Identifying and Referring Patients with Suspected Cancer

1
Identifying and Referring Patients with Suspected
Cancer

• Dr Nick Pendleton

2
NICE Clinical Knowledge Summaries (CKS)

• Cancer suspected (NICE referral advice)
• http//cks.nice.org.uk/specialityTabnt

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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 this presentation

• 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 Im here can you check this mole on my
  arm?

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A B C D E Rule

• ASYMMETRY
• IRREGULAR BORDER
• COLOUR gaining, losing(?), multiple colours
• Diameter greater than 6mm (1/4 inch)
• Evolving

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Mr Simpson 53, Company Director

•  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

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(No Transcript)
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Can I ask you some 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

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What are the worrying features 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

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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

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Ricky, 15

•  Coach said I should come and see you about my
  left leg Its interfering with my training. I
  play a lot of sport including football 3 times a
  week

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Tell me more about it..

• I dont remember injuring it, but Ive not been
  able to run on it for a few weeks now
• It is sore and tender to press on
• It hurts even when Im not walking about
• Its more sore this week than a few weeks ago
• On examination hes limping, there is a bony and
  tender swelling below the knee

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What is the Differential Diagnosis?

• Osgood-Schlatters 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

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What should you 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)

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OSTEOSARCOMA (MALIGNANT BONE TUMOUR)
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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

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Review appointment

• Alcohol intake 60 -70 units a week
• Dont 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)

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Review appointment 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

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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.

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Telephone Encounter

• 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 dont want to discuss anything at
  the moment. Ill come and see you at the surgery
  soon. Goodbye.
• What do you do next?

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Mrs Gladys Parker, 72

• Dysphagia and weight loss. Gastroscopy 1 month
  ago normal.
• Came with daughter. My mum is still losing weight
  and cant swallow properly. The Doctor we saw
  last week gave her some ensure drinks but
  somethings not right!

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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

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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?

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Response from 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.

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Mr Schonberg, 66

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A Cutaneous Horn 25 will have SCC at the base

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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
• Its not painful

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Examination

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

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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 .

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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
• Its not painful

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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

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Timothy, 6 years old

• Hes 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

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(No Transcript)
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Causes of Neck Swelling in Children

• LYMPHADENOPATHY (enlarged lymph nodes)
• LOCAL
• SYSTEMIC
• LYMPHADENITIS (inflamed lymph nodes) or ABSCESS
• NON-LYMPHADENOMATOUS NECK SWELLINGS

BMJ 2012344e3171
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LYMPHADENOPATHY (enlarged lymph nodes)

• 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 2012344e3171
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Lymphadenitis (inflamed lymph nodes) or abscess

• Bacterial lymphadenitis
• Mycobacterial lymphadenitis
• Abscess

BMJ 2012344e3171
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Non-lymphadenomatous neck swellings

• Cystic hygroma
• Sternocleidomastoid swelling
• Thyroid gland enlargement
• Thyroglossal cyst
• Dermoid cyst
• Branchial cyst
• Mumps

BMJ 2012344e3171
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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 gt 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)
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Timothy, 6 years old

• Hes 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

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Mrs Sullivan, 50, unemployed

• Ive got this ringing in my left ear!
• I cant hear as well either
• I sometimes have a spinning sensation in my head

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IN MY RIGHT EAR
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IN FRONT
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Weber without lateralization Weber lateralizes left Weber lateralizes right
Rinne both ears ACgtBC Normal/bilateral sensorineural loss Sensorineural loss in right Sensorineural loss in left
Rinne left BCgtAC Conductive loss in left Combined loss  conductive and sensorineural loss in left
Rinne right BCgtAC Combined loss  conductive and sensorineural loss in right Conductive loss in right
Rinne both ears BCgtAC Conductive loss in both ears Combined loss in right and conductive loss on left Combined loss in left and conductive loss on right
AC Air Conduction BC Bone Conduction
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Mr Sullivan, 50, unemployed

• Ive got this ringing in my left ear!
• I cant 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)

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A Large Acoustic Neuroma

• 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

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Mrs Simpson, 52

•  I am fed up with this, just look at my belly
  its massive, I feel bloated, but Ive got no
  appetite and when I do eat Ive either got
  diarrhoea or cant go at all. Also I keep having
  to urinate, I feel tired and my back hurts! 

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• OVARIAN CANCER
• VERSUS
• IRRITABLE BOWEL SYNDROME

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IRRITABLE BOWEL SYNDROME OVARIAN CANCER
Bloating Bloating
Abdominal Pain Pelvic or Abdominal Pain
Nausea/ Poor Appetite/Feeling Full/ Flatus/Belching Trouble Eating or Feeling Too Full Quickly
Constipation and/or Diarrhoea Constipation
Urinary Symptoms eg. frequency Urinary Symptoms eg. frequency
Fatigue Fatigue
Upset Stomach/Heartburn Upset Stomach
Back Pain Back Pain
Abdominal Swelling (with Weight Loss?) Abdominal Swelling with Weight Loss
Muscle pains Pain During Sex
Menstrual Changes
It is uncommon for IBS to first develop in women
over the age of 50
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Investigating Ovarian Cancer Symptoms in Primary
Care

• Measure serum CA125 in primary care in women with
  symptoms that suggest ovarian cancer
• If serum CA125 is 35 IU/ml or greater, arrange an
  ultrasound scan of the abdomen and pelvis
• For any woman who has normal serum CA125 (less
  than 35 IU/ml), or CA125 of 35 IU/ml or greater
  but a normal ultrasound assess her carefully for
  other clinical causes of her symptoms and
  investigate if appropriate

NICE CG 122 - OVARIAN CANCER
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Sally Smith, 39, Secretary

•  My Sister is 45 and having treatment for breast
  cancer and I want to know if I am at risk 
•  My Aunt died from Ovarian cancer 2 years ago 

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What is a Significant Family History?

