Recognizing Gynecological Cancer in Primary Care: Risk Factors, Red Flags, and Referrals

Advances in Therapy, Mar 2018

Early diagnosis of symptomatic gynecological cancer is likely to improve patient outcomes, including survival. The primary care practitioner has a key role to play in this—they must recognize the symptoms and signs of gynecological cancer and make prompt evidence-based decisions regarding further investigation and referral. However, this is often difficult as many of the symptoms of gynecological cancers are nonspecific and are more likely to be caused by benign rather than malignant disease. As primary care is generally the first point of patient contact, those working in this setting usually encounter cancer patients at an earlier, and possibly less symptomatic, stage than practitioners in secondary care. Despite these challenges, research has improved our understanding of the symptoms patients present to primary care with, and a range of tests and referral pathways now exist in the UK and other countries to aid early diagnosis. Primary care practitioners can also play a key role in gynecological cancer prevention. A significant proportion of gynecological cancer is preventable either through lifestyle changes such as weight loss, or, for cervical cancer, vaccination and/or engagement with screening programs. Primary care provides an excellent opportunity to discuss cancer risk with patients and to promote risk reduction strategies and lifestyle change. In this article, the first in a series discussing cancer detection in primary care, we concentrate on gynecological cancer and focus on the three most common forms that a primary care practitioner is likely to encounter: ovarian, endometrial, and cervical cancer. We outline key risk factors, briefly discuss prevention and screening strategies, and offer practical guidance on the recognition of symptoms and signs and the investigation and referral of women with suspected cancer. While this article is written from a UK primary care perspective, much of what is discussed will be of relevance to those working in other healthcare systems.

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Recognizing Gynecological Cancer in Primary Care: Risk Factors, Red Flags, and Referrals

Adv Ther Recognizing Gynecological Cancer in Primary Care: Risk Factors, Red Flags, and Referrals Emma J. Crosbie 0 1 2 0 W. Hamilton Exeter Medical School, University of Exeter , Exeter , UK 1 N. A. J. Ryan E. J. Crosbie Gynaecological Oncology Group, University of Manchester , Manchester , UK 2 G. Funston (&) H. O'Flynn Centre for Primary Care, University of Manchester , Manchester , UK Early diagnosis of symptomatic gynecological cancer is likely to improve patient outcomes, including survival. The primary care practitioner has a key role to play in this-they must recognize the symptoms and signs of gynecological cancer and make prompt evidence-based decisions regarding further investigation and referral. However, this is often difficult as many of the symptoms of gynecological cancers are nonspecific and are more likely to be caused by benign rather than malignant disease. As primary care is generally the first point of patient contact, those working in this setting usually encounter cancer patients at an earlier, and Cervical cancer; Cancer detection; Cancer diagnosis; Cancer prevention; Cancer - possibly less symptomatic, stage than practitioners in secondary care. Despite these challenges, research has improved our understanding of the symptoms patients present to primary care with, and a range of tests and referral pathways now exist in the UK and other countries to aid early diagnosis. Primary care practitioners can also play a key role in gynecological cancer prevention. A significant proportion of gynecological cancer is preventable either through lifestyle changes such as weight loss, or, for cervical cancer, vaccination and/or engagement with screening programs. Primary care provides an excellent opportunity to discuss cancer risk with patients and to promote risk reduction strategies and lifestyle change. In this article, the first in a series discussing cancer detection in primary care, we concentrate on gynecological cancer and focus on the three most common forms that a primary care practitioner is likely to encounter: ovarian, endometrial, and cervical cancer. We outline key risk factors, briefly discuss prevention and screening strategies, and offer practical guidance on the recognition of symptoms and signs and the investigation and referral of women with suspected cancer. While this article is written from a UK primary care perspective, much of what is discussed will be of relevance to those working in other healthcare systems. referrals; Endometrial cancer; General practice; Oncology; Ovarian cancer; Primary care OVARIAN CANCER Ovarian cancer (OC) is the fifth most common cause of cancer death amongst women in the UK and USA, and over 7000 and 22,000 women are diagnosed, respectively, each year [1, 2]. Most OC symptoms are nonspecific, and the same symptoms occur more frequently in benign conditions. This makes OC particularly challenging for primary care practitioners to identify, and it is recognized as one of a group of cancers termed ‘‘harder to suspect’’ [3]. The majority of women are not diagnosed until the disease is advanced, which contributes to the UK’s poor 5-year survival rate of 46% [1, 4]. Recognizing symptoms early, performing appropriate investigations, and referring promptly may improve patient outcomes [5, 6]. Risk Factors and Epidemiology OC is predominantly a disease of the middle aged and elderly, with 75% of cancers occurring in women aged over 55 years [7]. Whilst most cases are sporadic, 5–15% are due to inherited cancer predisposition syndromes [8]. Mutations in BRCA1/BRCA2 are the most common inherited cause, and, while around 1.3% of women in the general population develop OC in their lifetime, 39% of female BRCA1 carriers will develop the disease [9]. Lynch syndrome, or hereditary non-polyposis colorectal cancer (HNPCC), is associated with a 6.7% lifetime risk of OC [ 10 ]. While the UK National Institute of Clinical Excellence (NICE) provides guidance for referral when concern exists about familial breast cancer risk [ 11 ], it does not provide equivalent guidance for OC. We recommend that the possibility of a hereditary cancer syndrome be considered in higher-risk patients, e.g., if multiple relatives have been diagnosed with OC or breast cancer (especially if diagnosed at a young age), if breast cancer and OC occur in the same relative, if a relative has been diagnosed with multiple cancers associated with Lynch syndrome such as gynecological, colorectal, gastrointestinal, or urological, or if the patient has a relative with a proven gene mutation. In such women, referral to a clinical geneticist may be warranted. Lifestyle and environmental factors including obesity, long-term use of hormone replacement therapy, smoking, and asbestos exposure have all been linked to OC, and around 21% of ovarian cancers are thought to be ‘‘preventable’’ [8]. Factors that reduce the risk of OC include the oral contraceptive pill, childbirth, and breastfeedi (...truncated)


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Garth Funston, Helena O’Flynn, Neil A. J. Ryan, Willie Hamilton, Emma J. Crosbie. Recognizing Gynecological Cancer in Primary Care: Risk Factors, Red Flags, and Referrals, Advances in Therapy, 2018, pp. 577-589, Volume 35, Issue 4, DOI: 10.1007/s12325-018-0683-3