AngCN-NCG-G2
Management of Gynae Cancer
Anglia Cancer Network
GUIDELINES FOR THE MANAGEMENT OF GYNAECOLOGICAL CANCER 14-1C-107e through to 14-1C-114e
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AngCN-NCG-G2
Management of Gynae Cancer
Anglia Cancer Network
CONTENTS
Page
INTRODUCTION TO THE GUIDELINES................................................................................. 4 PATIENT CARE ....................................................................................................................... 4 PRIMARY CARE TEAM........................................................................................................... 5 SPECIALIST PALLIATIVE CARE ........................................................................................... 5 OVARIAN SECTION (14-1C-107E) Introduction to the Management of Ovarian Cancer .................................................................6 Outcome Measure Summary ………………………………………………………………………6 GP Guidelines………………………………………………………………………………………..7 Other Referral Route Guidelines…………………………………………………………………...7 Investigations…………………………………………………………………………………………8 Primary Treatment…………………………………………………………………………………...9 Follow Up and Routine Surveillance of Patients with Ovarian Cancer...................................12 Management of Recurrent Disease.........................................................................................12 Specialist Palliative Care .......................................................................................................122 Familial Disease.......................................................................................................................13 Population Screening...............................................................................................................13 Clinical Trial Overview .............................................................................................................13 Important Web Links ................................................................................................................13 Ovarian Pathway……………………………………………………………………………………14 ENDOMETRIAL SECTION (14-1C-106e) Introduction to the Management of Endometrial Cancer ......................................................155 Outcome Measure Summary...................................................................................................15 GP Referral Guidelines..........................................................................................................177 Other Referral Route Guidelines ...........................................................................................177 Investigations ...........................................................................................................................18 Primary Treatment…………………………………………………………………………………..18 Surgical Follow Up and Routine Surveillance of Patients with Endometrial Cancer..............19 Management of Recurrent and Advanced Disease ................................................................19 Familial Disease.......................................................................................................................20 Clinical Trial Overview .............................................................................................................20 Important Web Links:...............................................................................................................20 Radiotherapy Guidelines .........................................................................................................21 Endometrial Pathway……………………………………………………………………………….23 CERVICAL SECTION (14-1C-108E) ..................................................................................... 24 Introduction ..............................................................................................................................24 Outcome Measure Summary...................................................................................................24 GP Guidelines ........................................................................................................................255 Other Referral Route Guidelines .............................................................................................26 Investigations .........................................................................................................................266 Primary Treatment ...................................................................................................................27 Follow Up and Routine Surveillance of Patients with Cervical / Vaginal Cancer ...................28 Management of Recurrent Disease.......................................................................................288 Specialist Palliative Care .......................................................................................................288 Familial Disease.......................................................................................................................29 Population Screening...............................................................................................................29 Clinical Trial Overview .............................................................................................................29 Radiotherapy Guidelines .........................................................................................................29 Cervical Cancer Pathway ......................................................................................................333 GYNAECOLOGICAL SARCOMAS ....................................................................................... 35 Page 2 of 70 I:\CPC1\MEDICAL DIRECTORATE\SCN Team\4. 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Management of Gynae Cancer
Anglia Cancer Network
