Impact on a general hospital of the publication of National Institute for Health and Clinical Excellence (NICE) guidelines on diagnosis of epithelial ovarian cancer (EOC)  


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Abigail Ford1, Oliver Marshall1, S Michael Crawford1
1Airedale NHS Foundation Trust, Keighley, UK

Background

In April 2011 NICE recommended that women with symptoms suggesting EOC should have measurement of CA125 with ultrasound (U/S) examination of the pelvis for those with values 35 IU/ml or greater. The impact of the implementation of the guideline should be evaluated.

Method

We have used routine clinical databases to monitor the demand for services in the year following NICE publication and analysed the outcome of patients found to have elevated CA125 values through this hospital's laboratory. Its gynaecology services serve about 200,000 people.

Results

There were 486 requests to AGH laboratory for CA125 from primary care November 2010 - April 2011 compared with 1,314 in May-October 2011, an increase of 170%. 117 (8.9%, 95% CI 7.4-10.4%) post-April results were 35 IU/ml or more. Among requests from primary care practices known routinely to refer patients to us we identified 84 patients with elevated CA125 in the first six month period (May-October 2011). Among these, no follow-up test could be identified from hospital imaging records in 7 (8.3%, 2.4-14.2%)) patients. EOC was diagnosed in 7 (8.3%, 3.4-16.4%) cases, CA125 range 144-6645 IU/ML. Other cancers were diagnosed in 5. Nonmalignant pathology was found in 17 and 37 had U/S examinations, 11 of whom had repeat imaging, without an abnormality being identified. Five patients had chronically elevated stable CA125. In the second period (November 2011 to April 2012) there were 34 elevated measurements. One (2.9%, 0.1-15.3%) was not followed up, EOC was diagnosed in 5 (14.7%, 5.0-31.0%) CA125 range 268-2344.7 IU/ml. Other cancer was diagnosed in 5 cases, nonmalignant pathology was found in 16 and 5 had U/S with no abnormality detected. Two cases with chronically elevated CA125 were detected. In the first period 13 EOCs and 9 in the second period were diagnosed by other routes.

Conclusion

Primary care doctors have responded to NICE guidance with increased CA125 measurements. Most elevated values have been followed up. The impact of this on EOC diagnosis is not yet apparent; those that were diagnosed by this route had markedly elevated CA125 values. There were fewer elevated CA125 measurements in the second six months but the number of diagnoses of all types did not change; possibly primary care doctors are getting used to the system. The most common cause of raised CA125 is benign gynaecological pathology. Unexplained elevated CA125 levels will be a clinical dilemma in coming years.