Presentation is loading. Please wait.

Presentation is loading. Please wait.

Rapid Access clinics in Gynaecology Oliver Chappatte Consultant Gynaecologist Tunbridge Wells Hospital at Pembury Spire Tunbridge wells Hospital.

Similar presentations


Presentation on theme: "Rapid Access clinics in Gynaecology Oliver Chappatte Consultant Gynaecologist Tunbridge Wells Hospital at Pembury Spire Tunbridge wells Hospital."— Presentation transcript:

1 Rapid Access clinics in Gynaecology Oliver Chappatte Consultant Gynaecologist Tunbridge Wells Hospital at Pembury Spire Tunbridge wells Hospital

2 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 Ovary29 % Cervix12 %

3 Rapid Access Referrals

4 RAC at MTW NHS Trust Overview – 15,000 General Gynaecological referrals – 2000 RAC Referrals – ‘Slots’ per week – 4 Consultants + Gynae Oncologists – 10% have Cancer – 50% Gynaecological cancers come through other routes » Radio;ogy, General Medicine, Surgery, A&E.

5 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

6 Rapid Access Referrals Who to refer How to Refer What happens to the patient What we do

7 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

8 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

9 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

10 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

11 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

12 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.

13 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

14 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

15 Normal Cervix

16 Cervical Abnormalities

17

18 Nabothian Follicle

19 Multiple Nabothian Follicles

20 Cervix post Loop biopsy

21 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

22 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.

23 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.

24 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

25 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.

26 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!

27 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)

28 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”

29 Ovarian Cysts

30

31 Rapid Access Referrals Who to refer How to Refer = FAX 2 week wait Office What happens to the patient What we do

32 RAC Performa KMCN\KT\Clinical\GP Referral Proformas\Gynae\Published July of 2 Suspected Cancer Urgent Referral Criteria/Information Vulva Lesion suspicious of cancer on clinical examination Cervix / VaginaLesion 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)

33 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

34 Rapid Access Referrals Who to refer? How to Refer What happens to the patient ? What we do

35 Trans-vaginal Scan (PMB and mass)

36 Pipelle biopsy

37 Hysteroscopy

38 Vulval Biopsy

39 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!

40 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

41 Endometrial Cancer & Obesity Rising Incidence – 4 th Commonest cancer in women (5%) – 7536 cases in 2007 – 40% increase between 1993 – 2007 overall – Peak incidence 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

42 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


Download ppt "Rapid Access clinics in Gynaecology Oliver Chappatte Consultant Gynaecologist Tunbridge Wells Hospital at Pembury Spire Tunbridge wells Hospital."

Similar presentations


Ads by Google