Identifying and Referring Patients with Suspected Cancer

1. Identifying and Referring Patients withSuspected Cancer Dr Nick Pendleton

2. NICE ClinicalKnowledgeSummaries (CKS) • Cancer – suspected (NICE referral advice) http://cks.nice.org.uk/#specialityTabnt

3. Referral timelines • Immediate:an acute admission or referral occurring within a few hours, or even more quickly if necessary • Urgent:the patient is seen within the national target for urgent referrals (currently 2 weeks) • Non-urgent:all other referrals

4. About thispresentation: • The scenarios in this slide presention are based wholly or partly on real patients who have presented to GP surgeries. They have been anonymised for use as a teaching tool for GPs in Training. For realism the patients have been given fictional names, ages and professions.

5. Lesley Summers - 31 • Whilst I’m here can you check this mole on my arm?

6. A B C D E Rule ASYMMETRY IRREGULAR BORDER COLOUR – gaining, losing(?), multiple colours Diametergreaterthan 6mm (1/4 inch) Evolving

8. Mr Simpson 53, CompanyDirector • « I try and stay away from Doctors if I can but my wife has made this appointment! » • « What is your wife worried about!? » • « I have this lump on my leg… Its getting a bit bigger and its quite sore »

10. Can I askyousome questions about it? • « How long has it been there? » • « About 3 months or so » • « Is there any history of an injury? » • « Yes, come to think about it, I knocked my leg with an axe whilst chopping logs about 4 months ago »

11. What are the worryingfeatures of a palpable lump? • Refer urgently as suspected soft tissue sarcoma if: • Greater than about 5 cm in diameter • Deep to fascia, fixed or immobile • Painful • Increasing in size • A recurrence after previous excision • If there is any doubt about the need for referral, discussion with a local specialist should be undertaken

12. Mr Simpson was referred (2WW) • CT showed an homogenous mass with capsule formation. US scan appearances resembled a multi-locular cyst. The mass was excised. • Histology – necrotic debris, fibrin and blood clots. • Fortunately it was not a Sarcoma. • “A case of chronic expanding hematoma in the tensor fascia lata” • http://escholarship.org/uc/item/6wg5260x

13. Ricky, 15 « Coach said I should come and see you about my left leg –It’s interfering with my training. I play a lot of sport including football 3 times a week »

14. Tell me more about it.. • I don’t remember injuring it, but I’ve not been able to run on it for a few weeks now • It is sore and tender to press on • It hurts even when I’m not walking about • It’s more sore this week than a few weeks ago • On examination: he’s limping, there is a bony and tender swelling below the knee

15. Whatis the DifferentialDiagnosis? • Osgood-Schlatter’s Disease? • A Primary Bone Tumour? • Osteosarcoma most commonly presents between 10 and 24 years old • This is an age when a lot of people take part in sports

16. Whatshouldyou do next? • Patients with increasing, unexplained or persistent bone pain or tenderness, particularly pain at rest (and especially if not in the joint), or an unexplained limp should be investigated urgently ?Bone Tumour • CKS Guidance recommends an immediate Xray and then if bone tumour is a possibility – refer urgently (2WW)

17. OSTEOSARCOMA (MALIGNANT BONE TUMOUR)

18. Mr Jones, 46, Salesman • Blood results done as part of health screen: LFTs • ALP slightly raised 25% above normal • ALT raised 50% above normal • Other bloods and LFTs normal • Not on any medications, PMH nil, non-smoker

19. Reviewappointment • Alcohol intake 60 -70 units a week • ‘Don’t worry I will curb my drinking doctor – its just become a habit to open a bottle of wine after work with my wife’ • Plan: recheck LFTs in 4-6 weeks (NB. the guidance says 6 months)

20. Reviewappointment 2 • Alcohol intake 20 units a week • ‘We have also started healthy eating and exercising doctor! • LFT results: ALT still raised 50% above normal, ALP slightly better but still close to 25% above normal

21. Ultrasound Report • There is a hyperechoic mass with in one lobe of the liver. It is not possible to say whether this is a benign cyst or a sinister lesion. Referral for urgent MRI is indicated.

22. TelephoneEncounter • Hello Mr Jones – I am ringing about your Ultrasound report, is now a good time to talk? • No, sorry Doctor – we have just had a telephone call to say my mother has passed away in the nursing home. I don’t want to discuss anything at the moment. I’ll come and see you at the surgery soon. Goodbye. • What do you do next?

23. Mrs Gladys Parker, 72 • Dysphagia and weight loss. Gastroscopy 1 month ago normal. • Came with daughter. My mum is still losing weight and can’t swallow properly. The Doctor we saw last week gave her some ensure drinks but something’s not right!

24. Re-referral for gastroscopy Report:There is a circumferential stricture seen with the appearances of an advanced oesophageal carcinoma… The patient died 4 weeks later

25. Letter to Endoscopy Unit Dear Sister X I would like to enquire whether it is possible for a tumour of this advanced stage to appear with in this short time scale and do you have any video footage of the previous exam?

