OSCE — postcoital bleeding: focused assessment, investigation, and breaking-bad-news

Brief (to candidate)

A 38-year-old nulliparous woman presents with 3 months of postcoital bleeding. She is otherwise well, has never had a Pap smear, and is on the oral contraceptive pill. She is concerned she may have cancer. The examiner will role-play the patient and then provide a clinical photograph of an irregular friable lesion at the cervical os and a colposcopy image showing an acetowhite area with punctation. Tasks are: (1) take a focused gynaecological history with cervical cancer risk-factor checklist, (2) perform a chaperoned informed-consent speculum examination with systematic inspection, (3) interpret the provided colposcopy image and explain colposcopic biopsy findings, (4) break the news of a histological diagnosis of FIGO 2018 stage IB1 squamous cell carcinoma, and (5) outline the initial staging workup and the curative-intent management options (open radical hysterectomy, radical trachelectomy, or primary chemoradiotherapy). [1]

[1]

Marking domains (out of 100)

The station carries 100 marks distributed across six domains as follows. Focused history — postcoital bleeding, menstrual pattern, cervical screening history, HPV exposure factors, smoking, parity, and immunosuppression — 20 marks. Informed consent and chaperoned speculum examination — technique, systematic inspection of cervix and fornices, bimanual assessment — 15 marks. Interpretation of the provided colposcopy image — acetowhite, punctation, Lugol staining, and biopsy site selection — 15 marks. Breaking bad news — SPIKES framework, empathetic language, planned return visit — 20 marks. Initial staging workup — MRI pelvis, FIGO 2018 substages — and management options — open radical hysterectomy versus chemoradiotherapy, fertility-sparing trachelectomy — 20 marks. Documentation, follow-up, cervical screening awareness, and HPV vaccination discussion for relatives — 10 marks. [1]

[1] [3] [4]

Expected structured answer

Part 1 — Focused history

Confirm duration, frequency, and severity of postcoital bleeding; ask about intermenstrual and postmenopausal bleeding, abnormal vaginal discharge (watery, pink, brown, malodorous), pelvic pain, dyspareunia, urinary or rectal symptoms, and weight loss. Ask the last menstrual period and contraceptive history. Ask the date and result of the most recent cervical smear. Cervical cancer risk-factor checklist: age at first intercourse (under 17), number of lifetime sexual partners, partner with multiple partners, smoking (pack-years), parity, immunosuppression (HIV, transplant, steroids), in-utero diethylstilbestrol exposure, and HPV vaccination status.[4]

Part 2 — Speculum examination (chaperoned informed consent)

Explain the procedure, gain verbal consent, ensure a chaperone is present (mandatory). Use a warmed Cusco speculum, identify the cervix, and systematically inspect the entire ectocervix and vaginal fornices under direct light. Bleeding on light touch (friability) and an exophytic friable lesion at the os are highly suggestive of cervical cancer. Document the lesion's size (cm in greatest dimension), site, and morphology (exophytic, endophytic, ulcerative). Perform a bimanual examination assessing cervical mobility (fixed cervix implies parametrial invasion), uterine size, adnexal masses, and parametrial nodularity.[1]

Part 3 — Colposcopy interpretation

Five-percent acetic acid turns dysplastic epithelium acetowhite because of increased nuclear-cytoplasmic ratio. Punctation and mosaic vessel patterns are abnormal vascular markers of CIN. Lugol's (Schiller's) iodine stains glycogen-rich normal squamous epithelium brown; iodine-negative (pale) areas are suspicious for dysplasia. Directed punch biopsy from the most abnormal area is taken, plus endocervical curettage if the lesion extends into the canal.[1]

Part 4 — Breaking bad news (SPIKES)

Set up the interview (private room, sit down, eye contact, partner present if patient wishes). Assess the patient's perception of her illness. Obtain an invitation to share the news. Give knowledge in small chunks ("The biopsy shows that the cells have become cancerous") and avoid jargon. Respond to emotion with empathetic acknowledgement ("This must be very difficult to hear"). Summarise and strategise: explain next steps, give her time to ask questions, offer written information, and arrange a follow-up with a gynaecology-oncology nurse specialist.[1]

