title: Outcomes following implementation of symptom triggered diagnostic testing for ovarian cancer.
abstract: OBJECTIVE
  UK is the first country to implement symptom triggered testing for suspected ovarian cancer (OC) following guidance from National Institute of Clinical Excellence in 2011. We evaluated its impact on cancer outcomes and implications on clinical practice.
  
  
  METHODS
  This is a cohort study and we analysed data for all new urgent referrals for suspected OC from two large teaching hospitals using a prospectively collected electronic referral database, supplemented with clinical data from electronic records. We evaluated outcomes prior to (2011) and after (2013) implementation of guidance to evaluate stage shift, referrals workload and surgical procedures generated.
  
  
  RESULTS
  Secondary care received 2185 new referrals from primary care for women with suspected gynaecological cancer in post guideline cohort. Of these, 217 women were referred for suspected OC. 90% of primary care referrals were not compliant with guidance. Following implementation of guidance, more women with OC were diagnosed through urgent referral (rapid access clinics): Almost double, 21 of the total 67 (31.34%) OCs in 2013 (post guidance) in comparison to only 11 of 69 OCs (15.94%) were diagnosed in 2011 (pre guidance) through urgent referrals, p=0.03. The predictive value of detecting cancer through rapid access clinics increased, from 4.5% to 9.6%, p=0.04; however, no stage shift was noted. Over 25% of patients underwent surgeries for non-malignant conditions in the post-guideline cohort. No increase was seen in workload of cancer clinics.
  
  
  CONCLUSIONS
  Implementation of Symptom-triggered testing is challenging in clinical practice. Such testing results in more patients with OC accessing expedited care pathways leading to streamlined routes of diagnosis and care. However, current implementation does not lead to stage shift in diagnosis and may not achieve significant mortality benefit.
authors.affiliation: Pan Birmingham Gynaecological Cancer Centre. Dudley Road, West Midlands B18 7QH, Birmingham, United Kingdom.
authors.forename: Nirmala
authors.initials: N
authors.lastname: Rai
authors.affiliation: Pan Birmingham Gynaecological Cancer Centre. Dudley Road, West Midlands B18 7QH, Birmingham, United Kingdom.
authors.forename: James
authors.initials: J
authors.lastname: Nevin
authors.affiliation: Pan Birmingham Gynaecological Cancer Centre. Dudley Road, West Midlands B18 7QH, Birmingham, United Kingdom.
authors.forename: Gabrielle
authors.initials: G
authors.lastname: Downey
authors.affiliation: Birmingham Womens Hospital, Mindelsohn Way, Birmingham, West Midlands B15 2TG, United Kingdom.
authors.forename: Parveen
authors.initials: P
authors.lastname: Abedin
authors.affiliation: Birmingham Womens Hospital, Mindelsohn Way, Birmingham, West Midlands B15 2TG, United Kingdom.
authors.forename: Moji
authors.initials: M
authors.lastname: Balogun
authors.affiliation: Pan Birmingham Gynaecological Cancer Centre. Dudley Road, West Midlands B18 7QH, Birmingham, United Kingdom; School of Cancer Sciences, University of Birmingham, B15 2TT, United Kingdom.
authors.forename: Sean
authors.initials: S
authors.lastname: Kehoe
authors.affiliation: Pan Birmingham Gynaecological Cancer Centre. Dudley Road, West Midlands B18 7QH, Birmingham, United Kingdom; School of Cancer Sciences, University of Birmingham, B15 2TT, United Kingdom. Electronic address: s.s.sundar@bham.ac.uk.
authors.forename: Sudha
authors.initials: S
authors.lastname: Sundar
mesh_terms: D000328:Adult; D018394:CA-125 Antigen / Q000097:blood; D015331:Cohort Studies; D003955:Diagnostic Tests, Routine; D005260:Female; D006801:Humans; D008875:Middle Aged; D010051:Ovarian Neoplasms / Q000175:diagnosis* / Q000401:mortality / Q000503:physiopathology; D012017:Referral and Consultation; D063189:Symptom Assessment; D006113:United Kingdom
chemical_list: D018394:CA-125 Antigen
keywords: Diagnosis; Ovarian cancer; Referral; Symptoms