Download Obstet & Gynae Dept

Rapid Access clinics in
Gynaecology
Oliver Chappatte
Consultant Gynaecologist
Tunbridge Wells Hospital at Pembury
Spire Tunbridge wells Hospital
Gynaecological Cancer
Crude cancer incidence rate per 100,000 female
population
Uterus
24.9
Ovary
22.3
Cervix
10.4
Vulva
3.7
Vagina
0.9
Percentage presenting via A&E
Ovary
29 %
Cervix
12 %
Rapid Access Referrals
RAC at MTW NHS Trust
• Overview
– 15,000 General Gynaecological referrals
– 2000 RAC Referrals
– 30-40 ‘Slots’ per week
– 4 Consultants + Gynae Oncologists
– 10% have Cancer
– 50% Gynaecological cancers come through other
routes
» Radio;ogy, General Medicine, Surgery, A&E.
Rapid Access Process
Patient has to be seen within two weeks of
receiving faxed referral
(Referral fax is not seen by Consultant and
cannot be down-graded)
Diagnosed or suspicious cancer is then
discussed at the next MDT
Treatment starts within 31 days of diagnosis
or decision to treat or 62 days from GP
referral
Rapid Access Referrals
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•
•
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Who to refer
How to Refer
What happens to the patient
What we do
Who to refer?
Cases
1. 40 year old with pelvic pain and 14 week
? Fibroid mass
2. 49 year old with persistent irregular
perimenopausal bleeding
3. One episode of post-menopausal
bleeding on HRT
4. Abnormal looking cervix – bleeds on
contact
Who to refer?
Cases
1. 40 year old with pelvic pain and 14 week
? Fibroid mass
2. 49 year old with persistent irregular
perimenopausal bleeding
3. One episode of post-menopausal
bleeding on HRT
4. Abnormal looking cervix – bleeds on
contact
Who to refer?
Cases
1. 40 year old with pelvic pain and 14
week ? Fibroid mass
2. 49 year old with persistent irregular
perimenopausal bleeding
3. One episode of post-menopausal
bleeding on HRT
4. Abnormal looking cervix – bleeds on
contact
Who to refer?
Cases
1. 40 year old with pelvic pain and 14
week ? Fibroid mass
2. 49 year old with persistent irregular
perimenopausal bleeding
3. One episode of post-menopausal
bleeding on HRT
4. Abnormal looking cervix – bleeds on
contact
RAC Referrals
Vulva
Lesion suspicious of cancer on clinical
examination
Cervix / Vagina Lesion suspicious of cancer on cervix or vagina
on speculum examination
Endometrium Postmenopausal bleeding in women who are not
on HRT
HRT: unexpected or prolonged bleeding persisting
for more than 4 weeks after stopping the HRT
Postmenopausal bleeding in women on tamoxifen
Ovary
Palpable pelvic mass not obviously fibroids
Suspicious pelvic mass on ultrasound
Lichen Sclerosis
Vulva
Patients complaining of vulval
itch or discomfort do NOT merit
Rapid Access Referral unless
examination reveals a localised
lesion, or vulva shows a gross
generalised abnormality –
Patients with vulval itch or
discomfort should have
treatment, watch and wait until
such time as symptoms resolve
or diagnosis is confirmed.
Vulval RAC Referrals
Vulva
• The majority of
malignant lesions of
the vulva are
ulcerated or
exophytic.
• Rare
• Elderly
• Background of
Lichen Sclerosis or
VIN
• Delay in presentation
RAC Referrals
Vulva
Lesion suspicious of cancer on clinical
examination
Cervix / Vagina Lesion suspicious of cancer on cervix or vagina
on speculum examination
Endometrium Postmenopausal bleeding in women who are not
on HRT
HRT: unexpected or prolonged bleeding persisting
for more than 4 weeks after stopping the HRT
Postmenopausal bleeding in women on tamoxifen
Ovary
Palpable pelvic mass not obviously fibroids
Suspicious pelvic mass on ultrasound
Normal Cervix
Cervical Abnormalities
Nabothian Follicle
Multiple Nabothian Follicles
Cervix post Loop biopsy
RAC Referrals
Vulva
Lesion suspicious of cancer on clinical
examination
Cervix / Vagina Lesion suspicious of cancer on cervix or vagina
on speculum examination
Endometrium Postmenopausal bleeding in women who are not
on HRT
HRT: unexpected or prolonged bleeding persisting
for more than 4 weeks after stopping the HRT
Postmenopausal bleeding in women on tamoxifen
Ovary
Palpable pelvic mass not obviously fibroids
Suspicious pelvic mass on ultrasound
Post Menopausal Bleeding
• Non Gynaecological –
• Urinary tract
–Urethral Caruncule, Urinary tract bleeding
• GITract
–Haemorrhoids anal and rectal lesions
• Gynaecological
• Atrophic, Exogenous oestrogens, Endometrial
Cancer /polyps. Uterine sarcoma, fallopian tube
and ovarian carcinomas, cervical, vaginal and
vulval lesions.
Post Menopausal Bleeding
• Careful
history
• Examination
• Speculum
• Bimanual
examination
Non Gynaecological –
Urethral Caruncule, Urinary
tract bleeding
Haemorrhoids anal and
rectal lesions
Gynaecological
Atrophic,
Exogenous oestrogens,
Endometrial polyps
Cervical polyps
Endometrial Cancer Uterine
sarcoma, fallopian tube and
ovarian carcinomas, cervical,
vaginal and vulval lesions.
