Walsall Healthcare NHS Trust

Ovarian Cancer

Fateh GhazalConsultant Obstetrician & Gynaecologist

23/3/16

Outline• Background

• Primary care pathway

• Secondary care pathway

• ROCkeTS Study & IOTA rules

• Case presentations

Background• 1 in 10 women will have surgery for ovarian mass

• 1 in 10 of suspected ovarian masses are non ovarian

• Incidence of malignancy in symptomatic ovarian masses is:

• 1:1000 for premenopausal women • 3:1000 for 50 years old

Ovarian Cancer Spread• lifetime risk 2%

• Approximately 7000 women diagnosed in the UK each year

• Frequently diagnosed at Stage 3C/4

• Insidious onset with bloating and ascites

• Treated primarily with surgery and chemotherapy

Ovarian cancer• Symptoms & Signs:

– Persistent (>12 times a month)• Bloating• Feeling full• Pelvic pain• Urinary urgency / frequency

– >50 & newly diagnosed IBS

1 in 2 women, aged 45 -70 present to GP each year with symptoms,

Sasieini BMC 2014

Primary care investigations

Non-malignant disorders

Pelvic-mass associated

Multi-visceral tuberculosis

Meigs and pseudo-Meigs syndrome

Ovarian hyperstimulation syndrome

Non-pelvic mass associated

Liver cirrhosis

Tuberculosis peritonitis

Uraemia and renal failure

Nephrotic syndrome

Fulminant hepatic failure

Pancreatitis

Malignant disorders

Primary pelvic tumour

Ovarian cancer

Advanced uterine cancer

Advanced fallopian-tube cancer

Advanced rectal or bladder cancer

Secondary pelvic involvement

Lymphoma with peritoneal involvement

Pancreatic carcinoma

Breast cancer with peritoneal metastasis

Gastric cancer with peritoneal metastasis/ Advanced hepatocellular ca

Raised CA125

Internal auditGP referrals

CA125: 3:8 patients (37%)

USS: requested in 10:10 patients (100%)

USS images uploaded to fusion: 6:10 patients (60%)

First treatment (≤ 31 days)

Referral To Treatment (≤ 62 days)

Two week wait (≤ 14 days)

Diagnosis communicated

to patient

Cancer Treatment

Period Start date (Decision To

Treat)

Treatment Start Date

Cancer Referral to Treatment start date

Date first seen

Current system

Diagnosis communicated

to patient

Cancer Treatment

Period Start date (Decision To

Treat)

Treatment Start Date

Cancer Referral to Treatment start date

First treatment (≤ 31 days)

Referral To Treatment (≤ 62 days)

Four weeks (28 days)

Date first seen

Two week wait <14 days

New system

Pre menopausal – Simple cyst

Asymptomatic patient

Pre menopausal – Complex cyst

Post menopausal – Ovarian cyst

Post menopausal – Ovarian cyst

RMI = U x M x CA-125• USS features:

• multilocular • solid areas• metastases • ascites• bilateral lesions

– U = 0 (for an ultrasound score of 0), – U = 1 (for an ultrasound score of 1), – U = 3 (for an ultrasound score of 2–5).

• The menopausal status is scored as – 1 = premenopausal – 3 = postmenopausal

ROCkeTS Study & IOTA Rules• Multicentre• Portfolio Study – NIHR• 2 years period• Both pre and postmenopausal women with suspected ovarian

cancer• Exclusion simple ovarian cyst < 5 cm• No change in current management• Eligible patients will be invited for 3 extra tests

– Symptoms Questionnaire– Blood Test– Detailed TA/TV scan IOTA rules

B-rules M-rules

Unilocular cysts Irregular solid tumour

Solid components <7mm Ascites

Acoustic shadowing At least four papillary structures

Smooth multilocular <100mm

Irregular multilocular solid tumour >100mm

No blood flow Very strong blood flow

In conclusion• Ovarian cancer:

• 80% present at advanced stage • All stage 5 years survival <45%• The most common cause of gynaecological cancer death

• Suspect early, Investigate appropriately, Refer promptly

Thank you for listening,any questions?