VAGINAL AND VULVAL SECTION ...................................................................................... 36 Introduction ..............................................................................................................................36 Outcome Measure Summary...................................................................................................36 GP Referral Guidelines............................................................................................................37 Other Referral Route Guidelines .............................................................................................38 Investigations ...........................................................................................................................38 Primary Treatment ...................................................................................................................38 Follow Up and Routine Surveillance of Patients with Vulval Cancer......................................40 Management of Recurrent Disease.........................................................................................41 Specialist Palliative Care .........................................................................................................41 Familial Disease.......................................................................................................................42 Clinical Trials Overview ...........................................................................................................42 Important Web Links ................................................................................................................42 Radiotherapy Guidelines for Vulval Cancer ............................................................................43 Vulval/Lower Vagina Cancer Pathway ....................................................................................46 EVIDENCE OF AGREEMENT/DOCUMENT MANAGEMENT ............................................. 47 APPENDICES......................................................................................................................... 48 Appendix A - Surgicopathological Staging of Ovarian Cancer ...............................................48 Appendix B - Surgicopathological Staging of Endometrial Cancer.........................................50 Appendix C - Cervical staging according to FIGO system....................................................521 Appendix D - Vulval staging according to FIGO system.........................................................52 Appendix E - Guidelines for the Histopathological Reporting of Gynaecological Cancers, Anglia Cancer Network ........................................................................................................53 Appendix F – Chemotherapy regimes & the sites where they are delivered (replaced by Appendix G July 2011)(14-1C-110e)...................................................................................56 Appendix G – The Chemotherapy Regimens by Tumour Site ...............................................56 Appendix H – The AngCN Cervical Cancer Treatment Pathway(14-1C-113e)......................62 Appendix I – The AngCN Endometrial Cancer Treatment Pathway(14-1C-111e) .................63 Appendix J – The AngCN Vaginal Cancer Treatment Pathway(14-1C-114e) .......................64 Appendix K – The AngCN Vulval Cancer Treatment Pathway(14-1C-114e) .......................655 Appendix L – The AngCN Ovarian Cancer Treatment Pathway (14-1C-112e)....................656 Appendix M –Cancer Genetics Referral Guidelines .............................................................667 Appendix N – Summary of support and user groups currently running within the Anglia Cancer Network Area ……………………………………………………………………………669 CONTACTS PAGE................................................................................................................. 70
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Management of Gynae Cancer
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INTRODUCTION TO THE GUIDELINES The purpose of these guidelines is to provide a summary guide for the management of patients with gynaecological malignancy. They have been taken from the available published evidence and therefore should be regarded as a template for best practice. Their scope is to aid all health practitioners involved in the patient from primary care and referral through treatment to follow-up and to palliative care if necessary. However, as constant modifications are being made, these guidelines should only be used to give an indication of current management; they should not be used to treat patients without checking that changes have not been made. It is hoped that by formalising management strategies and refining quality objectives and outcome measures, the manual will enable objective auditing of the medical management process involving patients with gynaecological malignancy. Anglia West encompassing Addenbrooke’s Hospital, Queen Elizabeth Hospital, (King’s Lynn), Princess Alexandra Hospital, (Harlow), Bedford Hospital, Hinchingbrooke Hospital, West Suffolk Hospital, (Bury St. Edmunds) and Peterborough City Hospital: A weekly multidisciplinary meeting is held on a Tuesday at 13.00. Any referring clinician is welcome to attend these meetings at the Seminar room 6 (MDT room) Room, Ground Floor in the Rosie Hospital. Anglia East encompassing Norfolk and Norwich and James Paget Hospitals: A weekly multidisciplinary meeting is held on a Thursday at 12.00 in Room 7 of the Education centre at NNUH and video-conference to JPUH. Ipswich Hospital is at present not included in the gynaecological network for AngCN
PATIENT CARE Information Patients will be provided with clear, comprehensive verbal and written information. Women and their relatives will have access to discuss their condition with members of the Multi-Disciplinary Team. Written information sheets should be available on: • • • • • • •
Disease Diagnostic Procedures Treatment Options and Effects Outcomes Post-treatment Symptoms Contact Details for Co-ordinator of Specialist Team Psychological Support.
Access will be available to a named nurse (Key Worker) who has specialised knowledge in gynae/oncological cancer for all patients / carers. Access will be available to a specialist gynaecology radiographer for advice and support pre, during and post radiotherapy. Patients with Stomas – access will be available pre and post surgery for patients requiring either a temporary or permanent stoma.
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Management of Gynae Cancer
Anglia Cancer Network
Patients identified as having lymphoedema will be referred to an appropriate centre for treatment, support and information. Referral can be made by any practitioner when there is a concern about lymphoedema. Practical information and advice regarding sexual function and problems that may be encountered should be discussed at the commencement of treatment and addressed routinely during consultations as part of the patient assessment if appropriate.
