Rapid Access clinics in Gynaecology Oliver Chappatte Consultant Gynaecologist Tunbridge Wells Hospital at Pembury Spire Tunbridge wells
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Rapid Access clinics in Gynaecology
Oliver ChappatteConsultant Gynaecologist
Tunbridge Wells Hospital at PemburySpire Tunbridge wells Hospital
Gynaecological CancerCrude cancer incidence rate per 100,000 female populationUterus 24.9 Ovary 22.3Cervix 10.4Vulva 3.7Vagina 0.9
Percentage presenting via A&EOvary 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 ProcessPatient 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
• Who to refer• How to Refer• What happens to the patient• What we do
Who to refer?
Cases1. 40 year old with pelvic pain and 14
week ? Fibroid mass2. 49 year old with persistent irregular
perimenopausal bleeding3. One episode of post-menopausal
bleeding on HRT4. Abnormal looking cervix – bleeds on
contact
Who to refer?
Cases1. 40 year old with pelvic pain and 14
week ? Fibroid mass2. 49 year old with persistent irregular
perimenopausal bleeding3. One episode of post-menopausal
bleeding on HRT4. 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 ReferralsVulva• 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 ReferralsVulva 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 bleedingHaemorrhoids anal and rectal lesions
GynaecologicalAtrophic, Exogenous oestrogens, Endometrial polypsCervical polypsEndometrial Cancer Uterine sarcoma, fallopian tube and ovarian carcinomas, cervical, vaginal and vulval lesions.
RAC ReferralsVulva 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 CystsRefer 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 CystsOther 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
• Who to refer• How to Refer = FAX 2 week wait Office• What happens to the patient• What we do
RAC PerformaKMCN\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 tamoxifenGP
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 criterionthe patient must have a proper trial without HRT
• Persistent inter-menstrual bleedingWomen 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
• 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 careIncreased medical, nursing and psychosocial supportAbdominoplasty 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
MetforminBariatric surgery
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