National Ovarian Cancer pathway initiative in collaboration with National Cancer Control Programme (NCCP), Obstetrics/Gynaecology group (Obs/Gynae) and General Practice (GP) group

Abstract

Summary: Ovarian cancer is the sixth commonest cancer and the fourth commonest cancer cause of death in women in Ireland. Five year survival rates are Introduction: Ovarian cancer is the main cause of death from gynaecological cancer. Around 370 women are diagnosed each year; 80% are over 50 years of age. Most have advanced disease at presentation. Fewer than one-third have stage I or stage II disease at diagnosis. Ireland’s survival rate for ovarian cancer compares poorly internationally - less than 40% at 5 years (3). If diagnosed at an early disease stage, ovarian cancer has an excellent prognosis (stage I disease, five year survival >90%).(4) However, over 70% of cases are diagnosed at a late stage of illness with much poorer prognosis. Delay in diagnosis is often due to failure to recognise the symptoms of ovarian cancer which are non-specific. A collaboration involving GPs, the NCCP, Obstetrics/gynaecology and the Clinical Programme for Radiology developed a set of GP referral guidelines. Context: The guideline requires general practitioners (GPs) to undertake some investigations in the Primary Care setting if a woman is symptomatic i.e. serum CA125 and pelvic ultrasound. Pelvic ultrasound investigation of possible gynaecological pathology can be a multistep process. In most cases an initial trans-abdominal pelvic ultrasound (TAUS) is undertaken. This may be followed by a trans-vaginal pelvic ultrasound (TVUS). The TVUS may be undertaken during the same appointment as the TAUS or a follow up appointment may be arranged. The ultrasound is ordered if the CA125 is elevated (≥35 IU/ml) and gynae-oncology referral is only appropriate if ultrasound findings are suspicious of cancer, the CA125 is greater than 200 IU/ml or there are suspicious findings on clinical examination suggestive of ovarian cancer (1). The GP ovarian referral guideline was implemented on a pilot basis in an area of the country where GP access to ultrasound investigations was 100%. The aim of the pilot was to quantify any impact of this guideline on radiology and gynaecology services. This took place at St James’s Hospital. A survey was undertaken to assess the capacity of radiology departments in acute hospitals to implement the planned GP Ovarian Cancer Referral Guideline. The results of the survey revealed that CA125 increased by 28% but with no increase in U/S exams or at referrals to gynaecology/oncology. Aim and theory of change: All acute hospitals, where the service is available, should provide GP access to ultrasound investigations for suspected ovarian cancer. Standardised national criteria for referral for an ultrasound should be followed. Ultrasound facilities that are located in the Primary Care setting should adhere to these standardised referral criteria. These referral criteria should be monitored and evaluated periodically in conjunction with representatives from relevant disciplines such as radiology, gynaecology and general practice. Targeted population and stakeholders: Women (especially aged over 50 years) who present with the following persistent and frequent symptoms (i.e. more than 12 times per month): Abdominal distension, Early satiety, Loss of appetite, Pelvic or abdominal pain, Increasing urinary urgency or frequency, New onset Irritable Bowel Syndrome (IBS). Consider ovarian cancer in women who present with unexplained:· Ascites, DVT, Change in bowel habit, Weight loss, Fatigue. Sustainability: Once implemented, the guidelines should lead to a greater awareness of ovarian cancer, prompt referral and earlier diagnosis. Dissemination is taking place through ‘Train the Trainer’ and at GP study days.