PRIMARY CARE TEAM • • • • •
General Practitioners will have access to referral guidelines through ACN website and individual hospital and PCT Trusts websites (Knowledge System). General Practitioners will be notified of the patient’s plan of management within five days of attending the hospital as suspected cancer patients. GPs will be informed of the patient’s cancer diagnosis within 24 hours of breaking bad news to the patient. GPs will be informed of the treatment plan from the Multidisciplinary meeting within 24 hours by fax or NHS.net email. GPs will be informed of the patient’s discharge from hospital within 24 hours.
SPECIALIST PALLIATIVE CARE Palliative care is the active total care of patients when the disease is no longer curable and prognosis is limited. However the time that a patient may live with incurable cancer is much longer than even 10 or 20 years ago. Therefore patients may live for some years with difficult symptoms and joint working with specialist palliative care could provide significant relief. Palliative care focuses on maintaining and improving quality of life rather than curing disease. As palliative care is a specialty in its own right, only brief general advice can be given here about particularly high risk cases. The general rule is if in doubt “refer” or at least “discuss” with a specialist palliative care colleague. Advice can be given without full referral, particularly when the patient is sensitive or concerned about the idea of referral to a palliative care service which they may associate with the end of life only. Palliative care teams will consider the following patients at particularly high risk. •
• • • •
Those with difficult pains, e.g. neuropathic pain. These pains are characterised by sensory changes and unpleasant sensory changes and lancinating, shooting or electric shock-type sensations. They can be very difficult to manage and should be treated as early as possible with specific therapies. Those patients with young children or those who have suffered bereavement in childhood themselves. Those who have had severe psychological or social problems adjusting to or as a result of their illness. Patients with recent or multiple bereavements. Patients with difficult bodily changes such as extensive local recurrence, smelly or fungating disease
There are specialist palliative care teams throughout the network and referral guidelines are available locally.
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Management of Gynae Cancer
Anglia Cancer Network
OVARIAN SECTION (14-1C-107e) Introduction to the Management of Ovarian Cancer Outcome Measure Summary Referral: All patients meeting urgent referral criteria for ovarian cancer will be seen by a member of the specialist team within two weeks. Investigations: -Radiology. Changes from imaging CCG All patients will receive abdominal and pelvic CT imaging detailing the ovaries, their morphology, size, presence of bilateral lesions, the presence of ascites and other intra-abdominal evidence of metastases before initial diagnostic procedure. Details of the liver (appearance, presence of parenchymal metastases) and the renal tract will be recorded. A chest x-ray will be required in all women with ovarian cancer. -Tumour markers For women with cancer under the age of 40 years, the following tumour markers will be sent preoperatively: CA-125, beta hCG, AFP, LDH. For women with cancer above 40 years: CA 125. All patients with an ovarian cancer should have a RMI (risk of malignancy index) calculated preoperatively. All patients with a RMI > 200 should be referred to a cancer centre. Ref Obeidat BR, Amarin ZO, Latimer JA, Crawford RA. Risk of malignancy index in the preoperative evaluation of pelvic masses. Int J Gynaecol Obstet. 2004 Jun;85(3):255-8. Treatment: All patients with a suspected diagnosis of ovarian cancer will have their treatment plan discussed at a multi-disciplinary team meeting prior to starting treatment. All patients must have surgery within 31 days of the decision to operate or within 62 days from referral whichever is sooner unless there are documented clinical or social reasons for delay. All patients undergoing elective surgery for ovarian cancer should receive appropriate preparation. All patients with ovarian cancer must have definitive surgery by the gynaecological oncology team. Use of a structured report – operative note of ovarian cancer surgery includes all details as per guideline. Overall mortality for ovarian cancer within 1 month of surgery is approximately 5%. -Chemotherapy All women with ovarian cancer in the network should be discussed at the MDM.
