Tag: cervical

Gynaecology, Suspicion of Cancer Template

Scott McLaughlin

This is a dictation template to provide a reminder of the information required to complete the referral. The fields in red are mandatory and must be completed on the referral protocol.

Presenting Complaint

Main Presenting Complaint: [Text – 98 character maximum]

Reason for Referral: [Text]

World Health Organisation Performance Scale
Using the following as a guide, please select the most appropriate answer to describe the patients general health:

Options:

  • Asymptomatic
  • Symptomatic but completely ambulatory
  • Symptomatic, <50% in bed during the day
  • Symptomatic, >50% in bed, but not bedbound
  • Bedbound

Priority: Urgent Suspicion of Cancer

Date of Onset: [Date]

Will the patient accept any site for treatment:

  • Yes
  • No

Symptoms and Investigations

Symptoms

Persistant intermenstrual bleeding:

  • Yes
  • No

Persistent postcoital bleeding:

  • Yes
  • No

Postmenopausal bleeding (not on HRT):

  • Yes
  • No

Postmenopausal bleeding on combined continuous HRT or unscheduled bleeding on sequential HRT:

  • Yes
  • No

Persistent abdominal pain:

  • Yes
  • No

Abdominal distension:

  • Yes
  • No

Clinical Examination

Abdominal /  Pelvic mass palpable by abdominal examination:

  • Yes (If Yes, please provide brief details)
  • No

Ascites

  • Yes
  • No

Cervical or vaginal lesion, suspicion of cancer:

  • Yes
  • No

Vulval lesion suspicion of cancer:

  • Yes
  • No

Investigation

Please indicate if any of the following have been checked

FBC and ESR sent:

  • Yes
  • No

CEA sent (if ovarian cancer suspected):

  • Yes
  • No

CA125 sent (if ovarian cancer suspected):

  • Yes
  • No

Ultrasound scan arranged:

  • Yes (If Yes, please provide brief details)
  • No

Gynaecology, Suspicion of Cancer Guideline

 

 

Gynaecological, Suspicion of Cancer Referral

Scott McLaughlin
Gynaecological Cancers
Ovarian cancer

Over 90% of women with ovarian cancer are over the age of 40 years on diagnosis. Among women in Scotland with no family history the lifetime risk of developing ovarian cancer is estimated to be 1 in 55. Approximately 580 new cases of ovarian cancer are diagnosed in Scotland every year. Ovarian cancers are usually diagnosed late and approximately 30% of cases have a palpable pelvic mass. Symptoms are often non-specific abdominal symptoms but are characterised by their persistency and frequency.

Family history (both maternal and paternal) of breast or ovarian cancer can be used to identify women who have a higher risk of developing ovarian cancer. Guidance for referral to regional genetic centres for those with a family history is available at SIGN Website (SIGN 135) and Health Improvement Scotland website.

Endometrial cancer

Most patients (95%) with endometrial cancer present with postmenopausal bleeding. This cancer is uncommon in premenopausal women (< 5%). Approximately 639 new cases are diagnosed in Scotland each year. Risk factors for endometrial cancer include: tamoxifen, obesity, age over 45 years, nulliparity, family history of colon or endometrial cancer and exposure to unopposed oestrogens. A higher suspicion of risk should be used in these women.

Cervical cancer

Cervical cancer affects all adult age groups, with almost 50% of cases occurring between the ages of 30 and 50 years. The incidence of cervical cancer in Scotland is around 10.7 per 100,000 population and its estimated lifetime risk around 1 in 112. The majority of cases (80%) are diagnosed on speculum examination and up to 40% are screen detected. Typical symptoms include vaginal discharge, postmenopausal bleeding, postcoital bleeding and persistent intermenstrual bleeding. A cytology test is not required before referral, and a previous negative result is not a reason to delay referral.

