The management of cervical carcinoma within the South West Region of England

Objective 1. To audit the management of cervical carcinoma in the South West Region with the aim of identifying and addressing deficiencies. 2. To determine whether recent NHS restructuring has affected the provision of cancer care. Design Retrospective review of hospital case notes. Setting All hospitals in the South West Region of England. Population Three hundred and twenty-four women with a diagnosis of cervical carcinoma: 191 were diagnosed in 1989 and 133 in 1993. Main outcome measures Documentation of patient assessment and management. Results There was a mean delay of 17 days (range 0–66) from cervical smear to cytology report and 34 days (range 1–380) from general practitioner referral to attendance at a hospital clinic. Overall, 175 women (54%) had evidence of cytological assessment prior to treatment and 137 (42%) had a colpo-scopic assessment; 49% had cytological assessment and 37% had colposcopy in 1989, compared with 60% and 50%, respectively, in 1993. Excluding 49 cases of micro-invasive carcinoma, 238 case notes (86%) contained evidence of clinical examination; 195 women (71%) had had an examination under anaesthesia, 115 (42%) a chest radiograph, 123 (45%) an intravenous urogram or renal ultrasound, and 92 (33%) cystoscopy. One hundred and forty-seven women (53%) had FIGO staging recorded in the notes. As first line treatment, 69 had conservative surgery (39 for Stage IA), 138 had radiotherapy, and 107 had radical surgery. Ten had radical surgery for Stage IA but eight had a > 3 mm invasion or lymphatic/vascular spread. Thirty-one had Stage IB treated with radiotherapy of whom 14 were younger than 50 years of age. Following radical surgery 30% had evidence of sampling 10 nodes, and 9% had tumour extending to the resection margins. Conclusions Record keeping was inadequate but appeared to indicate inconsistent cytological, clinical, colposcopic and radiological assessment, leading to inappropriate clinical delays and conservative surgery. Radical surgery often appeared inadequate, but poor node sampling rates may also reflect insufficient histopathological preparation or reporting. There was a reduction in the number of new cases of cervical carcinoma diagnosed in 1993, perhaps reflecting an observed increase in cytological surveillance. No other alterations in clinical practice were observed over the four-year period. We feel it is imperative to standardise assessment throughout the region with a minimum clinical and histopathological dataset.