‘let’s get it right - referral for suspected cancer’ dr banchhita sahu consultant o&g mr...
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‘Let’s get it right - Referral for suspected Cancer’
Dr Banchhita Sahu Consultant O&GMr Nick Reed MDT lead, Consultant O&G
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2 week pathway
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Why?Increasing numbers
of 2WW referralsNo ability to down
grade referralsWorkload of the
Dept and MDTImpact on the
management of proven cancer.
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2 Week Wait Referrals and confirmed cancers
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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
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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]
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Post Menopausal BleedPost Menopausal bleed
40(80%) Appropriate
10(20%) Inappropriate
Inappropriate referrals
2 Heavy menstrual bleeding
2 perimenopausal2 Ring pessaries2 Hysterectomies2 Recent HRT
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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!
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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.
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Cervix
9 Post coital bleedAppropriate 4Inappropriate 5
PCB (Inappropriate)IMB 1No smear hx 3No swabs 4
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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]
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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]
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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
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‘’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
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Others
No information (2)Vague symptoms(2)Incidental raised Ca125(1)Pain/discomfort(2)
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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.
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Effect on 62 day target
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Reasons for breechWorkloadPoor trackingFirst Appointment 14+ daysPatient delayed investigationsDelay in referral to tertiary care
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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
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Patient information leafletsTLHPMB clinicPCB clinicGynae cancer booklet
2 week wait referral proforma
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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
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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