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Management of Gynae Cancer
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All women with very good prognosis stage I disease (stage Ia and Ib) should undergo full staging. This will include peritoneal washings, omental biopsy, appendicectomy, peritoneal biopsies, pelvic and para-aortic lymphadenectomy and if negative then no further treatment will be needed. All patients with poor prognosis stage IC disease (either poor differentiation or clear cell differentiation) or worse (>stage IC) should be offered platinum based chemotherapy – NICE TA55. Chemotherapy should commence within four weeks of primary surgery. Chemotherapy should be commenced within 31 days of decision to treat or within 62 days from referral whichever is sooner with neoadjuvant chemotherapy. Follow Up: All patients treated for ovarian cancer will have access to follow up. Follow up occurs as indicated in the guidelines modified by trial protocol, clinician or patient wish. All patients diagnosed with recurrent disease that are considered suitable for secondary cytoreduction, should be discussed at the Gynaecological Oncology MDM. Pathology: See appendix E Ovarian Cancer The standard management of ovarian cancer is a surgical approach combined with chemotherapy. Specialist gynaecological surgery and the management by the multi-disciplinary team are associated with a significantly longer survival. All suspected cases of ovarian cancer should be referred urgently to Gynaecological oncology team. GP Guidelines Measure serum CA125 levels in primary care for women with any of the following symptoms, especially if symptoms are persistent or occur on a frequent basis: - abdominal distension (bloating) - early satiety and/or loss of appetite - pelvic and/or abdominal pain - increased urinary urgency and/or frequency - new onset of symptoms of irritable bowel syndrome in women older than 50 years Arrange an urgent ultrasound scan of the abdomen and pelvis (should be requested in primary care) for women with CA125 levels of equal to or greater than 35 IU/L and refer the patient urgently (under the two-week-wait rule) to the gynaecological clinic. Arrange an urgent ultrasound scan of the abdomen and pelvis (should be requested in primary care) for women with clinical findings of ascites and/or pelvic or abdominal mass (excluding uterine fibroids). Other Referral Route Guidelines Patients Referred from Other Hospitals: (Referrals from Cancer Unit to Cancer Centre) The cancer unit will have facilities to assess women with possible ovarian cancer rapidly. The diagnosis of cancer should not be excluded on the basis of clinical impression alone.
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Anglia Cancer Network
The “risk of malignancy index (RMI)” allows a rational basis for referral of all with early ovarian cancer to the cancer centre for specialist management. The RMI is calculated from menopausal status, ultrasound features and CA-125. The menopausal status (M): Pre-menopausal Post-menopausal
(50 years or less) –1 (more than 50 years) – 3
The ultrasound features (U): Solid areas, septae, bilaterality, ascites and presence of intraabdominal metastases No features present: U = 0 1 feature present: U = 1 2 or more features present: U = 3 CA-125:
Absolute score
(NB. This requires that the referring hospitals have the availability for a CA-125 estimation performed at the request of the designated gynaecologist without regard to the histological diagnosis.) RMI = M x U x CA125. Patient with suspected ovarian cancer Using the RMI all patients with an RMI ≥200 should be referred and discussed at the specialist MDM. Patients with an RMI 200
Staging Biopsy, Cytology, CXR, CT Abdominal, Pelvic imaging
SMDT MEETING
OPA Decision to Treat (DTT)
Radiological Guided Bx (if required)
Other Ref errals i.e. 18w w referral, nonurgent GP ref erral, A/E, Inpatient
Oncology ------------Neo-adjuvant Chemotherapy
Tertiary Pathology Review
Consultant upgrade points e.g. referral meets NICE criteria; at first seen, during or after diagnostic tests; on or before MDT date & decision to treat date +62 days f rom these upgrade points. Please refer to the AngCN Consultant Upgrade Policy at w ww.angliacancernetwork.nhs.uk.
Surgical treatment know n or suspected cancer operated at the Centre only
Post Tx/ Follow Up MDT to assess Fitness f or subsequent treatment
Earliest clinically appropriate date, decision to treat (DTT)
Oncology
Horm one / Biological Therapy
Palliative Care
Management of treatment side eff ects e.g. psychosexual, lymphoedema, late effects.
Horm one / Biological Therapy
Consider Clinical Trial and Follow Up
Referral to extended MDT services at any point in pathw ay, e.g. Palliative care specialists and AHP support.
