Nearly 7,500 women and people with ovaries in the UK are diagnosed with ovarian cancer each year, according to charity The Eve Appeal. While it mainly affects post-menopausal women, it can affect women at any age.

Patients can present with a variety of symptoms that can mimic other causes, resulting in the diagnosis often being delayed. In some women, it can be particularly difficult to recognise the symptoms in the early stages, whereas other women may present late or are diagnosed late once they have presented symptoms.

The scene

A 57-year-old woman attended her GP practice complaining of a change in her bowel habit. This had been going on for about four months and fluctuated between constipation and increased bowel opening with occasional diarrhoea. She hadn’t lost any weight at this point but did feel nauseous on occasions with a reduced appetite. The patient was seen by a number of GPs over a period of several months. As the symptoms appeared to suggest bowel pathology, management focused on gastrointestinal investigations, including gastroscopy and colonoscopy. All investigations were unremarkable, and she was discharged from gastrointestinal follow-up.

Over time the patient returned to the practice complaining of ongoing symptoms. She developed intermittent low abdominal pain and her symptoms were put down to irritable bowel syndrome. At this point, she also complained of urinary frequency and a urine test was carried out, which excluded infection.

The patient continued to manage her symptoms at home but returned six months later with persistent pelvic pain and bloating. On examination her abdomen was notably distended. Ovarian cancer was considered at this stage. The patient’s CA125 was raised, and an urgent gynaecology referral was made. The patient was diagnosed with metastatic ovarian cancer. The patient was given a poor prognosis and palliative care in the community was arranged.

The GP called the MDU after receiving a letter of complaint from the patient criticising them for failing to consider and reach a diagnosis of ovarian cancer sooner. The patient felt that had the diagnosis been made sooner, the cancer would not have spread and her prognosis would have been better. The patient intimated that she would also be making a claim for clinical negligence.

MDU advice

The GP was advised to discuss the complaint at a significant event meeting at the practice so that the clinical care could be reviewed. This would allow any lessons to be identified and enable the GP to focus on their professional development. It was also recommended to the GP that they review the relevant NICE guidance on suspected cancer, which highlights the possible site of cancers in relation to presenting symptoms, as well as the NICE guidance on the recognition and initial management of ovarian cancer.

This guidance specifically mentions women presenting with persistent symptoms of abdominal distension, loss of appetite, pelvic or abdominal pain and increased urinary frequency or urgency. The guidance makes the point that it is unusual for a woman over the age of 50 to present with irritable bowel syndrome for the first time.

The practice concluded that it was reasonable to consider gastrointestinal causes for the patient’s symptoms when she first presented but, as these continued, earlier consideration should have been made to other possible causes given her age, including ovarian or other gynaecological pathology. The clinicians acknowledged the importance of good quality documentation particularly where continuity of care wasn’t possible, and a number of different doctors were seeing the patient for the first time.

With help from the MDU, the GP drafted a response that explained their actions and decision-making. The GP was able to reassure the patient that they had taken her symptoms seriously and had organised the investigations they thought were appropriate at the time based on the symptoms she had. The GP acknowledged that earlier consideration should have been made to ovarian pathology when the results of other investigations returned as normal.

The practice was advised to contact the CNSGP scheme in view of the patient’s comments about a possible claim for clinical negligence. The practice was advised not to disclose the patient’s personal details until they received confirmation that a claim was being considered.

The outcome

The response was sent to the patient and the practice also offered to meet with her and her partner to discuss her concerns further. The patient accepted this offer and after a detailed discussion was satisfied that the GP had reflected on their involvement in her care and that lessons had been learnt. Consequently, she decided not to take the complaint any further.

Advice on avoiding delayed diagnosis

Take a detailed history of the patient’s symptoms and record these in the notes. Detailed notes will be particularly helpful if continuity of care isn’t possible.
Review the relevant guidance.
Take a family history if cancer of any sort is suspected.
Consider other risk factors such as smoking, HRT, raised BMI, exposure to asbestos, diabetes and more.
Consider a CA125 in patients with non-specific symptoms.
Document your examination including any relevant negative findings.
Check for red flags and make sure the patient knows when to return and who to contact.
If a diagnosis is missed or delayed, apologise to the patient and/or their family, explain what happened and what you propose to do to put things right, if possible.
Have an adverse incident system in place, to analyse any delay in diagnosis or other problem that may occur to allow improvements in the service provided.

Delayed diagnosis of ovarian cancer

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