 78 %, specificity 87 %

13. Problem with tests - CA 125 and USS
CA 125 also elevated in
fibroids
medical problems such as heart failure
liver disease and other cancers
Endometriosis

14. Ovarian masses in pre-menopausal group
IOTA – International Ovarian Tumour Analysis Group
M-features and B-features
Reported sensitivity 95 % and specificity 91 %
M-rules
Irregular solid mass with irregular component 80 % of the tumour
Presence of ascites
At least 4 papillary structures with a height >= 3mm
Irregular multi-locular solid tumour with a max diameter > 10cm
Strong vascularity
B-rules
Unilocular cysts
Solid components <7 mm
Presence of acoustic shadowing
Smooth multilocular tumour with a
largest diameter <100mm
No blood flow

15. Case Scenario Clinical assessment Normal CA125
70 y old with persistent bloating and abdominal pain
Clinical assessment
Abdominal and pelvic examination – no masses/ascites
Normal CA125

16. OVA1 and HE4

17. Ovarian Cysts with normal CA125

18. Post-menopausal ovarian masses
Cysts 2-5 cms, unilateral, unilocular and echo-free with no solid parts or papillary formations
Risk of malignancy is less than 1%.
In addition, more than 50% of these cysts will resolve spontaneously within three months.
Thus, it is reasonable to manage cysts of 2–5 cm conservatively.
4 monthly scan and CA 125 x one year, no change discharge.
Other options Lap SO

19. Pre-menopausal cyst
The following cysts should be treated as simple cysts:
Ovarian/para-ovarian cyst, cysts containing daughter cysts
Cysts with one thin septation (<3mm, with no vascularity)
Cysts with small calcification in wall. If there is an obvious area of calcification; consider whether this may be a dermoid cyst.
Cyst criteria apply even if cysts are multiple (cysts completely separate from each other) or bilateral.

20. Pre-menopausal cyst - management
Less than 5cm
No follow up required unless there is clinical concern.
Findings are likely to be physiological in nature and almost always resolve within 3 menstrual cycles.

21. Pre-menopausal cyst - management
5 - 7cm - Suggest rescanning in four months.
If smaller or resolved no further follow up required.
If larger or persisting suggest further gynaecological review.
Ovarian cysts that persist or increase in size are unlikely to be functional and may warrant surgical management.
If symptomatic, for benign gynaecological review.
> 7 cm – suggest benign gynaecological team review with a view to surgical removal.

22. Summary Ovarian cancer management is multi-modal
CA 125 and TV US scan
Move to increase surgical efforts Vs quality of life
Cervical cancer – fertility preservation
HPV vaccination

23. 2 WW Referral criteria - PMB
2 WW referral – criteria changed in 2015
age (55) as a factor, Other non-PMB symptoms and tests
2 ww referral
if aged 55 and over with PMB
Consider
2 WW in under 55 with PMB [new 2015]
Suspected cancer: Recognition and referral
NICE Guideline June 2015

24. 2 WW Referral criteria - PMB
Consider direct access USS
if > = 55 with unexplained vaginal discharge
for first time or with thrombocytosis or report haematuria
visible haematuria with
low haemoglobin levels or thrombocytosis or high blood glucose levels. [new 2015]
Suspected cancer: Recognition and referral
NICE Guideline June 2015

26. Scan results and outcomes
5mm or thicker endometrium
Irregular endometrium
Unable to comment on all of the endometrium
Negative scan % ( negative exam)
Endometrial cancer 5-10%
Hyperplasia %
Benign pathology ~15%
Atrophic or benign %

27. Secondary Care - Laparoscopic Hysterectomy and BSO Enhanced Recovery
24-36 hour discharge
CNS phone call after 7-10 days and discuss results
inci

28. Case. 42 y old 4 weeks of IMB Stopped the POP one year ago
Normal vaginal examination
Would you refer on 2WW?
NO – IMB has been taken out of 2WW referral criteria

29. Questions ? Croydon University Hospitals
– or