1. Consultant Obstetrician & Gynaecologist
Walsall Healthcare NHS Trust
Ovarian Cancer
Fateh Ghazal
Consultant Obstetrician & Gynaecologist
23/3/16

2. Outline Background Primary care pathway Secondary care pathway
ROCkeTS Study & IOTA rules
Case presentations 2

3. 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 3

4. 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 4

6. 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 present to GP each year with symptoms,
Sasieini BMC 2014 6

7. Primary care investigations
≥ 35 IU/ml
TA/TV scan
Suspected ovarian cancer
2 WW referral
Normal
< 35 IU/ml
Exclude other pathologies 7

8. Raised CA125 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

9. Internal audit GP referrals CA125: 3:8 patients (37%)
USS: requested in 10:10 patients (100%)
USS images uploaded to fusion: 6:10 patients (60%)

10. Current system Cancer Referral to Treatment start date Date first seen
Referral To Treatment (≤ 62 days)
Cancer Referral to Treatment start date
Date first seen
Diagnosis communicated to patient
Cancer Treatment Period Start date (Decision To Treat)
Treatment Start Date
Two week wait (≤ 14 days)
First treatment (≤ 31 days)

11. New system Cancer Referral to Treatment start date Date first seen
Diagnosis communicated to patient
Cancer Treatment Period Start date (Decision To Treat)
Treatment Start Date
Two week wait <14 days
Four weeks (28 days)
First treatment (≤ 31 days)
Referral To Treatment (≤ 62 days)

12. Pre menopausal – Simple cyst
Simple ovarian cyst
< 5 cm
Discharge
5-7 cm
Annual
scan
> 7 cm
Consider surgery
No Tumour markers
Asymptomatic patient 12

13. Pre menopausal – Complex cyst
Complex ovarian cyst
< 200
Endometriosis / Fibroids excluded
> 200
CA 125
LDH, AFP, BHCG if <40 years
Oncology MDT 13

14. Post menopausal – Ovarian cyst
RMI
25-250
Lap BSO
>250
Oncology MDT
CA 125
TA/TV scan 14

15. Post menopausal – Ovarian cyst
RMI < 25
Simple cyst unilateral < 5 cm
CA 125 < 30
TV scan + CA 125
Every 4 months for
1 year
No change or resolved
Discharge
Increased in size / suspicious
Recalculate RMI
Other cyst
Consider surgery 15

16. 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 16

17. 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 17

18. Irregular solid tumour
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 18

19. 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 19

20. Thank you for listening,
any questions? 20