By Day 14 (1st seen)
Day 0
By Day 28 (LMDT)
By Day 42 (DTT)
By Day 62 (Treatment)
Day 0
Elapsed time f or f ollow up or presentation of recurrence, mets or predetermined gap betw een treatments
Key:
Unit / Centre
Centre
Access to specialist services
Recurrence Process
Author: Date: Version: Review Date:
GFOCW
By Day 31 (Treatment)
Pru Fong, Anglia Cancer Network 10th July 2009 1 Reviewed and reissued no changes Aug 2010, Next Review 2 Years.
Pathway agreed by SSG Chair Hisham Abdel-Rahman on 10/07/09 Pathway agreed by Anglia Gynae Chair and NCG meeti ng 30th June 2014
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AngCN-NCG-G2
Management of Gynae Cancer
Anglia Cancer Network
ENDOMETRIAL SECTION (14-1C-106e) Introduction to the Management of Endometrial Cancer The purpose of these guidelines is to provide a summary guide for the management of patients with malignant neoplasms of the uterus including carcinoma of the endometrium and sarcomas. Outcome Measure Summary Referral: All patients meeting urgent referral criteria for endometrial cancer will start on the diagnostic pathway within two weeks. All patients meeting urgent referral criteria for endometrial cancer will have a definitive diagnosis within four weeks. All patients will be referred to gynaecological oncology team within two working days of emergency admission or two working days of definitive diagnosis by another specialist. In the presence of a normal ultrasound (endometrial thickness (ET) ≤3-5 mm) and a normal examination of the lower genital tract (which could be in primary care), then the patient will be reassured and discharged back to her GP with clear instructions to seek medical advice if the bleeding reoccurs. The threshold of ET requiring a biopsy is not conclusive, although between 3 and 5mm is acceptable, the sensitivity reduces but specificity increases the higher the threshold. If the ET is ≥3-5mm, or irregular in outline, an outpatient hysteroscopy and/or endometrial biopsy will be arranged during the same visit or booked urgently as inpatient if appropriate. If an endometrial polyp is suspected, or the ET is greater than 10mm, then an outpatient hysteroscopy should be performed in spite of a normal endometrial biopsy. Malignancy within polyps can be missed following outpatient endometrial biopsies. Following histological diagnosis of endometrial cancer, surgery should be performed within 31 days or within 62 days from referral whichever is sooner after discussion of the diagnosis with the patient unless documented clinical or social reasons for delay. When a diagnosis of stage 1b or more and all G3 adenocarcinoma (poorly differentiated) or sarcoma (leiomyosarcoma, stromal sarcoma or carcinosarcoma/MMT) is made on biopsy, referral to the gynaecological oncology centre should be made pre-operatively. Investigations: -Radiology Pelvic (Transvaginal preferably) ultrasound will be performed prior to surgery. Usually this will have been done before the endometrial biopsy/hysteroscopy has been done. An MRI of the pelvis will be carried out prior to surgery unless contraindicated. A CT thorax, abdomen and pelvis can be used as an alternative to MRI in particular with type 2 and advanced cancers. A chest X-ray (or CT thorax) is required in all women with grade 3 or type 2 endometrial cancer. Chest imaging is not essential in low risk (grade 1 and 2) cancers.
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Management of Gynae Cancer
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Treatment: All patients with a diagnosis of endometrial cancer will have their treatment plan discussed preoperatively at a multi-disciplinary meeting. All patients undergoing elective surgery for endometrial cancer should receive appropriate preparation. All patients referred to the Cancer Centre for surgery must have their definitive surgery by the gynaecological oncology team. All patients at unit level should have their surgery performed under the care of the lead/deputy in gynaecological oncology. Combined post-operative complication rate after radical surgery (fistula, thrombosis, emergency surgery, unplanned ventilation) must be below 5%. Overall mortality for endometrial cancer surgery (within one month of surgery) should be less than 5%. Radiotherapy: All cases of advanced endometrial cancer (stage 1B, G2/G3) will be considered for radiotherapy as an adjuvant to surgery. If full staging with lymphadenectomy has been performed, radiotherapy may be omitted. The reason for not giving radiotherapy will be recorded. Radiotherapy should commence within 31 days of decision to treat unless there is a clear documented reason for the delay. Chemotherapy: Chemotherapy should be considered for patients of good performance status with recurrent or metastatic disease who have not responded to radiotherapy or hormone treatment. Serous papillary and clear cell subtypes will be considered for adjuvant chemotherapy regardless of stage. Follow Up: There is no clinical evidence to support the frequency of follow-up. All patients treated for endometrial cancer will have access to follow up. Pathology: See appendix E Patient Care: All patients will be offered clear and comprehensive written information on: • • • • •
Disease Diagnostic procedures Treatment options Outcomes Post-treatment symptoms
Access will be available to a named nurse (Key Worker) who has specialist knowledge in endometrial cancer for all patients / carers.