Part 5 — Staging and management

Initial staging workup: pelvic MRI for local extent (parametrial invasion, tumour volume, pelvic nodes), CT chest/abdomen/pelvis for distant disease, and PET-CT if nodes are enlarged. FIGO 2018 stage IB1 = clinically visible lesion ≤2 cm confined to the cervix.[1]

Two curative-intent options for stage IB1 in a nulliparous 38-year-old:[3]

1. Open radical hysterectomy (Wertheim) with bilateral pelvic lymphadenectomy — preferred in a woman not desiring fertility; open approach because LACC showed inferior disease-free survival with minimally-invasive surgery. Pre-treatment fertility cryopreservation (oocyte or embryo) should be offered regardless of the path chosen.[3]
2. Radical trachelectomy with pelvic lymphadenectomy — uterus-sparing option for IB1 under 2 cm; preserves fertility with oncologic outcomes comparable to radical hysterectomy in well-selected patients. A permanent cervical cerclage is placed at surgery and subsequent deliveries are by caesarean section.[3]
3. Primary concurrent chemoradiotherapy (cisplatin 40 mg/m² weekly IV plus EBRT 45–50 Gy plus intracavitary brachytherapy to a total EQD2 ≥ 80 Gy) — reserved for patients who decline surgery, are medically unfit, or have disease not amenable to resection. Palliation with bevacizumab (15 mg/kg IV 3-weekly) plus cisplatin and paclitaxel is reserved for metastatic (stage IVB) or recurrent disease per the GOG-240 regimen.[2]

In the offered scenario, fertility-sparing trachelectomy, radical hysterectomy, and primary chemoradiotherapy should each be discussed with oncological outcomes, recurrence risk, fertility implications, surgical complications, and sexual function side-effects.[1][3]

Examiner checkpoints (red-flag a fail)

The examiner marks a candidate down on the following points. Did not biopsy or refer for colposcopy is a failing station — post-coital bleeding is cancer until proven otherwise, and speculative reassurance is the most common pitfall. Suggested minimally-invasive radical hysterectomy fails evidence-based care because LACC established the open approach as the standard. Dismissed the abnormal-appearing cervix (calling it an ectropion or a pill side-effect) is a failing station. Failed to chaperone or document consent is a failing station on professionalism. No mention of multidisciplinary team (MDT) referral for staging and treatment planning is substandard. No smoking-cessation or HPV-vaccination advice for relatives when relevant is a missed opportunity for primary prevention.[3][4]

Common traps and the better answer

Common candidate traps and what a better answer would be. "Reassure, it's an ectropion" — better answer is to biopsy the visible lesion because post-coital bleeding is cancer until proven otherwise. "Smear test then review" alone — better answer is speculum first; an abnormal cervix needs a directed biopsy, not just cytology. "HPV test alone" without speculum examination — better answer is that inspection precedes any test, and the combination maximises sensitivity. "Radical hysterectomy laparoscopic" — better answer is the open approach post-LACC, and discuss fertility-sparing trachelectomy if appropriate. "Wait and see if bleeding continues" — better answer is that a symptomatic cervical mass mandates tissue diagnosis within two weeks (cancer pathway).[1][3][4]

References

1. [1]Bhatla N, Berek JS, Cuello Fredes M, et al. Revised FIGO staging for carcinoma of the cervix uteri. Int J Gynaecol Obstet, 2019.PMID 30656645
2. [2]Tewari KS, Sill MW, Long HJ III, et al. Bevacizumab for advanced cervical cancer: final overall survival and adverse event analysis of a randomised, controlled, open-label, phase 3 trial (Gynecologic Oncology Group 240). Lancet, 2017.PMID 28756902
3. [3]Ramirez PT, Frumovitz M, Pareja R, et al. Minimally Invasive versus Abdominal Radical Hysterectomy for Cervical Cancer. N Engl J Med, 2018.PMID 30380365
4. [4]Curry SJ, Krist AH, Owens DK, et al. (US Preventive Services Task Force). Screening for Cervical Cancer: US Preventive Services Task Force Recommendation Statement. JAMA, 2018.PMID 30140884