Ovarian and Endometrial Cancer Using risk factors to help triage

1. Ovarian and Endometrial Cancer Using risk factors to help triage Adam Rosenthal PhD MRCOG Consultant Gynaecologist and Gynaecological Oncologist

2. Ovarian Cancer

3. CR UK Ovarian Cancer Stats for UK and world • 5th commonest women’s cancer in UK (2nd after uterine) • 7,116 cases in 2011 - 19 women / day • 4,271 deaths in 2012 - 11 women / day – most lethal gynae cancer • Increasing incidence with age - 75% new cases aged > 54 yr • In Europe - 65,600 cases (estimated) in 2012 • Worldwide - 238,000 cases (estimate) in 2012

4. Number of New Cases per Year and Age-Specific Incidence Rates per 100,000 Population, UK, 2009-2011

5. Most cases occur in postmenopausal women

6. Stronger Ovarian Cancer Risk Factors • Family history (and Ashkenazi Jewish heritage) • Ovarian (any age but epithelial tumours only) • Breast (esp below 50 yr) • Endometrial, colorectal (esp young ages) – Lynch Syndrome • Age – 75% postmenopausal • Gynae history • Never used hormonal contraception • Nulliparous • Never breast fed • Early menarche/late menopause • Used HRT • Endometriosis • No tubal ligation/salpingectomy/hysterectomy Lifetime ovulations & hormones Weaker

7. Symptoms (NICE Clinical Guideline 122) New onset, persistent (esp if >x12/month) • Bloating/distension • Pelvic/abdominal pain • Feeling full quickly after eating/loss of appetite • Increased urinary urgency/frequency NB bowel dysfunction not in guideline but if primary bowel pathology excluded please consider ovarian cancer

8. Investigation (NICE Clinical Guideline 122) No mass/ascites CA125 >=35 u/ml <35 u/ml Re-assess / re-attend if symptoms persist TVS Abnormal Normal Refer if suspicious

9. Endometrial Cancer

10. CR UK Uterine Cancer Stats for UK and world • 4th commonest women’s cancer in UK (commonest gynae cancer) • 8,475 cases in 2011 - 23 women / day • 2,025 deaths in 2012 • 78% 5 yr survival • Increasing incidence with age – vast majority aged > 40 yr • In Europe – 100,000 cases (estimated) in 2012 • Worldwide - 319,000 cases (estimate) in 2012 • 50% increase in UK rate since 1990s

11. Uterine cancer Number of New Cases Per Year and Age-Specific Incidence Rates per 100,000 Population, UK

12. Most cases occur in postmenopausal women

13. Endometrial Cancer Risk Factors • Family History – Endometrial, colorectal (esp young ages) – Lynch Syndrome • Obesity • Age • Tamoxifen • Endometrial hyperplasia (esp atypical) • Gynae/medical history • Never used hormonal contraception • Nulliparous/early menarche/late menopause • Any HRT other than continuous combined • PCOS or ovarian granulosa cell tumour • Prior breast cancer • Pelvic radiotherapy Lifetime estrogens

14. Symptoms Postmenopausal bleeding Intermenstrual bleeding (age > 40 yr)

15. Two Week Wait Referral Form • Ascites/pelvic mass on examination/ultrasound (not obviously fibroids/urological/GI) • Raised CA 125 and strong clinical suspicion of ovarian cancer (with USS if available) • Persistent intermenstrual bleeding > 45 years of with normal vaginal examination (lasting > 6 weeks after stopping HRT/COCP if taken) • Postmenopausal Bleeding • HRT: Unexpected or prolonged bleeding for >6 weeks after stopping HRT • Any other relevant symptoms or signs not covered by the guidelines

16. Two Week Wait Referral Form • Lesion suspicious of cancer on cervix or vagina on speculum, or smear suggestive of cancer –refer urgently to colposcopy • Lesion suspicious of cancer on clinical examination of vulva or vagina

17. adam.rosenthal@uclh.nhs.uk