‘Let’s get it right - Referral for suspected Cancer’

Dr Banchhita Sahu Consultant O&GMr Nick Reed MDT lead, Consultant O&G

2 week pathway

Why?Increasing numbers

of 2WW referralsNo ability to down

grade referralsWorkload of the

Dept and MDTImpact on the

management of proven cancer.

2 Week Wait Referrals and confirmed cancers

Audit of 2 WW referrals (2014)88 2WW

referrals.

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 2015Endometrial cancer1.5.10 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 BleedPost Menopausal bleed

40(80%) Appropriate

10(20%) Inappropriate

Inappropriate referrals

2 Heavy menstrual bleeding

2 perimenopausal2 Ring pessaries2 Hysterectomies2 Recent HRT

NICE 2015

Cervical cancer1.5.13 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- 104.11 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 bleedAppropriate 4Inappropriate 5

PCB (Inappropriate)IMB 1No smear hx 3No swabs 4

NICE 2015- Ovary1.5.1 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 appetitepelvic or abdominal painincreased urinary urgency and/or frequency. [2011]

NICE 2015- Ovary1.5.6 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)

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 pathway20(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 breechWorkloadPoor trackingFirst Appointment 14+ daysPatient delayed investigationsDelay in referral to tertiary care

Actions TakenGuidelines and Pathways for –

Premenopausal Ovarian CystPost menopausal Ovarian cystPostmenopausal bleedingSuspicious cervix/PCB

One stop clinic- PMBPCB/suspicious cervix clinic?Vulval clinic

80% of endometrial cancer managed laparoscopicallyTLH /LAVHImproved turnover/bed capacity

Weekly meeting to discuss patients on pathways

Patient information leafletsTLHPMB clinicPCB clinicGynae cancer booklet

2 week wait referral proforma

Patient Details Name: Address: NHS No: Date of Birth: IMPORTANT To be able to contact the patient within 48 hours of referral (day and evening) please provide patients preferred contact telephone number: Home: Work: Mobile:

G.P. Details Name of Referring G.P.: Address: Telephone No: Fax No: G.P. Signature: Date of decision to refer:

Please ensure: You have discussed the possibility of a cancer diagnosis with this patient. The patient can attend an appointment within the next 14 days. The patient is aware the appointment may be at either RSH or PRH.

X

PROFORMA MUST BE SENT TOGETHER WITH A REFERRAL LETTER Reason for Referral (Please mark appropriate box) X

ENDOMETRIAL

POSTMENOPAUSAL BLEEDING

NOT on HRT

Patient taking tamoxifen

ON HRT with persistent or unexplained bleeding after cessation of HRT for 6 weeks

INTERMENSTRUAL BLEEDING

Persistent intermenstrual bleeding and negative pelvic examination

CERVICAL

Speculum examination of cervix shows clinical features that raise the suspicion of cancer

Post Coital bleeding in women >40 years of age

OVARIAN

****Serum CA125 is 35 IU/ml or greater AND suspicious abdominal scan

Palpable abdominal or pelvic mass

At the time of referral please request for CA125 and urgent Ultrasound scan of pelvis

Ascites

At the time of referral please request for CA125 and urgent Ultrasound scan of pelvis

****If CA125 is elevated GP to request urgent ‘Ultrasound Pelvis’ stating ‘CA125 high ?Ovarian Cancer’ If USS shows normal pelvis GP to consider other causes of raised CA125 e.g. pancreatic,gastric,colonic and breast carcinoma; also non malignant conditions e.g benign cysts, endometriosis, pelvic inflammatory disease and ascites; and in menstruation and pregnancy.Note – it may be normal in 50% of early stage ovarian cancer.

VULVAL / VAGINAL

Unexplained vulval lump

Unexplained vaginal lump/ulceration

Vulval bleeding due to ulceration

How can you help?Follow NICE referral guidelineGP to inform patient that they are being sent

as 2 week wait.Inform on referral when patient is

unavailable for review.Patient information leaflets