1. NICE guideline on Suspected cancer: recognition and referral (2015) Education package for GPs and Nurse Practitioners Quiz

2. How to use the quiz  The quiz can be used in a training session with the whole group or in smaller groups, or used by individual learners.  The questions are grouped by 12 cancer sites.  The questions are either true/ false, multiple choice or open-ended.  The answers are provided on the next slide.  There are also discussion points for each cancer site to stimulate thought and dialogue.

3. Lung cancer - Questions 1. All patients suspected of having lung cancer should be referred directly for a chest X-ray, before considering a 2 week wait referral. Is this true or false? 2. Which of the following blood abnormalities should prompt you to consider an urgent chest X-ray? a. anaemia b. thrombocytosis c. hypokalaemia d. elevated liver biochemistry 3. What other symptoms would prompt you to offer an urgent chest X-ray? 

4. Lung cancer - Answers 1. This statement is false – The NICE guideline recommends referring people directly for a 2 week wait appointment if they are aged 40 and over with unexplained haemoptysis. 2. The correct answer is b – thrombocytosis should prompt you to consider an urgent chest X-ray. 3. For people aged 40 and over offer an urgent chest X-ray if they have 2 or more of the following unexplained symptoms, or if they have ever smoked and have 1 or more of the following unexplained symptoms: cough, fatigue, shortness of breath, chest pain, weight loss, appetite loss.

5. Lung cancer – Discussion points  Some radiology departments will automatically arrange a CT scan for a patient with an abnormal chest X-ray. What are your local arrangements?  A chest X-ray is not completely reliable for detecting lung cancer, so you can still refer for a 2 week wait appointment following a normal chest X-ray if you are still concerned.

6. Upper GI cancer - Questions 1. Patients with suspected oesophageal cancer should be referred for a 2 week wait appointment. Is this true or false? 2. If a patient presents with weight loss and any of the following: upper abdominal pain, reflux or dyspepsia, at what age does NICE recommend referral for an urgent direct access upper GI endoscopy for suspected oesophageal cancer? a. 50 and over b. 55 and over c. 60 and over d. 65 and over 3. Which symptom of possible oesophageal cancer should you act on urgently for patients at any age?

7. Upper GI cancer - Answers 1. This statement is false – The NICE guideline recommends that patients with suspected oesophageal cancer should be referred for a direct access upper GI endoscopy. 2. The correct answer is b – Patients aged 55 and over that present with weight loss and any of the following: upper abdominal pain, reflux or dyspepsia, should be referred for an urgent direct access upper GI endoscopy for suspected oesophageal cancer. 3. You should act on dysphagia urgently as a symptom of possible oesophageal cancer for patients at any age.

8. Upper GI cancer – Discussion points  When a GP organises an upper GI endoscopy they are responsible for acting on the result. Do you have systems in place in your practice to make sure this happens?  In some geographical areas there are separate pathways for jaundice and iron deficiency anaemia. What are the arrangements in your local area?

9. Lower GI cancer - Questions 1. There are several age ranges related to the different symptoms that should prompt referral for suspected colorectal cancer. Is this true or false? 2. Which of the following is NOT listed in the NICE guideline as a test to diagnose colorectal cancer? a. full blood count b. serum iron c. faecal occult blood d. CEA 3. What symptoms or signs could lead you to suspect colorectal cancer?

10. Lower GI cancer - Answers 1. This statement is true - The NICE guideline contains recommendations for suspected colorectal cancer for patients under 50, under 60, over 40, over 50 and over 60. 2. The correct answer is d - CEA is a tumour marker but it is not recommended by NICE as a test to help diagnose colorectal cancer. 3. The symptoms or signs that could lead you to suspect colorectal cancer are unexplained weight loss, abdominal pain, rectal bleeding, anaemia, iron deficiency anaemia, changes in bowel habit, occult blood in faeces, a rectal mass or an abdominal mass.

11. Lower GI cancer – Discussion points  It is advised that you refer to these age ranges when you are considering how to manage suspected colorectal cancer for each patient.  Do you have access to testing for occult blood in faeces for suspected colorectal cancer in your locality, as many GPs do not?

12. Breast cancer - Questions 1. All patients aged 30 and over with an unexplained breast lump should be referred for a 2 week wait appointment. Is this true or false? 2. Which breast symptom should NOT prompt a referral for a 2 week wait appointment? a. breast pain b. skin changes c. axillary lump d. nipple changes 3. Which nipple changes should prompt a referral for a 2 week wait appointment?

13. Breast cancer - Answers 1. This statement is true – The NICE guideline recommends that all patients aged 30 and over with an unexplained breast lump should be referred for a 2 week wait appointment. 2. The correct answer is a - breast pain should not prompt a referral for a 2 week wait appointment. 3. People aged 50 and over with any of the following symptoms in one nipple only: discharge; retraction; other changes of concern, should be referred for a 2 week wait appointment.

