Avoiding diagnostic delays in gynaecological cancers

Gynaecological cancers including ovarian, cervical, womb, vulval and vaginal cancer, kill 21 British women every day. September is gynaecological cancer awareness month with charities aiming to make women more aware of the symptoms to look out for such as abdominal bloating or abnormal bleeding and encourage them to visit their GP if they have concerns.

While vaginal and vulval cancers are rare, there are 3,000 new cases of cervical cancer a year. Ovarian cancer is also the leading cause of death from gynaecological cancer in the UK. 

Diagnosing gynaecological cancers can be challenging as symptoms are often non-specific and can be similar to those of more common conditions, such as irritable bowel syndrome or anaemia. 

MDU cases

In the MDU's experience of looking at 52 incidents reported to us involving ovarian cancer during the years 2014 to 2017, a common cause of complaints is an allegation of missed or delayed diagnosis. Patients and relatives are understandably upset if they believe their doctor missed an opportunity to ensure prompt treatment and if this in turn leads to a poorer prognosis. The findings from the incidents we examined included:

  • The delay in diagnosis from symptoms starting ranged from one month to three years. 
  • The age ranges of the patient later diagnosed with ovarian cancer ranged from 25 to 80. 
  • Over half of the incidents (28) were claims for compensation, 24 were complaints. Of those files, two were referred to the GMC and one to the Ombudsman.

Dr Sharon Tate, Head of Primary Care Development at Target Ovarian Cancer, said: "Awareness of ovarian cancer among women and GPs is low. Just one in five women is able to name bloating as one of the main symptoms of the disease. Two-thirds of women are diagnosed once the cancer has already spread, and early diagnosis is crucial. At Target Ovarian Cancer, we work with GPs and GP practice nurses to make sure more women are diagnosed at the earliest possible stage by providing training tools, information on guidelines, and awareness resources."

Target Ovarian Cancer has two GP education modules available which contribute to CPD points. Visit www.targetovariancancer.org.uk/GP

Delayed diagnosis

Failure to diagnose cancer is not necessarily negligent but a claimant may have a case if they can show that a doctor's management fell below the expected standard, for example by not actively considering this diagnosis if a patient presents with persistent or frequent symptoms or failing to carry out the appropriate tests in a reasonable timescale.

Common symptoms reported in the incidents we reviewed included nausea, bloating including feeling full or having a distended abdomen, abdominal pain, lower back pain, urinary symptoms including dysuria and increased frequency, loose stools, reduced appetite and weight loss. 

Alternative diagnoses offered included:

  • diverticular disease, especially if the pain was left sided and this had been picked up on colonoscopy
  • irritable bowel syndrome, especially if the patient already had a history of this
  • gall stones and cholecystitis, especially if the pain was in the right upper quadrant
  • urinary tract infection, which was often also present
  • musculoskeletal pain.

Cervical screening

The NHS screening programme for cervical cancer covers women aged 25-64. 

The MDU recently carried out research into the reasons for complaints against nurses from cervical screening. Although the numbers of complaints was small (23), a common theme was that patients felt they hadn’t been given enough information before and after screening and therefore hadn't properly consented. It's important that patients are provided with full information about cervical screening and allowed to ask questions. 

Avoiding a diagnostic delay

There are steps that GPs can take to ensure that patients with a gynaecological cancer receive appropriate care and minimise the risk of an avoidable delay:

  • Consider relevant clinical guidelines such as NICE guidance on the Ovarian Cancer Quality Standard (QS18) 1. This includes advice on symptoms, initial investigations, referral and treatment.  
  • Document the patient's history, details of your examination, differential diagnosis and management plan. Record negative as well as positive findings.
  • If a potential diagnosis of cancer is being considered, take appropriate steps to exclude this. 
  • If an examination or blood test identifies signs suggestive of cancer, make an urgent referral in line with the NICE guidance.
  • Even if you do not believe a patient has cancer, ensure they are aware of likely response times for symptoms to resolve or treatment to take effect and the need to return if symptoms continue.
  • Consider implementing a computerised warning system to flag patients about whom you have concerns and whom you consider should be reviewed. 
  • Have an adverse incident reporting system in place so that you can analyse any delays in diagnosis or other problems that occur.
  • Be aware of local arrangements for contacting and following-up patients, for example under the NHS Cervical Screening Programme.
  • Ensure patients have been given adequate information to enable them to make an informed decision about screening and document this.

1 Ovarian cancer: Quality standard [QS18], NICE, May 2012 www.nice.org.uk/guidance/qs18

This guidance was correct at publication 28/09/2018. It is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.

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