Gynaecological Unit Leads
Welcome to the Gynaecology Unit section of the BGCS website.
This area will be of particular interest to those clinicians who are involved in gynaecological cancer care outside the regional Gynaecological Cancer Centres. This will include those who act as the lead clinician for gynaecological cancers in a Cancer “Unit” i.e. management in a secondary care setting of women with suspected or diagnosed gynaecological cancers, including treatment and follow-up. The local gynaecology oncology unit will also help to ensure that this management is coordinated between primary care, and specialist teams based in cancer centres. A number of useful links and information sources are listed in this section and will gradually be updated as guidelines change or more information becomes available, with research.
The role of the cancer unit is becoming more significant due to the requirement for an early diagnosis within the various cancer timelines and the work will only lead to a cancer diagnosis in a minority of patients. Hence there are now many more clinicians involved in the local multidisciplinary team – this includes the lead clinicians who may manage low-grade, low-risk endometrial cancers, colposcopists, clinicians involved in the diagnostic clinics (such as one-step Rapid Access Clinics and other clinics), nurse specialists, trainees, as well as GP’s.
Cancer survival in the UK is still lower than the European average, partly due to later stage at diagnosis. The NHS aim is for early diagnosis. Further information on the Routes to Diagnosis is available through NCRAS (National Cancer Recognition and Analysis Service). Click Here.
Significant information regarding screening, diagnosis, statistics and other information relevant to the health professional is available here.
In the future there will also be a section on the basic job plan for a clinician working in a cancer unit, both at diagnostic level and those leading the service, performing the surgery for endometrial cancers.
The Royal College of Obstetricians & Gynaecologists provides the syllabus for Advanced Skills Training Modules (ATSMs) relevant to gynaecological oncology at unit level. These are based on various competencies. The following relevant links are provided:
For those clinicians who wish to become a Unit Lead Clinician. Click here.
For those who wish to develop some of the diagnostic skills required in hysteroscopy. Click here
The London Cancer Alliance has published some guidelines for diagnosis and treatment which are very helpful for the unit clinicians. Quoting verbatim from the guidelines “Cancer units have a full range of diagnostic and supportive services; they have arrangements for the close integration of primary and secondary care and the identification of appropriate rapid referral patterns for patients with symptoms indicating a high risk of a malignancy. Cancer units have site-‐specific consultations in clinics led by consultant specialists. The responsibilities of the cancer unit relate to the initial diagnostic procedures such as clinical examination, biopsies of endometrial, cervical, vaginal and vulval lesions, ultrasound scanning and tumour marker assays. In addition, the designated lead gynaecologist should normally carry out surgery for early stage low-‐risk endometrial carcinoma, microinvasive cervical carcinoma (stage IA1) and for pelvic masses where the risk of malignancy is low. Cancer units provide rapid assessment services for patients with pelvic masses or post-‐menopausal vaginal bleeding, a dedicated colposcopy service for the evaluation of abnormal cervico-vaginal cytology, and systems for data collection and audit within the 31-day cancer waiting times guidance for patients referred within the 2 week wait system. Each unit has a lead gynaecology oncology surgeon who attends the specialist multidisciplinary team (MDT) at the referring cancer centre. There should be a dedicated clinical nurse specialist in each unit”. These guidelines can be downloaded here.
Nationally, the National Institute for Health and Care Excellence (NICE) has published guidance on “Suspected cancer: recognition and referral” https://www.nice.org.uk/guidance/ng12, with the full guidelines available here.
Clinicians often require more detailed imaging than a basic ultrasound scan in planning treatment, especially for pelvic masses. “Recommendations for cross-sectional imaging in cancer management, Second edition (2014)” is available here.
