03/10/2017

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Identifying and Referring Patients with Suspected Cancer

Dr Nick Pendleton

NICE Clinical Knowledge Summaries (CKS)

• Cancer – suspected (NICE referral advice)

https://pathways.nice.org.uk/pathways/suspected-cancer-recognition-and-referral

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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

Lesley Summers - 31

• Whilst I’m 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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Dermnet New Zealand

http://www.dermnetnz.org/topics/melanomafor-health-professionals/

Mr Schonberg, 66

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

Some other skin lesions

https://creativecommons.org/licenses/by-nc-nd/3.0/nz/legalcode

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https://creativecommons.org/licenses/by-nc-nd/3.0/nz/legalcode

SCC BCC

Some other skin lesions

BCC SCC

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Solar or Actinic Keratoses

BCC SCC

Some other skin lesions

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Normal Mole

Cherry Haemangiomas

Some other skin lesions

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Seborrhoiec Keratoses

Finally what is this?

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Finally what is this?

Bowen’s Disease or Squamous

Cell Carcinoma in Situ

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 »

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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

What is the Differential Diagnosis?

• Osgood-Schlatter 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)

OSTEOSARCOMA (MALIGNANT BONE TUMOUR)

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Osgood-Schlatter Disease

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!

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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

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.

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

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Examination

• Abdomen examination normal, no mass

• PR examination normal

• What would you do next?

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

• It’s not painful

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

110 g/L or below, an urgent referral should be made

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Timothy, 6 years old

• 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

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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 2012;344:e3171

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 2012;344:e3171

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Lymphadenitis (inflamed lymph nodes) or abscess

• Bacterial lymphadenitis

• Mycobacterial lymphadenitis

• Abscess

BMJ 2012;344:e3171

Non-lymphadenomatous neck swellings

• Cystic hygroma

• Sternocleidomastoid swelling

• Thyroid gland enlargement

• Thyroglossal cyst

• Dermoid cyst

• Branchial cyst

• Mumps

BMJ 2012;344:e3171

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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 > 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)

Timothy, 6 years old

• 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

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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! »

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

Investigating Ovarian Cancer Symptoms in Primary Care

• If the physical examination is abnormal then make an urgent 2WW referral

NICE CG 122 - OVARIAN CANCER

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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

Other Causes of a raised CA125 – Peritoneal trauma, disease, or irritation.

– Other cancers such as primary peritoneal cancer, lung cancer, and pancreatic cancer.

– Endometriosis.

– Pelvic inflammatory disease.

– Ovarian cyst torsion, rupture, or haemorrhage.

– Pregnancy.

– Heart failure.

• Ovarian Cancer Differential Diagnosis:

• http://cks.nice.org.uk/ovarian-cancer#!diagnosissub:1

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https://pathways.nice.org.uk/

pathways/ovarian-cancer

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-cancer

What is a Significant Family History?

• 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)

http://www.patient.co.uk/doctor/familial-breast-cancer

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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-cancer

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

Identifying and Referring Patients with Suspected Cancer CLINICAL RECORD REVIEW

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Tony Frazer 36, National Account Manager (Sales)

• July 2015

• Dr A on-call

• Telephone triage encounter:

• Haematemesis fresh and dried (coffee bean) blood

• Abnormal weight loss, 3 stone in 7/12

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 14)

• 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

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.

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

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

7 February 2016

• Diagnosis of CFS confirmed by specialist

• 16 September 2016 – making progress with CFS therapy and a return to work is possible in early 2017

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15 September 2017

• Came for review 1 year later

• Went back in to work for but had to leave on Day 2 due to tiredness and inability to cope

• Weight static, Hopes to try work again soon

• Still being paid by employer and admits this is unusually generous

Principles of CFS management • Chronic fatigue syndrome (CFS) causes persistent

fatigue (exhaustion) that affects everyday life and does not go away with sleep or rest

• Affects 250,000 people in the UK

• Usually develops in early 20s to mid-40s. Children can also be affected, usually between the ages of 13 and 15.

• Mild, Moderate or Severe

http://www.nhs.uk/Conditions/Chronic-fatigue-

syndrome/Pages/Introduction.aspx

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Postulated Causes of CFS

• Viral or bacterial infection

• An immune system dysfunction

• Endocrine dysfunction

• Psychiatric – stress/emotional trauma

• Genes – more common in families

http://www.nhs.uk/Conditions/Chronic-fatigue-syndrome/Pages/Causes.aspx

Treatment of CFS • Cognitive Behavioural Therapy

• Graded Exercise Therapy

• Activity Management –setting individual goals and gradually increasing activity

• Medications – nil specific. Symptom relief eg. Analgesia for pain, antidepressants (amitriptyline)

• Pacing – balancing activity with rest

• Relaxing, avoiding stress, avoid excessive sleep, relapse management

• With treatment many people do improve with time

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Summary

• Melanoma, Cutaneous Horn + other lesions

• Bone Tumour

• Dysphagia/Oesophageal Cancer

• Rectal Bleeding

• Neck Lump in a Child

• Ovarian Cancer and CA125

• Breast Cancer FH

• Abnormal Weight Loss – Case Review

DISCUSSION

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FOR (outcome of previous group’s work)

• Less DNAs, inappropriate/trivial appts

• Encourage use of other resources

• More time to consult and make decisions

• Saves money

• More appts for those who need them

• Less strain on A&E

• Happier Drs and staff – less stressed/busy

AGAINST (outcome of previous group’s work)

• Against principle of NHS and Drs

• Deterrent to consulting appropriately

• Poorer health – late presentations and poorer follow up

• Higher expectations, harder to address ICE

• Shifts burden to A&E and will end up shifting cost

• Damages Dr-patient relationship

• More consulting with multiple problems to get ‘value for money’

• Impact on working population

• Incentive for quantity over quality - unethical

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DVD Consultation Analysis

‘A Tingling Arm’

Upcoming Sessions • 17th October 2017: Mental Health (NP)

• 25th October : AKT Exam Sitting

• 31st October: Women’s Health (Dr Helen Wall)

• 14th November : Diabetes (Dr Becky Lund)