Transcript Clinical case scenarios: slide set

Ovarian Cancer
Clinical case scenarios for primary care
Implementing NICE guidance
April 2011
NICE clinical guideline 122
What this presentation covers
Four clinical case scenarios,
including :-
• presentation
• medical history
• examination
The clinical decisions surrounding
diagnosis will then be examined
Case scenario 1 : Fiona
Presentation
Fiona is 59 years old. She has had lower abdominal pain
intermittently over the last 6 weeks, and claims that she has lost
weight without trying
Medical history
Fiona has had two children, both of whom were bottle-fed
On examination
Normal abdominal and pelvic examination
Next steps for diagnosis
1.1 Question:
You suspect ovarian cancer. Which test would you do first?
Fiona
1.1 Answer:
Measure serum CA125
1.2 Question:
Fiona’s serum CA125 level is 97 IU/ml. What should be
the next step for diagnosis?
Fiona
1.2 Answer:
Arrange for Fiona to have an ultrasound of her abdomen
and pelvis
1.3 Question:
The ultra sound comes back suggestive of ovarian
cancer. What should be the next step for diagnosis?
Fiona
Answer 1.3
Refer Fiona urgently to a gynaecological cancer
service (the national target in England and Wales for
referral for suspected cancer is currently 2 weeks)
Case scenario 2 : Maria
Presentation
Maria is 63 years old and married. She complains of feeling bloated
and of losing her appetite over the last 2 months, and feels full after
eating only a small meal
Medical history
Maria has a history of infertility, which was investigated
On examination
You find a lower abdominal mass on abdominal examination. On
pelvic examination this appears to lie on the left adnexa.
Next steps for diagnosis
2.1 Question:
You suspect ovarian cancer. Which test would you do
first?
Maria
2.1 Answer:
None
A pelvic or abdominal mass is highly suggestive of
ovarian cancer, and Maria should be referred urgently
to a gynaecological cancer service rather than having
tests in primary care
(the national target in England and Wales for referral for
suspected cancer is currently 2 weeks)
Case scenario 3: Hettie
Presentation
Hettie is 24 years old. She reports feeling bloated after eating, and
has moved up a clothing size in the last 8 weeks
Medical history
Hettie’s mother had ovarian cancer. Hettie has one child, who was
bottle-fed, and currently uses an intrauterine contraceptive device.
On examination
Normal abdominal and pelvic examination
Next steps for diagnosis
3.1 Question:
You suspect ovarian cancer. Which test would you do first?
Hettie
3.1 Answer:
Measure serum CA125
3.2 Question:
Hettie’s serum CA125 level is 57 IU/ml. Which test would
you do next?
Hettie
3.2 Answer:
Arrange for Hettie to have an ultrasound of her abdomen
and pelvis
3.3 Question:
The ultrasound comes back normal. What is the next step
for diagnosis?
Hettie
3.3 Answer:
Ovarian cancer is unlikely. Further clinical assessment of
Hettie’s symptoms and signs should now be carried out.
If these point towards a different diagnosis, further
investigation may be required
If there is no obvious clinical cause of Hettie’s symptoms
and no specific signs, she should be advised to return if
her symptoms persist and/or become more frequent
Case scenario 4: Aamina
Presentation
Aamina is 45 years old. She has noticed an increased frequency of
micturition associated with dysuria over the past 3 days. She claims
to have been having similar episodes on a weekly basis over the last
2 months
Medical history
Aamina has had one previous urinary tract infection. She went
through the menopause aged 38 and has been on hormone
replacement therapy since then
On examination
Normal urine dipstick analysis. Normal abdominal and pelvic
examination
Aamina
Next steps for diagnosis
4.1 Question:
You suspect a urinary tract infection. You offer antibiotics,
which are declined (SIGN), and send a mid-urine
specimen (MSU) for analysis. What is the next step for
diagnosis?
Aamina
4.1 Answer:
Await the result of the MSU analysis and act accordingly.
Treat as recommended if the result is positive, but if the
result is negative or equivocal it is important to see
Aamina again. In particular, you need to know if her
symptoms persist
4.2 Question:
The MSU result is negative but Aamina’s symptoms
persist. You suspect ovarian cancer. What should you
do next?
Aamina
4.2 Answer:
Measure serum CA125
4.3 Question:
Aamina’s serum CA125 level is 35 IU/ml. What should
you do next?
Aamina
4.3 Answer:
The cut-off value for a normal CA125 is below 35 IU/ml.
Arrange for Aamina to have ultrasound of her abdomen
and pelvis
4.4 Question:
The ultrasound is suggestive of ovarian cancer. What is
the next step for diagnosis?
Aamina
4.4 Answer:
Refer Aamina urgently to a gynaecological cancer
service (the national target in England and Wales for
referral for suspected cancer is currently 2 weeks)
Find out more
Visit www.nice.org.uk/guidance/CG122 for:
•
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the guideline
the quick reference guide
‘Understanding NICE guidance’
costing statement
audit support
baseline assessment tool
awareness raising slide set
podcasts
NB. Not part of presentation
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