14. Breast cancer – Discussion points  Could the ‘one stop shop’ system that many breast clinics offer (where there is history, examination and investigation offered in one place and time) apply to any other cancer pathways?  GPs can also access ‘breast symptomatic’ clinics. Although these are not fast track referrals for suspected cancer, most patients are still seen within 2 weeks.

15. Gynaecological cancers - Questions 1. Serum CA125 testing can be used to aid diagnosis of ovarian cancer? Is this true or false? 2. Which two of the following are early symptoms of ovarian cancer? a. vomiting b. haematuria c. bloating d. feeling full 3. How is post ‑ menopausal bleeding defined in the NICE guideline?

16. Gynaecological cancers - Answers 1. This statement is true – Serum CA125 testing can be used to aid diagnosis of ovarian cancer. Ultrasound of the abdomen and pelvis should only be carried out when serum CA125 is 35 IU/ml or greater. 2. The correct answers are c and d - bloating and feeling full are early symptoms of possible ovarian cancer. 3. Post ‑ menopausal bleeding is defined in the NICE guideline as ‘Unexplained vaginal bleeding more than 12 months after menstruation has stopped because of the menopause’.

17. Gynaecological cancers – Discussion points  Some GPs are arranging urgent ultrasound of the abdomen and pelvis and referring for a 2 week wait appointment for suspected ovarian cancer at the same time to speed up the assessment process. Do you do this?  Significant event analyses of ovarian cancer cases has shown that GPs often attribute early symptoms to irritable bowel syndrome.

18. Urology cancers - Questions 1. A prostate ‑ specific antigen (PSA) test is recommended as a screening test for all men over 60. Is this true or false? 2. The age for referral for a 2 week wait appointment for unexplained visible haematuria without urinary tract infection for possible bladder or renal cancer is over: a. 45 b. 50 c. 55 d. 60 3. Which physical examination does NICE recommend to detect possible prostate cancer?

19. Urology cancers - Answers 1. This statement is false – The NICE guideline recommends a prostate ‑ specific antigen (PSA) test to assess for possible prostate cancer for men of all ages with any lower urinary tract symptoms or erectile dysfunction or visible haematuria. 2. The correct answer is a - the age for referral for a 2 week wait appointment for unexplained visible haematuria without urinary tract infection for possible bladder or renal cancer is over 45. 3. Digital rectal examination is recommended to detect possible prostate cancer for men with any lower urinary tract symptoms or erectile dysfunction or visible haematuria.

20. Urology cancers – Discussion points  What could be the negative consequences of performing a PSA test on all men?  Do you know the age-specific reference ranges for PSA testing in your laboratory and is there any local advice on repeating this test?

21. Skin cancers - Questions 1. Patients with a skin lesion that raises the suspicion of squamous cell carcinoma should be considered for referral for a 2 week wait appointment. Is this true or false? 2. Which 2 statements are correct about patients with suspected basal cell carcinoma. They should: a. be referred for a 2 week wait appointment b. be referred for a routine appointment c. not be referred at all d. only be referred for a 2 week wait appointment in particular circumstances. 3. List the weighted 7 point check list for malignant melanoma.

22. Skin cancers - Answers 1. This statement is true - Patients with a skin lesion that raises the suspicion of squamous cell carcinoma should be considered for referral for a 2 week wait appointment. 2. The correct answers are b and d. Patients with suspected basal cell carcinoma should be considered for a routine referral. Only consider referral for a 2 week wait appointment if there is particular concern that a delay may have a significant impact, because of factors such as lesion site or size. 3. Weighted 7 ‑ point checklist for malignant melanoma (refer people for a 2 week wait appointment if they have a score of 3 or more) Major features of the lesions (scoring 2 points each): change in size irregular shape irregular colour. Minor features of the lesions (scoring 1 point each): largest diameter 7 mm or more inflammation oozing change in sensation.

23. Skin cancers – Discussion points  Some GPs have developed skills in using dermoscopy to help identify a malignant melanoma. Does anyone in your practice have these skills?  Dermatologists have expressed concern about the potential increase in the number of referrals for suspected basal cell carcinoma. How is this organised in your local area?

24. Head and neck cancers - Questions 1. A dentist cannot directly refer a patient with suspected oral cancer to hospital. Is this true or false? 2. With regard to the length of time patients have had symptoms of possible head and neck cancers before they should be referred for a 2 week wait appointment, which of the following statements is true: a. there are no timeframes for any symptoms b. timeframes are defined for all symptoms c. the only defined timeframe is for hoarseness which has to have lasted for more than 3 weeks d. the only defined timeframe is for unexplained ulceration in the oral cavity which has to have lasted for more than 3 weeks 3. What are the symptoms of possible oral cancer?

25. Head and neck cancers - Answers 1. This statement is false - A dentist can directly refer a patient with suspected oral cancer to hospital. 2. The correct answer is d. The only defined timeframe for possible head and neck cancers is for unexplained ulceration in the oral cavity which has to have lasted for more than 3 weeks. This is a symptom of possible oral cancer. 3. The other symptoms of possible oral cancer are: a red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia a persistent and unexplained lump in the neck a lump on the lip or in the oral cavity.

