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Case history

image An 85-year-old woman presented to her GP with a 3 month history of abdominal pain, bloating and urinary frequency. Past medical history included type 2 diabetes mellitus and vaginal prolapse, managed with a ring pessary. At her recent diabetic review, her HbA1c level was 70 mmol/mol and she had chronic kidney disease (stage 3 with estimated glomerular filtration rate [GFR] 55 ml/min) and mild sensory neuropathy. Regular medications were metformin, gliclazide, ramipril, simvastatin and paracetamol. She lived alone in a bungalow, walked with a stick, and was independent in her activities of daily living (ADL) but required her daughter's help with shopping. GP-measured serum CA-125 was >1000 U/ml; pelvic ultrasound revealed a large adnexal mass. She was referred for urgent investigation for suspected ovarian cancer.

Staging investigations showed a large pelvic mass causing bilateral hydronephrosis, small-volume ascites and omental deposits (International Federation of Gynecology and Obstetrics [FIGO] stage IIIC). Omental biopsy confirmed a high-grade serous adenocarcinoma of ovarian origin. The gynae-oncology multidisciplinary team (MDT) recommended neoadjuvant chemotherapy with interval debulking surgery. Bilateral ureteric stents were inserted to prevent development of renal failure.

At her initial oncology appointment, she had poorly controlled pelvic pain, was opening her bowels on alternate days and getting up twice a night to pass urine with increased urgency and dysuria following the stent insertion. Her Eastern Cooperative Oncology Group (ECOG) performance status (PS) was 2. The patient agreed to treatment with carboplatin. A regular low-dose opiate and laxative were started. She was asked to monitor her blood glucose daily.

Cycles 1 and 2 were well tolerated with mild fatigue and constipation. When she attended for cycle 3, the chemotherapy nurses noticed that she was unkempt and confused. Assessment on the acute oncology unit found that she was incontinent of urine and faeces, had gradually worsening constipation, followed by diarrhoea, and had increasing urinary frequency with a feeling of incomplete voiding and dysuria. Her Abbreviated Mental Test Score (AMTS) was 7/10 and she was unsteady on her feet with postural drop >30 mmHg. Her rectum was loaded with hard stool and her pessary was poorly fitting. Urea, creatinine and blood glucose were elevated. Urinalysis suggested infection, which was confirmed by microscopy and culture. She was diagnosed with delirium due to urinary tract infection (UTI), faecal incontinence due to constipation, poor glycaemic control, and postural hypotension due to dehydration and medication. She was admitted to hospital.

What was the goal of cancer treatment for this patient?

How was her incontinence managed?

What is the evidence base for her cancer treatment?

What patient-related factors influenced her cancer treatment plan?

How can incontinence be identified and managed in cancer services?

What was the goal of cancer treatment for this patient?

In common with 75% of women with ovarian cancer, this patient presented with advanced disease (FIGO stage III or IV). Standard treatment is platinum-based chemotherapy and debulking surgery, performed by a ...

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