1. Background The 2 week wait referral system was designed to expedite the referral of patients, suspected to have cancer, from Primary to Secondary care (DoH 2000), with the aim being to facilitate early diagnosis and improve outcomes. It is recognised however, that the early diagnosis of ovarian cancer remains a challenge and as a result, in April 2011, NICE published Clinical Guidance 122 on “ The recognition and initial management of Ovarian Cancer ”. The key recommendation was that “GPs should perform a blood test to measure serum CA125 levels in women who present with symptoms that might indicate ovarian cancer”. Aim of audit 1. To audit the “ recognition and initial management of suspected Ovarian Cancer ” against agreed standards in the NICE CG 122 2. To further assess the impact of the publication of NICE CG 122 on the following:- a. The number of Ca 125 requests, 2ww referrals for suspected ovarian cancer, and the actual numbers of ovarian cancers diagnosed. b. The proportion of patients with ovarian cancer that were identified through the 2ww system pre and post guidance. c. Whether the 2ww system was being used appropriately by GPs. Methods All patients referred on the 2ww pathway for suspected ovarian cancer between April 2011 and March 2012 were identified from the Cancer Office “Somerset” Database. Clinical data was retrieved by a retrospective review of clinical notes and results on the hospital’s electronic reporting system - ICE. The data was then compiled in an Excel spreadsheet for analysis. Results 116 patients were referred on the 2ww pathway for suspected ovarian cancer between April 2011 and March 2012. The age range was 22 – 96 years with an average age of 55 years. The reasons for referral were as shown in Figure 1. Figure 1: The cancer waiting times statistics were as follows: 1. Referral to clinic date – average 8 days (maximum 25) 2. Referral to diagnosis – average 18 days (minimum 3 and maximum 42) All patients referred on the 2ww system had a pelvic ultrasound scan in “one stop” pelvic mass assessment clinics. 97% had an ultrasound scan as the first imaging investigation and 3% had CT/MRI. In the latter group, all had ovarian pathology identified as an incidental finding during investigation of presumed non ovarian pathology. Of the 116 patients referred on the 2ww system, pathology was identified in 100 as detailed below;  22 gynaecological malig nancy (14 ovarian cancers, 5 borderline tumours, 3 endometrial cancers).  4 non-gynaecological malignancies (breast, lung, pancreas and sigmoid)  74 patients had benign pathology including benign ovarian cysts, fibroids, endometriosis, hydrosalpinges, cirrhotic liver disease, sigmoid adenoma, diverticular disease, Meckel’s diverticulum, appendix abscess, cardiac failure and sarcoidosis. Only 14% of the patients referred were found to have no pathology. See Figure 2. Figure 2: As regards the impact of NICE CG122 on the 2ww service and ovarian cancer diagnoses, we found the following:  A 42 % increase in Ca 125 request compared to a prior audit 2 (Figure 3) in the 12 months following introduction of the guidelines Figure 3:  A 117% increase in number of 2ww referrals.  Only 1 ovarian cancer diagnosed in patients referred on the 2ww pathway for suspected ovarian cancer in the 6 months prior to the new guidance compared with 14 ovarian cancers diagnosed in the 12 months following the new guidance (Figure 4). Figure 4: The 14 ovarian cancers diagnosed during the audit period were staged as follows:  5 Stage 1 (2 Stage 1a, 3 Stage 1c)  2 Stage 2  4 Stage 3  3 Stage 4  Prior to introduction of NICE CG 122, only 4% of ovary cancers came via the 2ww system, but this increased to 35% in the 12 months afterwards. Conclusions  NICE CG 122 appears to have increased the awareness amongst GPs of potential ovarian cancer symptoms, as within 12 months of publication there has been a 42% increase in Ca 125 requests and a 117% increase in 2ww referrals to exclude ovarian cancer.  22% (26/116) of patients referred on the 2ww system had cancer. Overall, 86% of patients were found to have some pathology showing a very responsible use of the 2ww system by GPs.  97% of patients referred on the 2ww system had an Ultrasound scan as the primary radiological investigation. This was used to calculate a Risk of Malignancy Index and stratify risk.  The proportion of Ovary cancers identified through the 2ww system increased from 4% to 35% after publication of NICE CG122.  Of the 14 Ovary cancers that came via the 2ww pathway after NICE guidance, 5 (36%) were stage1 This audit suggests an increased awareness of Ovary Cancer and a very responsible use of the 2ww system among GPs. The relative high proportion of stage 1 disease identified via the 2ww system is encouraging and it is hoped that if this trend continues, it will contribute to an improvement in prognosis of this disease. References 1.National Institute of Clinical Excellence. Ovarian Cancer – The Recognition and Initial Management of Ovarian Cancer. NICE Clinical Guideline 122. April 2011. 2.Duncan A et al. Effect of NICE Clinical Guidance 122 on Number of Ca125 Requests. Northampton General Hospital. Nov 2011. 3.National Cancer Intelligence Network. Routes to diagnosis - NCIN data briefing. London: NCIN, 2010. Northampton General Hospital NHS Trust