• One first-degree female relative diagnosed with
  breast cancer at younger than age 40 years
• One first-degree male relative diagnosed with
  breast cancer at any age
• One first-degree relative with bilateral breast
  cancer where the first primary was diagnosed at
  younger than age 50 years
• Two first-degree relatives, or one first-degree
  and one second-degree relative, diagnosed with
  breast cancer at any age
• One first-degree or second-degree relative
  diagnosed with breast cancer at any age and one
  first-degree or second-degree relative diagnosed
  with ovarian cancer at any age (one of these
  should be a first-degree relative)
• Three first-degree or second-degree relatives
  diagnosed with breast cancer at any age

http//www.patient.co.uk/doctor/familial-breast-ca
ncer
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Alternative Scenario

• Mother had breast cancer aged 50. No other family
  history.
• Offer information and reassurance, secondary care
  referral not indicated unless the family history
  contains
• Bilateral breast cancer, Male breast cancer
• Ovarian cancer, Jewish ancestry
• Sarcoma in a relative younger than age 45 years
• Glioma or childhood adrenal cortical carcinomas
• Complicated patterns of multiple cancers at a
  young age
• Paternal history of breast cancer (two or more
  relatives on the father's side of the family)

http//www.patient.co.uk/doctor/familial-breast-ca
ncer
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Mr Jenkinson 71

• Telephone call  I cannot tolerate this shoulder
  pain any longer. Surely I need an X-ray or
  something. The Drs have said there would be no
  point as it would just confirm arthritis, but it
  is getting worse and my arm is loosing muscle and
  strength! 
• XRAY request 6 months of right shoulder pain now
  needing morphine

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PANCOAST TUMOUR AT RIGHT APEX
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Summary of the Session

• A Mole Possible Malignant Melanoma
• Lump on the Leg Possible Sarcoma
• Leg Pain Osteosarcoma or Osgood-Schlatters
• Abnormal LFTs ?Hepatocellular Carcinoma
• Dysphagia with normal gastroscopy Oesophageal
  Tumour
• Cutaneous Horn SCC
• Rectal Bleeding - Referral Guidance
• Neck Lumps in Children
• Tinnitus and Hearing Loss Acoustic Neuroma
• IBS versus Ovarian Cancer
• Breast cancer - Family History
• Shoulder Pain - Lung Cancer (Pancoast Tumour)

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Identifying and Referring Patients with Suspected
CancerCLINICAL RECORD REVIEW

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Tony Frazer 36, National Account Manager (Sales)

• July 2013
• Dr A on-call
• Telephone triage encounter
• Haematemesis fresh and dried (coffee bean) blood
• Abnormal weight loss, 3 stone in 7/12

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Same day appointment with Dr B

• Heamatemesis after drinking excessive alcohol and
  vomiting
• 2 stone weight loss in 7 months
• Exam normal, weight 65kg (75kg Sept 12)
• Needs 2WW referral, upper GI poss mallory weiss
  tear but in combination with weight loss need to
  r/o malignancy.

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14 August Dr C

• Gastroscopy normal, h.pylori -ve
• Very tired
• Intermittent diarrhoea
• No appetite, weight 63kg
• Mood OK but a lot of stress in last year
• Blood tests requested to exclude coeliac
• Start omeprazole 20mg bd

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Dr C 22 August

• Omeprazole caused dizziness
• TTG IgA test normal
• c/o No appetite, mood ok, loss of
  concentration, memory disturbance, stressful life
  events
• Not open to possible depression
• Wanted to go private GI consultant

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2nd October

• Continues to lose weight - wt 59Kg
• Consuming 2000 calories in food from McDonalds
  and 2500 calories in supplements
• Upper GI consultant suggested the cause of his
  weight loss is depression and suggested starting
  him on mirtazapine (and arranges CT)
• Patient thinks this is wrong as he has a great
  life and everything to feel good about.

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Weight Chart

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25 September Dr D

• CT scan was normal
• Now feels too weak and tired to work
• Weight stable
• Feels frustrated and down in mood
• TATT, sleeping lots, buying own high calorie
  supplements
• Awaiting further GI consultant review. See in 3
  weeks

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25 November Dr C

• Gaining weight
• Taking mirtazapine
• Has seen consultant again who suggests Chronic
  Fatigue Syndrome (CFS) is the possible diagnosis
• Referred CFS Specialist for opinion
• In the meantime wants to try hydrotherapy to get
  some fitness back

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Weight Chart

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7 February 2014

• Diagnosis of CFS confirmed by specialist
• 16 September 2014 making progress with CFS
  therapy and a return to work is possible in early
  2015

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About this presentation

• 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.