Postcoital Bleeding

  • Check the cervical screening (smear) history and take a smear only if woman is a defaulter. NB A negative smear result could be a false negative in a woman with symptoms
  • Perform speculum and bimanual examination – urgent gynaecology cancer referral if suspicious
  • Take swabs (including chlamydia) and treat / refer GUM accordingly

Routine referral to gynaecology for:

  • any single heavy episode of postcoital bleeding at any age group
  • light postcoital bleeding persisting for over 4 weeks in over 35 age group
  • light postcoital bleeding persisting for over 12 weeks in under 35 age group

Vulval cancer

Most cases of vulval cancer occur in women over 65 years and 90% of patients have a visible tumour on clinical examination. Patients usually present with bleeding, discomfort, itch or a burning sensation. There are about 106 new cases of vulval cancer diagnosed every year in Scotland.

Vaginal cancer

Vaginal cancer is rare and comprises approximately 2% of gynaecological cancers. It is most commonly diagnosed in women above 60 years and is rare in women less than 40 years. Approximately 30 new cases of vaginal cancer are diagnosed in Scotland every year.

Good practice points

An abdominal palpation should be undertaken, CA125 blood serum level measured and urgent pelvic ultrasound scan carried out in:

  • any woman over 50 years who has experienced new symptoms within the last 12 months that suggest irritable bowel syndrome or
  • women (especially those over 50 years) with one or more unexplained and recurrent symptoms (most days) of:
  • abdominal distension or persistent bloating
  • feeling full quickly or difficulty eating
  • loss of appetite
  • pelvic or abdominal pain
  • increased urinary urgency and/or frequency
  • change in bowel habit.

A full pelvic examination, including speculum examination of the cervix, should be carried out in women presenting with:

  • significant alterations in their menstrual cycle
  • intermenstrual bleeding
  • postcoital bleeding
  • postmenopausal bleeding
  • vaginal discharge, or
  • pelvin pain.
  • A vulval examination should be carried out for any woman presenting with any vulval symptom.

If there is significant concern, awaiting the results of any investigation should not delay referral.

Urgent Suspicion of Cancer (Gynaecology)

Urgent Suspicion of Cancer (Gynaecology)

Ovarian CancerAbnormal ultrasound scan and/or CA125 level.
Ascites and/or ultrasound-confirmed pelvic or abdominal mass (that is not obviously uterine fibroids, gastrointestinal or urological in origin).
Endometrial CancerAny woman on hormone replacement therapy (HRT), presenting with persistent or unexplained postmenopausal bleeding, after cessation of HRT for 4 weeks.
Unscheduled vaginal bleeding in a patient taking tamoxifen
Postmenopausal bleeding.
Persistent intermenstrual bleeding, especially with other risk factors despite a normal pelvic examination.
A woman presenting with a palpable abdominal or pelvic mass on examination that is not obviously uterine fibroids, gastrointestinal or urological in origin should be referred urgently for ultrasound scan and, if significant concern, simultaneously to a specialist. Awaiting results of the ultrasound scan should not delay referral.
Cervical CancerAny woman with clinical features (vaginal discharge, postmenopausal, postcoital and persistent intermenstrual bleeding) and abnormality suggestive of cervical cancer on examination of the cervix.
Vulval CancerAny unexplained vulval lump found on examination.
Vulval bleeding due to ulceration.
Vaginal CancerAny suspicious abnormality of the vagina on speculum examination.

Primary care management

  • Symptoms (see above) persisting or worsening for any woman who has a normal CA125 with normal ultrasound, assess for other clinical causes and investigate as appropriate or refer to appropriate secondary care services, depending on local arrangement.
  • Women presenting with vulval symptoms of pruritus or pain should be examined prior to initiation of any treatment and follow up should also include examination until symptoms are resolved or a diagnosis is confirmed.

Refer urgently or routinely, if symptoms persist, depending on the symptoms and the degree of concern about cancer.

Reference:
Scottish Referral Guidelines for Suspected Cancer. Scottish Government, August 2014
SIGN 135: Management of Epithelial Ovarian Cancer
Lead Clinician: Dr Sreedevi Gurram, Consultant Gynaecologist
Review Date April 2017