Evaluation of women referred to the two-week wait gynaecology clinic with suspected ovarian cancer

Abstract

Objectives

Ovarian cancer is the leading cause of death from gynaecological cancer in the UK, making early diagnosis key. The two-week wait pathway aims to facilitate rapid referrals from primary to secondary care for suspected cancer thus increasing rates of early diagnosis. The objective of this study was to evaluate referrals made via the two-week wait pathway for suspected ovarian cancer.

Study Design

A retrospective analysis of 215 women referred on the two-week wait pathway to a tertiary centre in the United Kingdom with suspected ovarian cancer in 2018.

Results

Only 16% of women referred were subsequently diagnosed with gynaecological malignancy. Of those diagnosed with ovarian cancer, 78% had late stage disease at diagnosis. Pre-menopausal women made up 29% of those referred, but only 6% of those diagnosed with cancer.

Conclusion

Despite its goal of increasing early stage diagnosis of cancer, the majority of women referred via the two-week wait pathway do not have cancer, and the majority of those who do are referred with late stage disease. These results highlight the need for an effective screening programme for ovarian cancer.

Introduction

Ovarian cancer is a disease in which the majority (55–58%) of cases present at a late stage, when curative treatments are not possible, thus making it the leading cause of death from gynaecological cancer in the UK [1]. If patients are diagnosed with early stage disease, treatments are much more likely to be curative. In advanced stage disease, management can be associated with a significant degree of morbidity for patients with the ensuing negative impact on their remaining quality of life [2]. NHS England aims to improve the numbers of patients diagnosed with International Federation of Gynaecology and Obstetrics (FIGO) stage 1 ovarian cancer, to improve survival rates, as laid out in the Achieving World Class Cancer Outcomes Strategy 2015–2020 [3].

The National Institute for Health and Care Excellence (NICE) Guidance for Suspected cancer includes the criteria for two-week referral for suspected ovarian cancer and includes if ‘Physical examination suggests ascites and/or pelvic or abdominal mass obviously not a fibroid or ‘USS of abdomen and pelvis suggests ovarian cancer’ [4]. Patients are also referred at time with a raised CA125 level taken in primary care prior to any imaging being undertaken.

The Two-Week Wait referral pathway is in place in England, to facilitate rapid referral and review of patients with suspected cancer from primary to secondary care. Anecdotally, the majority of patients who are referred on a Two-Week Wait pathway to Gynaecology for suspected ovarian cancer do not have ovarian cancer. Although Two-Week Wait is the most common pathway in which women in England and Wales are diagnosed with ovarian cancer [5], this only accounts for one third of diagnoses; many patients present via other avenues such as emergency admissions once their disease has reached ‘crisis point’ for example causing bowel obstruction due to the non-specific symptoms associated with the disease.

This study evaluates the number of women referred on a Two-Week Wait pathway from 1st January to 31st December 2018 to the Gynaecology Two-Week Wait service at one large teaching hospital in the north of England, who were subsequently diagnosed with ovarian cancer. These results will be fed back to primary care via the local Clinical Commissioning Group to educate and inform colleagues on issues surrounding the diagnosis of ovarian cancer and hopefully improve the rates of early diagnosis in the future. It is hoped the results will also be used to help reduce anxiety for many women with benign ovarian cysts who are frequently referred on this pathway.