Identifying%20and%20Referring%20Patients%20with%20Suspected%20Cancer

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

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 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?

6
A B C D E Rule

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

7

8
Behind the Headlines

• 19 October 2015
• More than 11 moles on your right arm? You may
  have skin cancer!

9
The Study

• British Journal of Dermatology
• Simon Ribero - Kings College London
• Studied 3000 female twins for 8 years
• Data collection about skin type and moles
• Repeated study on 400 melanoma patients
• More than 11 moles on right arm were more likely
  to have over 100 on whole body.
• Because melanoma develops from a mole
• Increased number of moles increased risk

10
Explanation from one of the researchers

• http//www.bbc.co.uk/news/health-34569961

11
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

12
(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

14
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

15
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

16
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

17
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

18
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

19
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)

20
OSTEOSARCOMA (MALIGNANT BONE TUMOUR)
21
Osgood-Schlatter Disease
22
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

23
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)

24
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

25
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.

26
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?

27
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!

28
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

29
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?

30
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.

31
Mr Schonberg, 66

32
A Cutaneous Horn 25 will have SCC at the base

33
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

34
Examination

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

35
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 .

36
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

37
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

38
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

39
(No Transcript)
40
Causes of Neck Swelling in Children

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

BMJ 2012344e3171
41
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
42
Lymphadenitis (inflamed lymph nodes) or abscess

• Bacterial lymphadenitis
• Mycobacterial lymphadenitis
• Abscess

BMJ 2012344e3171
43
Non-lymphadenomatous neck swellings

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

BMJ 2012344e3171
44
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)
45
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

46
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

47
IN MY RIGHT EAR
48

IN FRONT
49

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
50
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)

51
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

52
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! 

53

• OVARIAN CANCER
• VERSUS
• IRRITABLE BOWEL SYNDROME

54
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
55
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
56
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 

57
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
58
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
59
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

60

PANCOAST TUMOUR AT RIGHT APEX
61
Summary of Part 1

• 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)

62
Identifying and Referring Patients with Suspected
CancerCLINICAL RECORD REVIEW

63
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

64
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.

65
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

66
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

67
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.

68
Weight Chart

69
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

70
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

71
Weight Chart

72
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

73
15 September 2015

• 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

74
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-syndr
ome/Pages/Introduction.aspx
75
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-syndr
  ome/Pages/Causes.aspx

76
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

77
Case study 2 Lynn Buchanan, 71

• 6 March 2015
• Abdominal pain right-sided upper abdo and RLQ.
  Tender generally. No masses. Uses paracetamol for
  pain. PMH TAH, BSO, endometrial cancer, breast
  cancer. Bloods in Jan. Plan US scan and review.
  Declined stronger analgesia

78
US REPORT

• ABDOMINAL ULTRASOUND
• MILD FATTY LIVER, NO FOCAL LIVER LESION, NORMAL
  PANCREAS, SPLEEN AND KIDNEYS, NO FREE FLUID, NO
  ABNORMALITY SEEN.
• CONCLUSION NORMAL

79
2nd Consultation

• 17 April (5w)
• Abdominal pain now generalised. US was normal.
  Abdo generally swollen and tender.
• Explained that we need to look further to find
  the cause of the pain. Urgent MRI arranged.
  Struggles with oral painkillers. Try pain patch.
  Explained what it is and side-effects, may cause
  drowsiness. If has side-effects and cannot
  tolerate then take of the patch and seek medical
  advice. Weight 80 kg (-3kg in 1y)

80
MRI bounced back

• Message from Radiology
• This may need to be done with contrast and as a
  GP you cannot request this investigation directly
• Please refer to Gastroenterology
• 17 April Gastroenterology referral (same day)

81
Letter from Gastroenterology

• 29 April Thank you for your referral we will
  arrange a CT abdomen, follow her up and let you
  know the outcome
• 18 May
• Cancer care review
• Has sadly been diagnosed with a cancer in the
  peritoneum and has been referred to the Christie.
  Would like to know exact nature and prognosis. No
  letter yet. Will chase.

82
Letter received

• Exact nature of lesion uncertain - to have
  biopsy. Started on oral morphine
• 1 June consultation had biopsy last week may
  get result today. has started vomiting and having
  opiate related side-effects. Now on longtec and
  shortec tabs. Start oral cyclizine.
• 3 June Home visit disappointed I had not
  received the biopsy result that showed pancreatic
  cancer. Going to Christie next week. Macmillan
  referral done.

83
Following the diagnosis

• Admitted to Christie from clinic for ascitic tap
• Chemotherapy planned
• Started with haematuria
• Continued opiate side-effects
• Levomepromazine syringe driver
• Reaccumulation of ascites
• Further vomiting, cyclizine in syringe driver
• Anticipatory medicines written up
• Developed diabetes, insulin started

84
Following the diagnosis

• Started on methylnaltrexone injections for
  opiate-induced constipation
• Worsening of pain
• Ascitic drain planned at Christie
• Admitted to Bolton for ascitic drain
• Drain became infected and was taken out
• Discharged home with care package
• Family unable to cope
• Now on fentanyl patch for pain

85
Following the diagnosis

• Hospice contacted for possible admission
• Hospice bed arranged but not immediate
• Reaccumulation of ascites painful and limiting
  breathing
• Readmission to hospital for drain with a view to
  discharge to hospice
• Admitted to hospice
• Became gradually weaker
• Died about a week later on 21 August

86
Upcoming Sessions

• 3rd November 2015 Physical Activity in Clinical
  Practice (Public Health England)
• 17th November 2015 COPD (Michaela Bowden)
• 1st December 2015 MPS Consent and Chaperone
  Training (Jasmit Harrar)

87
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.