The use, quality and effectiveness of pelvic examination in primary care for the detection of gynaecological cancer: a systematic review

Problem

Urgent suspected cancer referral (USC) guidelines recommend that women presenting with potential gynaecological cancer symptoms should undergo pelvic examination (abdominal palpation, bimanual vaginal examination +/- visualization of the cervix) prior to referral. It is not known how well general practitioners (GPs) comply with the recommendation, how well they perform pelvic examination (PE), or to what extent it shortens diagnostic intervals. We conducted a systematic review of the use, quality and effectiveness of PE in primary care to diagnose gynaecological cancer.

Approach

Three research questions (RQ) were explored: (RQ1) Is PE used by GPs to assess symptoms suggestive of a gynaecological cancer? (RQ2) What is the quality of PE performed by GPs? (RQ3) What is the association between PE and cancer referral outcomes?PRISMA guidelines were followed. MEDLINE, EMBASE and Cochrane databases were searched using a combination of four MeSH terms and synonyms: pelvic examination; primary care; competency and gynaecological cancer. Citation lists of all identified papers were searched with independent duplicate review of screened titles, abstracts and full texts of publications. Data extraction was performed in duplication and independently by PW and either PM, CMB or CB. Paper quality was assessed using the relevant CASP checklist. Emergent themes and contrasting issues were explored in an ecological synthesis.

Findings

21 papers were identified which met the inclusion criteria: 5 RQ1; 6 RQ2; 10 RQ3.Examination rates prior to referral were generally low: 50% or less of patients with suspicious symptoms had a PE. No papers directly explored GPs’ competence at performing PE; but one paper auditing ‘clinically suspicious’ cervixes referred by GPs for colposcopy found 39% were normal and 41% had benign pathology. Pre-referral PE was associated with reduced diagnostic delay and early stage diagnosis. Ecological synthesis demonstrated a complex interplay between patient and practitioner factors and the environment in which examination is performed. Presenting symptoms are commonly misattributed by patients and practitioners resulting in misdiagnosis and lack of PE. Patient age, presenting symptom, practitioner experience and knowledge appear to be key. PE appears to be under-performed pre-referral in symptomatic women despite current USC guideline recommendation. While no evidence was found to support GPs’ competence for performing PE, there was an association with shorter diagnostic delay and earlier stage cancer in those women where it was performed.

Consequences

PE is underperformed and it appears to matter because when it’s done outcomes may be better for patients. More research is needed to confirm these findings, and to understand how to optimize adherence to the guidelines, and improve performance and interpretation of PE for maximum benefit to patients. This is likely to lead to changes to the recommendations, guidelines and advice for GPs.