STEP 2: Presentation, initial investigations and referral
This step outlines the process for the general practitioner to initiate the right investigations and refer to the appropriate specialist in a timely manner. The types of investigations the general practitioner undertakes will depend on many factors, including access to diagnostic tests, the availability of medical specialists and patient preferences.
The following signs and symptoms should be investigated:
- vaginal bleeding after menopause
- bleeding between periods
- abnormal, watery or blood-tinged vaginal discharge
- unexplained weight loss
- pelvic pain
- difficult or painful urination.
The presence of multiple signs and symptoms, particularly in combination with other underlying risk factors, indicates an increased risk of endometrial cancer. However, the presence of these symptoms may be due to other conditions.
- Any bleeding or abnormal vaginal discharge after menopause (more than 12 months after the last period) should be investigated without delay.
- Any new, persistent or progressive symptoms in patients over the age of 40 should be investigated within four weeks of presenting with symptoms.
- Symptoms that do not respond to treatment initiated by the general practitioner (e.g. oral contraception or progesterone) should be evaluated within three months of treatment beginning.
General practitioner examinations and investigations should include:
- a general and pelvic examination (including a speculum examination and cervical screening test)
- referral to an experienced gynaecological ultrasonographer for a transvaginal pelvic ultrasound.
To help determine menopausal status and key considerations for pre-, peri- and postmenopausal women, refer to A practitioner’s toolkit for managing the menopause.
To help assess abnormal bleeding in pre-, peri- and postmenopausal women, refer to Cancer Australia’s Abnormal vaginal bleeding in pre, peri and postmenopausal bleeding: a guide for general practitioners and gynaecologists.
The general practitioner should have the results and review the patient within two weeks of the patient initially presenting with symptoms.
If the diagnosis of endometrial cancer is suspected, then refer to a specialist gynaecologist for further investigation. If the diagnosis is confirmed with initial tests, then refer to or consult with a gynaecological oncologist or service.
Patients should be enabled to make informed decisions about their choice of specialist and health service. General practitioners should make referrals in consultation with the patient after considering the clinical care needed, cost implications (see referral options and informed financial consent), waiting periods, location and facilities, including discussing the patient’s preference for health care through the public or the private system.
Referral for suspected or diagnosed endometrial cancer should include the following essential information to accurately triage and categorise the level of clinical urgency:
- important psychosocial history and relevant medical history
- family history, current symptoms, medications and allergies
- results of current clinical investigations (imaging and pathology reports)
- results of all prior relevant investigations
- notification if an interpreter service is required.
Many services will reject incomplete referrals, so it is important that referrals comply with all relevant health service criteria.
If access is via online referral, a lack of a hard copy should not delay referral.
The specialist should provide timely communication to the general practitioner about the consultation and should notify the general practitioner if the patient does not attend appointments.
Aboriginal and Torres Strait Islander patients will need a culturally appropriate referral. To view the optimal care pathway for Aboriginal and Torres Strait Islander people and the corresponding quick reference guide, visit the Cancer Australia website. Download the consumer resources – Checking for cancer and Cancer from the Cancer Australia website.
If any investigations cannot be provided in a local setting, then referral to a specialist to enable appropriate investigation and diagnosis should occur within four weeks of initial presentation to the general practitioner.
The patient’s general practitioner should consider an individualised supportive care assessment where appropriate to identify the needs of an individual, their carer and family. Refer to appropriate support services as required. See validated screening tools mentioned in Principle 4 ‘Supportive care’.
A number of specific needs may arise for patients at this time:
- assistance for dealing with the emotional distress and/or anger of dealing with a potential cancer diagnosis, anxiety/depression (particularly regarding potential loss of fertility), interpersonal problems and adjustment difficulties
- management of physical symptoms including pain, fatigue and mobility issues
- nutritional assessment and weight management where appropriate
- encouragement and support to increase levels of exercise (Cormie et al. 2018; Hayes et al. 2019).
For more information refer to the National Institute for Health and Care Excellence 2015 guidelines, Suspected cancer: recognition and referral.
For additional information on supportive care and needs that may arise for different population groups, see Appendices A and B, and special population groups.
The general practitioner is responsible for:
- providing patients with information that clearly describes to whom they are being referred, the reason for referral and the expected timeframes for appointments
- requesting that patients notify them if the specialist has not been in contact within the expected timeframe
- considering referral options for patients living rurally or remotely
- supporting the patient while waiting for the specialist appointment (Cancer Council nurses are available to act as a point of information and reassurance during the anxious period of awaiting further diagnostic information; patients can contact 13 11 20 nationally to speak to a cancer nurse).
Refer to Principle 6 ‘Communication’ for communication skills training programs and resources.