Much of the work of the unit is related to triage of abdomino-pelvic masses/cysts. NICE has published “Ovarian cancer: recognition and initial management Clinical guideline [CG122] Published date: April 2011” available from https://www.nice.org.uk/guidance/cg122
Risk of Malignancy Index is used to triage ovarian masses – “The International Ovarian Tumor Analysis (IOTA)” group covers a multitude of studies examining many aspects of gynaecological ultrasonography within a network of contributing centers throughout the world that are coordinated from KU Leuven. https://www.iotagroup.org/
Many women will be diagnosed with endometriosis as a result of raised serum CA125 levels. The European Society of Human Reproduction and Embryology Guideline on the management of women with endometriosis Issued : 18 September 2013, is available to download.
Relevant publications from the Royal College of Obstetricians & Gynaecologists
The following RCOG publications will be of use to the Unit clinician:
- Fertility-sparing Treatments in Gynaecological Cancers (Scientific Impact Paper No. 35) Published: 01/02/2013 Download.
- Endometrial Hyperplasia, Management of (Green-top Guideline No. 67) Published: 26/02/2016
- Ovarian Cysts in Postmenopausal Women (Green-top Guideline No. 34) Published: 19/07/2016
- Ovarian Masses in Premenopausal Women, Management of Suspected (Green-top Guideline No. 62) Published: 02/12/2011
- Breast Cancer, Pregnancy and (Green-top Guideline No. 12) Published: 27/04/2011
- Genetic Predisposition to Gynaecological Cancers, Management of Women with a (Scientific Impact Paper No. 48) Published: 04/02/2015
- Ascites in Ovarian Cancer Patients, Management of (Scientific Impact Paper No. 45) Published: 19/11/2014 Download.
- High-grade Serous Carcinomas, The Distal Fallopian Tube as the Origin of Non-uterine Pelvic (Scientific Impact Paper No. 44) Published: 19/11/2014
- Management of Female Malignant Ovarian Germ Cell Tumours (Scientific Impact Paper No.52) Published: 25/11/2016
- Guidelines for the Diagnosis and Management of Vulval Carcinoma, Published: 28/05/2014
Between 2007 and 2009 there were an average of 7,800 uterine cancer cases diagnosed annually in the UK, making this the fourth most common cancer in women and the most common gynaecological cancer. Trends in endometrial cancer and variation by age, in the UK can be observed at the NCRAS (National Cancer Recognition and Analysis Service) site, via the following link.
Some interesting information regarding NHS patients with a record of a major resection for uterine cancer, by sex, age and deprivation quintile, 2004-2006, followed up to 2007 can be found here.
Laparoscopic or minimal access surgery is an important part of enhanced recovery for endometrial cancer surgery. An interesting poster on the feasibility of minimal access surgery for uterine cancer, analysing hospital episode statistics (HES) (Elleray and Nordin, 2013) is available to download from http://www.ncin.org.uk/view?rid=2363. This originally showed considerable variation in laparoscopic surgery rates between hospitals. There has however, been a significant increase in the proportion of endometrial cancers since then.
Cancer Unit Clinicians currently perform most of the surgery for low-grade, low-risk endometrial cancers. The proportion of Evidence supporting the use of laparoscopy versus laparotomy for presumed early stage endometrial cancer has been reviewed for the Cochrane Primary Review Group.
Gynaecological, Neuro-oncology and Orphan Cancer Group and the review can be downloaded here.
There is also NICE interventional procedures guidance supporting laparoscopic hysterectomy for endometrial cancer, available through https://www.nice.org.uk/Guidance/IPG356
When surgery may not be an option, hormonal treatment may be the only option available. The Cochrane Primary Review Group Gynaecological, Neuro-oncology and Orphan Cancer Group reviewed hormonal therapy for endometrial cancer https://www.cochrane.org/CD007926/GYNAECA_the-effect-of-hormonal-treatment-on-advanced-or-recurrent-endometrial-cancer.
Obesity affects a high proportion of the UK population and is particularly relevant for endometrial cancer, with surgery often challenging as a result. The Royal College of Obstetricians & Gynaecologists published “Endometrial Cancer in Obese Women (Scientific Impact Paper No. 32, Published: 06/06/2012)” available to download.