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AngCN-NCG-G2
Management of Gynae Cancer
Anglia Cancer Network
Access will be available to a specialist gynaecology radiographer for advice and support pre, during and post-radiotherapy. Patients identified as having lymphoedema will be referred to an appropriate lymphoedema service for treatment, support and information. Practical information and advice regarding sexual function and problems will be discussed at commencement of treatment and where appropriate, patients referred on for specialist advice to psycho-sexual counsellor. Endometrial cancer: Women presenting with post-menopausal bleeding (PMB) off HRT or unscheduled bleeding on HRT. Women with PMB will be offered a transvaginal scan and then be managed according to the schema. If the (ET) ≤3-5 mm and regular, then no biopsy is required, the remainder require. an outpatient hysteroscopy and/or endometrial biopsy . If an endometrial polyp is suspected, or the ET is greater than 10mm, then an outpatient hysteroscopy should be performed in spite of a normal endometrial biopsy. An examination of the lower genital tract will be performed in all patients, which may be in primary care. It is highly unusual for a post-menopausal woman to have an endometrial carcinoma with no symptoms of vaginal bleeding or discharge. An incidental finding of a thickened endometrium of >10mm in asymptomatic patients should still be investigated by hysteroscopy and endometrial biopsy The diagnosis of endometrial cancer is occasionally made on a hysterectomy specimen for other reasons e.g. prolapse. These cases should be discussed at the following MDT. http://www.nice.org.uk/page.aspx?o=261652 http://www.sign.ac.uk/guidelines/fulltext/61/index.html GP Referral Guidelines The majority of patients will be referred with abnormal vaginal bleeding. For the purposes of this document, referrals of patients with abnormal vaginal bleeding are considered urgent if postmenopausal (with or without hormone replacement therapy) or when taking tamoxifen. There is an increasing incidence of endometrial cancer in pre and peri-menopausal women. Consideration of risk factors (diabetes, hypertension and obesity) may warrant urgent investigation of abnormal bleeding in this group. Other Referral Route Guidelines Patients should be referred to the gynaecological oncology team within two working days of their emergency admission or within two working days of a definitive diagnosis. Other referral routes will include: • Via genetics department for further investigation if appropriate • Other surgeons following emergency admission • Other clinicians e.g. radiologist, histopathologist • General Medicine
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Investigations Pelvic ultrasound FBC U&E Liver function test CA125 Chest x-ray to exclude lung metastases (may be omitted in G1-2 cancers) MRI pelvis and/or CT chest, abdomen and pelvis Primary Treatment Patients with a diagnosis of endometrial cancer will be discussed at the multi-disciplinary meeting and a treatment plan formulated. This will include the entry into clinical trials where appropriate. Pre-operative Treatment: Usually surgery is the primary modality for treatment as this is the most effective way of controlling symptoms of bleeding as well as establishing the accurate stage. Preparation for Surgery will include: 1. Informed consent 2. Group and save or Cross-matching 3. Thrombo-embolism prophylaxis 4. Antibiotic infection prophylaxis Aim of Endometrial Surgery: The uterus, cervix, fallopian tubes and ovaries should be removed. Laparoscopic surgery should be considered for all patients. The role of lymphadenectomy in endometrial cancer management is controversial. It