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 Ovary 29 % Cervix 12 %

3. Rapid Access Referrals

4. RAC at MTW NHS Trust Overview 15,000 General Gynaecological referrals
2000 RAC Referrals
30-40 ‘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
40 year old with pelvic pain and 14 week ? Fibroid mass
49 year old with persistent irregular perimenopausal bleeding
One episode of post-menopausal bleeding on HRT
Abnormal looking cervix – bleeds on contact

8. Who to refer?
Cases
40 year old with pelvic pain and 14 week ? Fibroid mass
49 year old with persistent irregular perimenopausal bleeding
One episode of post-menopausal bleeding on HRT
Abnormal looking cervix – bleeds on contact

9. Who to refer?
Cases
40 year old with pelvic pain and 14 week ? Fibroid mass
49 year old with persistent irregular perimenopausal bleeding
One episode of post-menopausal bleeding on HRT
Abnormal looking cervix – bleeds on contact

10. Who to refer?
Cases
40 year old with pelvic pain and 14 week ? Fibroid mass
49 year old with persistent irregular perimenopausal bleeding
One episode of post-menopausal bleeding on HRT
Abnormal looking cervix – bleeds on contact

11. RAC Referrals examination
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 examination
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

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. Ovarian Cysts

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 / Vagina Lesion 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
4th 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