GP Information

Who should manage your female patients that have genital tract cancer?

There is accumulating evidence showing that patients with gynaecological cancer do better, in terms of survival and lower treatment related morbidity and mortality, if they are treated by Certified Gynaecological Oncologists (CGO) Eisenkop 1992. There are only some 30 Certified Gynaecological Oncologists in the entire country and they can easily be recognised by the letters CGO after their name. This designates them as having done at least three extra years of training, on top of their specialist O&G training, in the management of female genital tract cancers.

Eisenkop, SM. et al, The impact of subspecialty training on the management of advanced ovarian cancer. Gynecol Oncol. 1992 Nov;47(2):203-9.

Most referrals to sub-specialist Gynaecological Oncologists come via other specialists, mainly Gynaecologists. If as a GP you believe one of your patients has a female genital tract malignancy you can either refer them directly to a CGO, or you can refer them to a specialist Gynaecologist to undertake further investigations with a view to clarifying the diagnosis.

There are certain scenarios that do require further investigation. Some of the important ones are as follows:

Post-menopausal bleeding - this should be assumed to be due to cancer until proven otherwise. At the very least these patients require a pelvic, preferably trans-vaginal, ultrasound to look for a thickened endometrial echo that might indicate endometrial cancer. Even better they should have a hysteroscopy and uterine curettage.

Post-menopausal bleeding is never due to 'hormones' and should never be treated with progestins (Primolut N, Provera etc) or other hormones until an endometrial cancer has been excluded.

Endometrial cancer needs to be excluded in all patients with the following:

All patients with post-menopausal bleeding

Post-menopausal women with endometrial cells on a Pap smear

Post-menopausal women with a pyometra

Peri-menopausal women with intermenstrual bleeding or increasingly heavy periods

Pre-menopausal women with abnormal uterine bleeding and a history of anovulation.

Post-coital bleeding - this is often due to innocent factors, e.g., cervical erosion, but a cervical cancer should be excluded. Take a Pap smear or even better a Thin-Prep, even if the patient is bleeding. If it is positive (High grade epithelial abnormality) you have useful information. If it is negative then it should be disregarded and the patient needs further assessment preferable by a gynaecologist or a gynaecological oncologist.

Unexplained abdominal swelling +/- non-specific GIT symptoms - think about the possibility of an ovarian cancer. This can be easily excluded by a pelvic ultrasound and a Ca125 estimation. If there is ascites, with or without a pelvic mass and the Ca125 is raised then the woman provisionally has an ovarian or primary peritoneal cancer and should be referred to a Certified Gynaecological Oncologist.

Management of Ovarian Cysts - this is a short summary on the principles and approaches to managing ovarian cysts. It is easy to follow and is useful to help explain management to patients. It can also be provided to patients as a aid memoire for later reference.