26. Head and neck cancers – Discussion points  How quickly does your local hospital turn around biopsies for patients with possible head and neck cancers?  The NICE guideline uses the terms ‘persistent’ and ‘unexplained’. How would you define these terms in reference to a neck lump?

27. Brain and CNS cancers - Questions 1. The NICE guideline recommends referral for a 2 week wait appointment for adults with progressive, sub ‑ acute loss of central neurological function. Is this true or false? 2. The NICE guideline defines the symptoms of progressive, sub ‑ acute loss of central neurological function as: a. headaches b. sensory loss c. weakness d. none of the above 3. How are the symptoms of possible brain and CNS cancers in children and young people defined in the NICE guideline, and what action should be taken when a child or young person presents with these symptoms?

28. Brain and CNS cancers - Answers 1. This statement is false – The NICE guideline recommends that an urgent direct access MRI scan of the brain (or CT scan if MRI is contraindicated) is considered for adults with progressive, sub ‑ acute loss of central neurological function. 2. The correct answer is d - the NICE guideline does not describe the symptoms of progressive, sub ‑ acute loss of central neurological function. 3. The symptoms of possible brain and CNS cancers in children and young people are defined in the NICE guideline as ‘newly abnormal cerebellar or other central neurological function’. You should consider a very urgent referral for an appointment within 48 hours for children and young people that present with these symptoms.

29. Brain and CNS cancers – Discussion points  How do you access urgent direct access MRI scan or CT scan of the brain?  In reality what would you do if you were seeing a patient with ‘progressive, sub ‑ acute loss of central neurological function’?

30. Haematology cancers - Questions 1. A blood test should be arranged within 2 weeks for adults that present with symptoms of possible leukaemia. Is this true or false? 2. Which tests can help detect multiple myeloma? a. erythrocyte sedimentation rate and plasma viscosity b. protein electrophoresis c. full blood count and calcium d. all of the above 3. Describe the symptoms of a possible lymphoma?

31. Haematology cancers - Answers 1. This statement is false – A very urgent full blood count within 48 hours should be considered for adults that present with symptoms of possible leukaemia. 2. The correct answer is d - all of the tests listed can help detect multiple myeloma. 3. The symptoms of a possible Non ‑ Hodgkin's lymphoma are unexplained lymphadenopathy or splenomegaly. The symptoms of a possible Hodgkin's lymphoma are unexplained lymphadenopathy. When considering referral, take into account any associated symptoms, particularly fever, night sweats, shortness of breath, pruritus, weight loss or alcohol ‑ induced lymph node pain.

32. Haematology cancers - Discussion points  If you arranged a full blood count for a patient, and it was reported back as suspected leukaemia, what systems are in place in your practice to ensure it is acted on? How quickly would it be acted on?

33. Sarcoma - Questions 1. There are different recommendations for bone and soft tissue sarcoma. Is this true or false? 2. Which of the following statements is false? a. an X-ray can help to diagnose bone sarcoma b. an ultrasound scan can help diagnose soft tissue sarcoma c. children should be referred for an appointment within 2 weeks for suspected sarcoma d. GPs have a responsibility to act on the tests they organise 3. How does NICE define a possible soft tissue sarcom a?

34. Sarcoma - Answers 1. This statement is true - There are different recommendations for bone and soft tissue sarcoma. 2. The correct answer is c – for children with suspected sarcoma the appointment or appropriate investigation should take place within 48 hours. 3. NICE defines a possible soft tissue sarcoma as ‘an unexplained lump that is increasing in size’.

35. Sarcoma - Discussion points  Have you ever seen a patient with a sarcoma? How was the original diagnosis made?

36. Childhood cancers - Questions 1. A referral should be considered for a child if their parent or carer has persistent concern or anxiety about the child's symptoms, even if the symptoms are most likely to have a benign cause. Is this true or false? 2. Which of the following has specific recommendations for children? a. breast b. lymphoma c. skin d. urology 3. Which childhood cancers should prompt a very urgent referral for an appointment or investigation within 48 hours when they are suspected?

37. Childhood cancers - Answers 1. This statement is true - A referral should be considered for a child if their parent or carer has persistent concern about the child's symptoms, even if the symptoms are most likely to have a benign cause. 2. The correct answer is b - lymphoma has specific recommendations for children. 3. The following childhood cancers should prompt a very urgent referral for an appointment or investigation within 48 hours when they are suspected: brain and central nervous system, leukaemia, lymphoma, bone sarcoma, soft tissue sarcoma, neuroblastoma and Wilms' tumour.

38. Childhood cancers - Discussion points  If you saw a child and suspected one of the cancers listed on the previous slide, how could you ensure they were seen by a paediatric specialist within 48 hours?

39. We hope you found this resource useful The SCN education package for GPs and Nurse Practitioners also includes:  A video of the SCN GP lead talking about the impact that the changes in the guideline will have;  A video of the SCN GP lead talking about an implementation model developed in the East Lancashire area;  Power point slides of the NICE recommendations;  Power point slides containing case scenarios.