Louise Hayes

Consultant Obstetrician & Gynaecologist

Post Menopausal Bleeding &

Suspected Gynaecological

Cancer Referral Pathway Up Date

Endometrial Cancer

• Most common gynaecological malignancy

• It represents the 4th most common female cancer in the UK

• 9100 new cases diagnosed per year

• Incidence is increasing 21% in last decade

• Most of the increase is due to low grade type I cancers

• The main risk factor is Obesity

Risk factors

• Obesity -34%

• Nulliparity -35-40% of cancers

• Late menopause

• Ageing population Peak incidence 60-79

• Diabetes

• Family History

Recent Audit at YTH

• Aim to look to improve the service & enhance the quality of care

• Average time between USS & referral 7 days

• 9% had Endometrial Ca

• 10% had suspicious findings at Hysteroscopy

Average waiting time 7 days

95%

5%

time between referral and

hysteroscopy

≤14 days >14 days87%

13%

time between ultrasound and

referral

≤14 days >14 days

Correlation between Hysteroscopy Findings & Histology

normal 24%

atrophy 19%

polyp 29%

fibroid 10%

abnormal 8%

suspicious 10%

HYSTEROSCOPY FINDING

85%

5%

9% 1%

HISTOLOGY

benign hyperplasia endometrial ca cervical ca

Heading body copy

NICE Guidance 2015

• Changes to referral pathway due to changes introduced by NICE

• Streamline referral

• Electronic Referral

• Patients can be seen in a timely manner

• Improve communication

Patient information and support What patient information and support should I offer?

For people with suspected cancer:

• Discuss referral & the process. Include carers as appropriate, accounting for the need for confidentiality.

• Explain that they are being referred to a cancer service. Reassure that most people who are referred will not have a diagnosis of cancer.

• Provide information on the possible diagnoses (both benign and malignant) in accordance with their wishes for information.

• If the person has additional support needs because of their personal circumstances, inform the specialist (with the person's agreement).

The information given to people with suspected cancer and their families and/or carers should cover, among other issues: – Where the person is being referred to.

– How long they will have to wait for the appointment.

– How to obtain further information about the type of cancer suspected or help before the specialist appointment.

– What to expect from the service the person will be attending.

– What type of tests may be carried out, and what will happen during diagnostic procedures.

– How long it will take to get a diagnosis or test results.

– Whether they can take someone with them to the appointment.

– Who to contact if they do not receive confirmation of an appointment.

– Other sources of support.

When Should I refer a person with Suspected Endometrial Cancer ?

• Post menopausal Bleeding. Any bleeding >12 months after LMP

• History & Vaginal EXAMINATION

• Ultrasound Scan URGENTLY in Primary Care

• USS abnormal Endometrial Thickness >5mm then REFER 2WW

• There are some exceptions (HRT, Coil, Tamoxifen)

Ultrasound Scan of Endometrium

What Happens after Referral? Outpatient Hysteroscopy Clinic

• Consent

• Analgesia prior to appointment

• Hysteroscopy 2mm scope (Thinner than a coil)

• Endometrial Biopsy

• If an endometrial polyp present removal either in outpatients or as a Day case under GA

• Histology results approx. 10 days

What We See at Hysteroscopy!

Results:

• Normal Histology:- Write with results

• Abnormal Histology:- Seen in outpatients within 5 working days of results.

• Carcinoma diagnosis referred to GynaeOncology MDT Hull

• Surgery performed in Scarborough for Stage I Adenocarcinoma all other types operated at Castle Hill, Hull

NICE 2015 When should I refer a person with suspected ovarian cancer?

• History

• Examination

• >50 years Old

• Ca 125

• Ultrasound Scan

Suspected Ovarian Malignancy

•Relative Malignancy Index (RMI)

=

U x M x s CA125

U –ultrasound features

M – menopausal status

>250 Refer MDT

Rapid Referral for suspected Ovarian Ca.

• If USS & Clinically Ovarian = C T Scan Chest, Abdo. & Pelvis

• If suspicious RMI>250 but No Ascites, Omental cake = MRI for diagnosis & staging

• All referred to Gynae Oncology MDT Hull

• All surgery Castle Hill

Referral for suspected cervical cancer

• Consider a suspected cancer pathway referral for women if, on examination, the appearance of their cervix is consistent with cervical cancer (new NICE recommendation for 2015).

Cervices Normal Or Abnormal

Referral to Fast Track Gynae Clinic

• Cervical examination +/- Colposcopy

• Cervical Biopsies +/- LLETZ

• Histology Results 7-10 days

• Early Cervical Carcinoma a1 & a2 can be treated surgically in Scarborough after referral & discussion in the MDT.

• All others go to the Centre (Castle Hill)

Cervix -Normal???

Colposcopy

• DNA Rates

• Patient Education

• Nurse Colposcopists

Referral for Suspected Vulval Cancer

• Lumps/Masses

• Ulcers

• History of Lichen Sclerosis

• L.S need annual review

Refer to Fast Track Clinic for Suspected Vulval or Vaginal Cancers

• Seen in fast track clinic

• Imaging as appropriate or Biopsies performed

• Refer to Gynae.Oncology MDT

• Management at the Oncology Centre

Heading body copy

Thank You

• ANY QUESTIONS?