Increased PFS associated with optimal surgery is limited to patients with less advanced disease, arguing for case selection rather than aggressive debulking in all patients irrespective of disease extent. Lymphadenectomy may have beneficial effects on PFS in optimally debulked patients.

Delay in the delivery of treatment for gynaecological cancers has been previously investigated.1 2 In some cases, the delay reflects the illness behaviour of women; in others, it was inherent in the system for delivering health care. Few studies have linked delay in treatment with survival, although a study from Israel found that survival from endometrial cancer was not affected by a delay in treatment of four months. 3 We investigated links between delays in treatment and survival, using a recently completed audit of endometrial cancer treatment in Scotland. Methods and resultsWe collected data from the case notes of all women resident in Scotland who were diagnosed between 1 January 1996 and 31 December 1997 as having endometrial carcinoma. Of 781 cases, we found case notes for 714, and, out of these, we analysed the 703 cases that involved operative treatment.We calculated time intervals from the dates of general practitioner referral letters, clinic appointments, investigations, and operations. We allocated an International Federation of Gynaecology and Obstetrics (FIGO) stage to each case retrospectively 4 ; we then categorised cases by FIGO stage. 5 We linked these data to survival information from ISD-Scotland and did a univariate analysis using the Kaplan-Meier method and multivariate analysis using Cox's proportional hazards analysis.Delay and survival were inversely related: women with the shortest delay had more advanced disease and survival was least likely for these patients (table). This trend is seen most starkly in the delay from general practitioner referral to first hospital visit.The median interval from referral to definitive operation was 62 days (90th centile 150 days). Large variations between health board areas existed: the median interval from referral to definitive operation varied from 46 to 81 days (74 to 287 days). CommentThe interaction between survival and delay in treatment is complex: we found that patients who experience the longest delay in treatment are more likely to survive. This is paradoxical: it is popularly assumed that delay has a significant and harmful impact on survival.This interaction is partially accounted for by the relation between stage and delay but is only partly explained by the FIGO stage category in a Cox proportional hazards model corrected for age, stage, and use of radiotherapy.The traditional view is that delay caused by organisational defects has an adverse effect on the disease: this influences survival. Our study suggests that disease influences delay, and so delay is a confounding factor.The fact that the strongest effect between delay and survival is seen in the interval between referral and the first hospital visit suggests that general practitioners communicate information related to presentation in some way to consultants. This communication ensures that consultants respond faster to patients who are at higher risk. Consultants seem to be able, from first clinic visit, to differentiate patients at greater risk and to ensure that cancer is diagn...

We present a 21-year-old woman with a short history of pelvic pain. The history was unremarkable apart from that of undergoing a surgical termination of pregnancy (TOP) some three-and-half years ago. Examination revealed a foreign body at the cervical os. Subsequent investigations revealed more foreign bodies within the cervical canal and uterine cavity, which were removed. Histologically these were found to be bones. Removal of the bone fragment initially discovered lead to an improvement of symptoms. Although the patient was treated for pelvic-inflammatory disease, no infective cause could be established. The condition of intrauterine retained fetal bones is recognized, but rare. Patients experiencing pelvic pain usually present sooner after TOP than did this patient. Although rare, it is an important condition to diagnose as it represents a treatable cause of infertility.

Staging quality is related to the survival of women with endometrial cancer: a Scottish population based study. Deficient surgical staging and omission of adjuvant radiotherapy is associated with poorer survival of women diagnosed with endometrial cancer in Scotland during 1996 and 1997 The association between treatment variation and survival of women with endometrial cancer was investigated. A retrospective cohort based upon the complete Scottish population registered on in-patient and day-case hospital discharge data (Scottish Morbidity Record-1) and cancer registration (Scottish Morbidity Record-6) coded C54 and C55 in ICD10, between 1st January 1996 to 31st December 1997 were analysed. Seven hundred and three patients who underwent surgical treatment out of 781 patients that were diagnosed with endometrial cancer in Scotland during 1996 and 1997. The overall quality of surgical staging was poor. The quality of staging was related to both the year that the surgeon passed the Member of the Royal College of Obstetricians and Gynaecologists examination and also to 'specialist' status but was not related to surgeon caseload. Two clinically important prognostic factors were found to be associated with survival; whether the International Federation of Obstetrics and Gynaecology stage was documented, RHR=2.0 (95% CI=1.3 to 3.1) and also to the use of adjuvant radiotherapy, RHR=2.2 (95% CI=1.5 to 3.5). The associations with survival were strongest in patients with advanced disease, International Federation of Obstetrics and Gynaecology stages 1C through to stage 3. Deficiencies in staging and variations in the use of adjuvant radiotherapy represent a possible source of avoidable mortality in patients with endometrial cancer. Consequently, there should be a greater emphasis on improving the overall quality of surgical staging in endometrial cancer. British Journal of Cancer (2002) Endometrial cancer is the second most common gynaecological cancer in the UK (Coleman et al, 1999) with approximately 400 cases diagnosed annually in Scotland. International comparisons show that survival in the UK, and in particular Scotland, is poor compared to other European countries (Gatta et al, 1998) but this data, from cancer registries, does not reveal the reasons for poor survival. There is little published in the literature describing variations in the management of this disease. An audit in south-east England found that inappropriate management was related to poorer survival outcome (Tilling et al, 1998). Endometrial cancer, unlike other gynaecological cancers, has traditionally been regarded as easy to treat (Lawton, 1997) nevertheless 25% of women will die of recurrence within 5 years of diagnosis (ISD, 2000).The overall aim of this study was to improve the understanding of variations in survival of women with endometrial cancer in Scotland. Specifically the objectives of the Scottish endometrial cancer study were to describe current practice, to investigate the consistency of staging and to relate these to survival outcomes. ...

As clinicians, we are familiar with the Hippocratic albatross 'Primum non nocere', 'first, do not harm'. We understand that every weapon in our clinical armour chest is double-edged, and every cure has a potential harm, this has never more true than during the global pandemic of SARS-CoV-2.