should not be undertaken in low risk cases (G1-G2, stage IA), but may be considered with G3, IB or type 2 cancers. The extent of lymphadenectomy is usually restricted to the pelvis but para-aortic dissection can be considered in type 2 cancers. There is limited evidence of a therapeutic role for lymphadenectomy, hence its use must be closely allied to plans for adjuvant therapy. The risk of toxicity from dual therapy (lymphadenectomy and radiotherapy) is considerable and should be avoided where possible. Suspicious nodes should be removed if identified preoperatively on MRI pre-operatively or identified intra-operatively. Lymphadenectomy should be performed laparoscopically where possible. Morbidly obese and high morbidity patients can be an indication for vaginal hysterectomy only and removal of tubes and ovaries only if surgically possible. Washings of the pelvis for cytology should be taken as a routine. If uterine serous carcinoma suspected, then an omentectomy/omental biopsy should be taken. Stage 2 disease is usually managed by simple hysterectomy and adjuvant radiotherapy. There may be cases which benefit from radical hysterectomy. There must be clear discussion between radiation oncologist and surgeons to establish an agreed pathway of care. Stage III and IV disease should be individualised. There is evidence that debulking surgery to less than 1-2cm residual disease confers a survival advantage. Radiotherapy: See Radiotherapy guidelines Page 18 of 70 I:\CPC1\MEDICAL DIRECTORATE\SCN Team\4. Cancer 13\NCGs\Gynaecology\Key documents (all areas)\AngCN Key Documents\Documents being updated\AngCN-NCG-G2 Gynae Clinical Guidelines 2014 v4.0
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Chemotherapy: Adjuvant chemotherapy may be considered for uterine serous carcinoma and carcinosarcomas (malignant mixed Mullerian tumour) regardless of stage. Chemotherapy may be useful for treatment of advanced disease. Hormone Therapy: Progestagens will not be offered in the adjuvant setting. In the palliative setting, progestagens may be beneficial, Megace 160mg od orally or Mirena IUS. Other hormone manipulation such as aromatase inhibitors may be considered. Emergency Surgery: The patient should be stabilised and referred by the On Take Team to the gynaecological oncology team within two working days. Documentation: Details of the operation should be electronically recorded for audit purposes. Hormone Replacement Therapy: There is no definitive evidence to indicate HRT stimulates or accelerates recurrence. However, there are theoretical reasons for concern. Combined HRT should therefore only be offered to patients who have been fully informed of the potential implications of HRT. Sarcomas: Surgery is the central part of treatment. External beam therapy should be used for stage two or for positive margins. Adjuvant chemotherapy and radiotherapy will be discussed at the MDM. Surgical Follow Up and Routine Surveillance of Patients with Endometrial Cancer There is no clinical evidence to support the frequency of follow-up. Follow up for 2-3 years is usually recommended with a frequency of between 3 and 6 months appointments. The frequency of follow up usually reduces with time. Patients should be made aware of symptoms suspicious of recurrence including bleeding, pelvic pain, weight loss and a persistent cough. All patients should have a clear route of access if symptoms occur. There is no value in routine vaginal vault smears. Trial Patients: Follow up intervals and investigations as indicated by protocol. Management of Recurrent and Advanced Disease Recurrent and Advanced Disease These patients will be considered for: 1. Referral for radiotherapy / chemotherapy. 2. Referral to Palliative Care Service.
