Lothian Primary Care CA125 Guidance Notes - RefHelp：锡安的初级保健指南- refhelp CA125

Lothian Primary Care CA125 Guidance Notes - RefHelp：锡安的初级保健指南- refhelp CA125 Feb 2014 Lothian Primary Care CA125 Guidance Notes INTRODUCTION In Scotland, ovarian cancer is the sixth most common female cancer, and the fourth most common 1cause of female cancer death . The incidence of ovarian cancer in the UK is one of the highest in 23Europe . Survival rates in the UK are lower than the European average and there are approximately 4500 avoidable deaths annually in the UK . Diagnosis is often delayed due to the non-specific symptoms seen in ovarian cancer and investigations when performed being focussed on finding gastrointestinal pathology. Hence we need to reduce our threshold for also investigating for ovarian cancer. It is recognised that this is an area of great diagnostic uncertainty and challenge. This guidance aims to assist primary care physicians in the triage of patients who require investigation for ovarian cancer, so that the level of risk can be assessed earlier in the diagnostic process, reducing delays for those more likely to have a malignancy. The referral pathways suggested are not mandatory and current methods of referral can still be used at the clinician?s discretion. This Lothian guidance on the use of CA125 (Cancer Antigen 125) is based on NICE Guideline 122 on 5ovarian cancer . A primary aim of the NICE guideline is to increase awareness of ovarian cancer amongst patients and clinicians with the aim of achieving a timely diagnosis and improved outcomes 5by earlier investigation and treatment . GPs are in an optimal position to identify and appropriately investigate women with potential symptoms of ovarian cancer. These investigations include measurement of serum CA125 and a pelvic USS which can together be used to calculate a Risk of Malignancy Index 1 (RMI1) score. This can help to triage the speed of their onward referral to secondary care services as necessary. This Lothian guidance has been developed in collaboration with PLIG and the departments of Gynaecology, Clinical Biochemistry and Radiology; it recommends interpretation of the biochemical result in conjunction with clinical and ultrasound findings. A new, specific Ultrasound referral pathway for ovarian cancer is now available on Refhelp for this, analogous to the existing one for the investigation of post-menopausal bleeding. USE OF CA125 IN LOTHIAN (please read in conjunction with the guidance flowchart) It is important that post-menopausal women of any age (amenorrhoea for more than one year) or those over 50 years old are treated with a higher degree of suspicion when presenting with suspicious symptoms of ovarian cancer (as stated in the flowchart). When assessing peri-menopasual women one should err on the side of caution. CA125 measurement requires a serum (brown top) tube and is processed by Clinical Biochemistry every weekday. Typically the result is available the following day to facilitate rapid onward referral as Written by Dr Catriona Finlayson and Dr Clare Tucker Feb 2014 required. The last menstrual period (LMP) and menopausal status should be stated on the request form and the sample should not be taken during menstruation. All women in whom a CA125 test is being considered should ideally have a pelvic and abdominal examination. If a suspicious mass is found which is thought to be gynaecological in origin, a referral to Gynaecology should be generated on SCI Gateway (select „urgent - suspicion of cancer?). The Gynaecology Oncology clinic is on a Monday morning. Dr Graeme Walker (Consultant Gynaecologist) can be contacted for urgent queries via The Royal Infirmary of Edinburgh switchboard. Please try to include a CA125 result in the referral letter and also request an urgent pelvic Ultrasound Scan (USS) – again „urgent – suspicion of cancer?), but not delay referral to Gynaecology. If the examination is normal but CA125 is ? 35 kU/L, request a pelvic USS via SCI Gateway (“Investigation of suspected ovarian cancer”). Please include the CA125 result and menopausal status on the referral if possible. This would therefore allow the Radiology department to refer directly on to the Gynaecology Oncology clinic if the USS is suspicious of ovarian cancer. It would also prompt them to consider a transvaginal USS if the ovaries had not been fully visualised on the abdominal view. A report will be returned to the requesting clinician informing them of this onward referral. If the USS is not suspicious of ovarian cancer, the report will be returned to the requesting clinician to calculate the Risk of Malignancy Index 1 (RMI1). The USS will be reported in such a way that this can be easily calculated. In low risk women (young, non-specific symptoms such as bloating, normal examination and CA125) there is no need to request an „urgent - suspicion of cancer? scan: these will still be done quickly but should not take precedence over the high risk referrals. RMI1 is a tool which is used to assess the risk of ovarian cancer in a woman who has symptoms. It is not a diagnostic test. It is evidence-based and has been used by the Royal College of Obstetricians and Gynaecologists for many years. It is a numerical calculation based on an USS score, menopausal status and CA125 level. RMI1 = U x M x CA125 U = ultrasound score (score one point for each M = menopausal status (No periods for more of the following multilocular cysts, solid areas, than a year, or over 50 yrs old and had metastases, ascites, bilateral lesions hysterectomy) U = 0 for an USS score of 0 points, 1= pre-menopausal U = 1 for an USS score of 1 point, 3= post-menopausal U = 3 for an USS score of 2-5 points) CA125 measured in kU/L If the USS score is 0 the RMI1 will also therefore be 0. In this context it is thought to be very unlikely that the patient will have ovarian cancer regardless of the CA125. However if CA125 is high it should be repeated at roughly 5 weeks (thereby minimising the chances of a repeated spurious result if this is due to menstruation). The result of this should aid in the decision regarding the need for and urgency of gynaecology referral. Written by Dr Catriona Finlayson and Dr Clare Tucker Feb 2014 If RMI1 ? 250 - patient should be referred via SCI Gateway to the Gynaecology clinic (select „urgent – suspicion of cancer?) If RMI1 < 250 repeat the CA125 at 5 weeks. If CA125 is still ? 35 kU/L, refer to Gynaecology via SCI Gateway (select „urgent?). It is important to remember that there are other causes of a raised CA125. These are outlined in the following table. For women who have a normal pelvic and abdominal examination and a normal CA125, it is important to remember that CA125 is not elevated in up to 30% of women with ovarian cancer and may be falsely reassuring. Always reassess the patient to consider both gynaecological pathology and diagnoses involving other systems. It may be appropriate to request a pelvic USS via the usual route in many instances. The diagnosis and management of ovarian cancer is an evolving field. SIGN are currently working on guidance for Scotland. There are also new tumour markers which may become available in the future to aid in this area of diagnostic uncertainty. REFERENCES 1. Information and statistics Division Scotland, 2. GLOBOCAN 2008, 3. Eurocare 4 Database, 4. Abdel-Rahman M., Stockton D., Rachet B., Hakulinen T. and Coleman M.P., 2009. What if Cancer Survival were the same as in Europe: how many deaths are avoidable? British Journal of Cancer 101 (Suppl 2): S115-24. 5. NICE clinical guideline 122 Ovarian cancer. The recognition and initial management on ovarian cancer. ACKNOWLEDGEMENTS Dr John Donald, General Practitioner and Lothian Referrals Adviser Dr Catriona Morton, General Practitioner, Primary Care Laboratory Interface Group Dr Cathie Sturgeon, Dept of Clinical Biochemistry, Royal Infirmary of Edinburgh Dr Graeme Walker, Consultant Gynaecologist, Royal Infirmary of Edinburgh Dr Jane Walker, Consultant Radiologist, Royal Infirmary of Edinburgh Written by Dr Catriona Finlayson and Dr Clare Tucker