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Overview: Management Of Ovarian Cancer in Primary Care
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(1) Fabian Lee, Foundation Year 2. (2) Gbolahan Somoye, Senior Registrar. (3) Sherif Saleh, Consultant Gynaecologist.
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Gynaecology Department, Aberdeen Royal Infirmary, NHS Grampian, Scotland, UK.
Email: [email protected]
Methods
Introduction and Objectives
Ovarian cancer is the leading cause of
gynaecology cancer deaths in the UK with a 5-year
survival rate of less than 35%; often presenting
late with vague non-specific symptoms.
A high index of suspicion in primary care may lead
to the instigation of appropriate investigations and
prompt referrals to secondary care.
This study aims to provide an overview of the
recognition and initial management of suspected
ovarian cancer in primary care by:
1.Examining the quality of urgent referrals for
suspected ovarian cancer to a specialist gynaeoncology service in Aberdeen, NHS Grampian
(Scotland), UK;
2.Comparing and evaluating any change in
practice of CA-125 testing and ultrasound (USS)
investigations before (B) and after (A) the
introduction of the NICE 122 guideline (April 2011).
96 urgent referral letters from primary care for
suspected ovarian malignancies received between
October 2010 - September 2011 were reviewed.
Quality of referral letters before (B) and after (A)
the introduction of the new NICE 122 guideline
were examined. Clinical information provided
along with relevant investigations requested in
primary care before referral to secondary care
were collated, looking specifically at:
3. Duration of symptoms in referrals =
56.3%.(B57.1% A55.6%)
4. Enquiry of specific symptoms = 74.0%
(B71.4% A75.9%)
5. Enquiry of general symptoms = 50.0%
(B47.6% A51.9%)
6. No details of any specific and/or general
symptoms = 17.7%
(B16.7% A18.5%)
- Documentation of positive and negative physical
examination findings (ascites and/or
pelvic/abdominal mass – not obviously uterine
fibroids)
- Duration of symptoms
Conclusions
- Specific symptoms (any one or more of the
following; abdominal bloating, early satiety,
abdominal or pelvic pain, urinary symptoms, or
age >50 with symptoms of IBS)
Referral letters from primary to secondary care
lack important clinical information.
The study suggests that initial investigations of
suspected ovarian cancer in primary care can be
optimized further.
Woman presents to GP
- General symptoms (any one or more of
unexplained weight loss, fatigue, altered bowel
habit, in which ovarian cancer is suspected)
GP assesses symptoms
Tests in primary care
Suspicion of ovarian cancer
Urgent referral: assessment in secondary care
Suspicion of ovarian cancer
Support and information
Ascites and/or pelvic or abdominal
mass
- Initial investigations (CA-125 & USS). Chi-square
analysis was used to evaluate for change in
practice of CA-125 testing and ultrasound (USS)
investigations by comparing before (B) and after
(A) percentages.
Results
Review by specialist multidisciplinary team
(MDT)
Confirmation of diagnosis:
· surgical staging or
· tissue diagnosis by histology (preferably)
or cytology if considering chemotherapy
before or instead of surgery for advanced
ovarian cancer
Management of suspected
early ovarian cancer
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Management of advanced
ovarian cancer
GP referrals – Clinical information provided:
1.Documented abdominal examination = 68.8%.
(B69% A68.5%)
2.PV examination performed = 27.1%.
(B19.0% A33.3%)
Initial investigations done in primary care:
1. Serum CA-125 requested = 80.2%
(B71.4% A87.0%)
2. USS requested = 72.9%
(B78.6% A68.5%)
3. Both CA-125 and USS requested = 60.4%
(B59.5% A61.1%)
4. No CA-125 and/or USS = 7.3%
(B9.5% A5.6%)
Comparison of initial investigations before and
after the introduction of the new NICE
guidelines suggest no change in practice (pvalue 0.3703 >0.01).
Greater vigilance and instigation of investigations
in primary care in accordance to the NICE 122
guideline will ensure prompt, good quality and
correct referrals which may lead to early diagnosis
and treatment thus improving outcome associated
with late presentations.
References
NICE Clinical Guideline 122 – Ovarian Cancer: The
Recognition And Initial Management Of Ovarian
Cancer.
http://www.nice.org.uk/guidance/CG122