26. Responsefrom GI Consultant Thank you for your letter. No I do not think this lesion could have arisen in this short time scale. I think it was missed during the first examination. We will be exploring this with the endoscopist. We do not currently video the examinations.

27. Mr Schonberg, 66

28. A Cutaneous Horn – 25% will have SCC at the base

29. Mr Chandra, 46, IT Developer • I have been passing blood from my back passage every time I go to the toilet for the last 3 days • No change in bowel habit • Its bright red • Its after a motion • It’s not painful

30. Examination • Abdomen examination normal, no mass • PR examination normal • What would you do next?

31. WHAT DOES THE CKS GUIDANCE SAY? • In patients 40 years of age and older, reporting rectal bleeding with a change of bowel habit towards looser stools and/or increased stool frequency persisting for 6 weeks or more, an urgent referral should be made. • In patients 60 years of age and older, with rectal bleeding persisting for 6 weeks or more without a change in bowel habit and without anal symptoms, an urgent referral should be made .

32. Mr Chandra, 46, IT Developer • I have been passing blood from my back passage every time I go to the toilet for the last 3 days • No change in bowel habit • Its bright red. • Its after a motion • It’s not painful

33. WHAT DOES THE CKS GUIDANCE SAY? • In patients with equivocal symptoms who are not unduly anxious, it is reasonable to use a period of 'treat, watch and wait' as a method of management • In men of any age with unexplained iron deficiency anaemia and a haemoglobin of 11 g/100 mL or below, an urgent referral should be made

34. Timothy, 6 yearsold • He’s got a lump on his neck! Its getting bigger • 3 cm lymph node in posterior triangle • Hard and irregular in shape • Recent URTI/sore throat • Pallor

36. Causes of Neck Swelling in Children LYMPHADENOPATHY (enlarged lymph nodes) • LOCAL • SYSTEMIC LYMPHADENITIS (inflamed lymph nodes) or ABSCESS NON-LYMPHADENOMATOUS NECK SWELLINGS BMJ 2012;344:e3171

37. LYMPHADENOPATHY (enlargedlymphnodes) • LOCAL • Viral or bacterial upper respiratory tract • Ear infection, Oropharyngeal infection • Headlice infestation, Dental abscess • Cat scratch disease (gram –ve bacteria Bartonella Henselae or Quintana) • SYSTEMIC • Malignancy (lymphoma or leukaemia) • Viral infections (Epstein-Barr virus, cytomegalovirus, rubella) • Kawasaki disease • Mycobacterial infection (tuberculous or non-tuberculous), Sarcoidosis • Systemic lupus erythematosus • Juvenile idiopathic arthritis BMJ 2012;344:e3171

38. Lymphadenitis (inflamed lymph nodes) or abscess • Bacterial lymphadenitis • Mycobacterial lymphadenitis • Abscess BMJ 2012;344:e3171

39. Non-lymphadenomatousneck swellings • Cystic hygroma • Sternocleidomastoid swelling • Thyroid gland enlargement • Thyroglossal cyst • Dermoid cyst • Branchial cyst • Mumps BMJ 2012;344:e3171

40. Features of High Risk Neck Lumps in Children • Non-tender, firm or hard lymph nodes • Progressively enlarging • Lymph nodes in the supraclavicular area or axillary area • Lymph nodes > 3 cm in size • Lymph nodes in children with a history of malignancy • Hepatosplenomegaly, Fever, Weight Loss • Night Sweats Clinical Otolaryngology, 31, 433 – 434 and GP Notebook (lymphadenopathy)

41. Timothy, 6 yearsold • He’s got a lump on his neck! • 3 cm lymph node in posterior triangle • Hard and irregular in shape • Recent URTI/sore throat, Pallor • Clearly fits urgent referral criteria for a suspicious neck lump

42. Mrs Sullivan, 50, unemployed • I’ve got this ringing in my left ear! • I can’t hear as well either • I sometimes have a spinning sensation in my head

43. “IN MY RIGHT EAR”

44. “IN FRONT”

45. AC = Air Conduction BC = Bone Conduction

46. Mr Sullivan, 50, unemployed • I’ve got this ringing in my left ear! • I can’t hear as well either • I sometimes have a spinning sensation in my head • Examination: sensorineural hearing loss • Diagnosis – small acoustic neuroma (tumour of vestibulocochlear nerve)

47. A Large AcousticNeuroma Can cause these additional symptoms: • headaches with blurred vision • numbness or pain on one side of the face • problems with limb coordination on one side of the body • less often, muscle weakness on one side of the face  • in rare cases, changes to the voice or difficulty swallowing

48. Mrs Simpson, 52 « I am fed up with this, just look at my belly its massive, I feel bloated, but I’ve got no appetite and when I do eat I’ve either got diarrhoea or can’t go at all. Also I keep having to urinate, I feel tired and my back hurts! »

49. OVARIAN CANCER VERSUS IRRITABLE BOWEL SYNDROME

50. It is uncommon for IBS to first develop in women over the age of 50