RAC Referrals
Vulva
Lesion suspicious of cancer on clinical
examination
Cervix / Vagina Lesion suspicious of cancer on cervix or vagina
on speculum examination
Endometrium Postmenopausal bleeding in women who are not
on HRT
HRT: unexpected or prolonged bleeding persisting
for more than 4 weeks after stopping the HRT
Postmenopausal bleeding in women on tamoxifen
Ovary
Palpable pelvic mass not obviously fibroids
Suspicious pelvic mass on ultrasound
Pelvic Mass
• If fibroids are suspected clinically a scan should be requested
and the results reviewed by the GP before referral to the
Rapid Access Clinic.
• If the scan suggests an ovarian cyst: not all ovarian cysts merit
referral to the Rapid Access Clinic as the risk of malignancy
may be low.
Pelvic Mass
• If fibroids are suspected clinically a scan should be requested
and the results reviewed by the GP before referral to the
Rapid Access Clinic.
• Characteristic Ultrasound features
• Smooth, round , occasionally cystic
• Smooth, bosselated, mobile on
• bimanual examination
• Beware rapidly expanding and
• Post menopausal painful fibroid
• May be very large!
Ovarian Cysts
Refer to the Rapid Access Clinic if:
• Ovarian cysts on scan > 5 cm in diameter
• Ovarian cysts on scan with cystic and solid areas irrespective
of size
• Ovarian cysts of any size in a post menopausal woman (12/12
from LMP)
• Other scan finding suggestive of ovarian malignancy (e.g.
ascites, peritoneal seedlings)
Ovarian Cysts
Other ovarian cysts may be managed by rescan and
referral to general gynaecological clinics.
If a GP suspects that a women of any age merits a Rapid
Access Clinic Referral based on any of the criteria in
this section it would be helpful if a Ca 125 could be
initiated in primary care, marking the pathology
request form:
“URGENT - PATIENT AWAITING RAPID ACCESS CLINIC”
Ovarian Cysts
Ovarian Cysts
Rapid Access Referrals
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•
•
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Who to refer
How to Refer = FAX 2 week wait Office
What happens to the patient
What we do
RAC Performa
KMCN\KT\Clinical\GP Referral Proformas\Gynae\Published July 2010 1 of 2
Suspected Cancer Urgent Referral Criteria/Information
Vulva
Lesion suspicious of cancer on clinical examination
Cervix / Vagina
Lesion suspicious of cancer on cervix or vagina on speculum
examination
Ovary
Palpable pelvic mass not obviously fibroids
Suspicious pelvic mass on ultrasound (Please enclose a copy of the
report)
Endometrium Postmenopausal bleeding in women who are not on HRT
HRT: unexpected or prolonged bleeding persisting for more than 4
weeks after stopping the HRT
Postmenopausal bleeding in women on tamoxifen
GP
•
Signature:______________________________________________________________
___ Date: _____ /_____ /______
(Date of decision to refer)
RAC Proforma
• Women NOT on HRT:
Postmenopausal bleeding in women – Post
menopausal means >12 months since last period
• Women ON HRT:
Inappropriate bleeding in women on HRT – to
refer under this criterion
the patient must have a proper trial without HRT
• Persistent inter-menstrual bleeding
Women over 40 years of age who have persistent
inter-menstrual bleeding need NOT be referred
under the 2 week wait rule but nevertheless merit
urgent assessment either in a menstrual disturbance
or specialist gynaecological clinic
Rapid Access Referrals
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•
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Who to refer?
How to Refer
What happens to the patient ?
What we do
Trans-vaginal Scan
(PMB and mass)
Pipelle biopsy
Hysteroscopy
Vulval Biopsy
Outcome
• Most discharged back
• Review with biopsy results
• Instigate further tests
–CT scan, MRI
–GA hysteroscopy biopsies etc
• Refer to MDT for decision on
management
• Clock still ticking!
Conclusions
• Please tell patient why they are being
referred urgently and what to expect.
• Stressful for patient but most will not
have Cancer
• Significant pressure on hospital service
• Avoid inappropriate referrals
• Urgent cases can be seen outside RAC
Endometrial Cancer & Obesity
• Rising Incidence
– 4th Commonest cancer in women (5%)
– 7536 cases in 2007
– 40% increase between 1993 – 2007
overall
– Peak incidence 60-79 years (50%
increase)
• Obesity
– 25% of adults in UK are obese
– Strong link with endometrial Cancer
(BMI over 30)
– Linear increase with BMI
– Difficulty staging ( MRI)
– Comorbidities
• Diabetes, hypertension,
cardiovascular disease
Endometrial Cancer & Obesity
•
Surgery
– Peri-opertive complications
– Sleep apnoea, arrhythmias, cardiac and venous events
– Operative complications
– Laparoscopic ? Open hysterectomy BSO +/- Lymphadenectomy
– Post-operative Care
Intensive care
Increased medical, nursing and psychosocial support
Abdominoplasty may reduce would infection rate but increase surgical
time
•
Improved survival
– 77% five year survival
(73% in lower S.E.C)
•
Prevention
– Mirena coil
Weight loss, exercise
Metformin
Bariatric surgery