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Specialist Palliative Care The commonest symptom control problems resulting from advanced Carcinoma of the endometrium are due to distant metastases. Metastases due to bone, brain or retroperitoneal lymph nodes are likely to cause significant symptoms. Patients will need individual management to deal with symptoms such as recurrent ascites, breathlessness, cough or bone pain. Local recurrence of disease can also cause significant symptom control issues with bleeding, pain and lymphoedema. Again individual management is appropriate and referral for specialist palliative care advice should be made to the patient’s local service. Familial Disease Less than 5% of endometrial cancer has a genetic basis. Inheritance of a predisposing gene should be suspected in those individuals with early age at onset, synchronous or metachronous tumours elsewhere and in those individuals with a family history of endometrial cancer and/or bowel cancer. Patients with hereditary non-polyposis colon cancer syndrome (HNPCC) shall be referred to the regional Department of Clinical Genetics. Female gene carriers have a lifetime risk of 60% for endometrial cancer. Surveillance of this group: • •
• • •
Awareness of significance of inter-menstrual or post-menopausal bleeding and prompt referral Trans-vaginal ultrasound of the endometrium or endometrial sampling. Neither technique is proven in this context. At present, we offer annual hysteroscopy & biopsy as outpatient in addition to transvaginal scanning and CA125 estimation Risk reducing surgery on completion of family Will also require regular colonoscopy Mutation analysis is possible if there are consenting affected family members alive
All high risk families should be seen in the regional Department of Clinical Genetics. (Please see Appendix M for referral guidelines and contact arrangements). Clinical Trial Overview Patients should be encouraged to enter clinical trials. This is an ongoing area of focus within the Anglia Cancer Network – there being a dedicated team and plan for improvement in place as part of the AngCN Gynae Network Cancer Group. Important Web Links: http://www.nci.nih.gov/cancertopics/types/endometrial http://www.nci.nih.gov/cancertopics/types/uterinesarcoma
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Radiotherapy Guidelines Protocol
CP/ENDOMETRIAL
Endometrial cancer – radiotherapy treatment Scope Radiotherapy SUMMARY • Surgery is the curative treatment of choice for endometrial cancer of any histology. • Adjuvant radiotherapy reduces local recurrence but does not affect survival. 1,2 POST-OPERATIVE RADIOTHERAPY INDICATIONS 1,2 All ages: IBG3, IIGx, IIIGx Age 60: LVSI and IB or G3 TREATMENT REGIME • Radiotherapy • Brachytherapy
PRE-TREATMENT PROCESSES • Immobilization • Localization • Target volume definition
• • • •
Technique Dosimetry plan Normal tissue limits Plan verification
45Gy in 25# over 35 days Post-EBRT: 7Gy in 1# (HDR) Alternative is 11Gy in 2# No EBRT: 21Gy in 3# once a week (HDR) Or 22Gy in 4# twice a week Prescribe at 0.5cm depth, top 2 or 3cm.
Patient supine in leg stocks, bladder full CT plan. See protocol. SUPERIOR: bottom of L5 1 INFERIOR: bottom of obturator foramen LATERAL: 1cm beyond pelvic brim ANTERIOR: mid-symphysis pubis POSTERIOR: 2.5-3cm anterior to sacral hollow Note: Width of lateral volume should be ~10cm. 4-field brick See protocol None Not required. See protocol.
ON-TREATMENT ASSESSMENT • Review See local protocol. • Portal imaging See local protocol. • Normal tissue dose assessment None. • Treatment sheet verification See local protocol. • Follow-up See local protocol. Assess for BT. RADICAL RADIOTHERAPY INDICATIONS
Unfit for surgery
TREATMENT REGIME • Radiotherapy • Brachytherapy
45Gy in 25# over 35 days 14Gy in 2# over 4 days prescribed to serosa (HDR)
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Approved and Published: June 14
AngCN-NCG-G2
Management of Gynae Cancer
Anglia Cancer Network
PRE-TREATMENT PROCESSES • Immobilization Patient supine in leg stocks, bladder full • Localization CT plan. See protocol. • Target volume definition As for post-operative treatment Note: Ensure minimum margin of 1cm around GTV (uterus + cervix) • Technique 4-field brick • Dosimetry plan See local protocol. • Normal tissue limits See local BT protocol • Plan verification Not required. See local protocol. ON-TREATMENT ASSESSMENT • Review See local protocol • Portal imaging See local protocol • Normal tissue dose assessment None • Treatment sheet verification See local protocol • Follow-up See local protocol Assess for BT References 1 2
Creutzberg, CL. Lancet, 355, 1404-1411, 2000. Keys, HM. Gynecol Oncol, 92, 744-751, 2004.
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Approved and Published: June 14
AngCN-NCG-G2
Management of Gynae Cancer
Anglia Cancer Network
ENDOMETRIAL CANCER PATHWAY (E&W) Version 1
Other Referrals i.e. 18w w referral, nonurgent GP referral, A/E, Inpatient
Surgical Treatment 2 or GFR
