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
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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)