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 I’m here can you check this mole on my arm?

6. A B C D E Rule A SYMMETRY IRREGULAR B ORDER C OLOUR – gaining, losing (?), multiple colours D iameter greater than 6mm (1/4 inch) E volving

8. 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 »

10. 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 »

11. 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

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. What is the Differential Diagnosis? 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. 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)

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. Review appointment 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. 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

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. 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 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. 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.

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 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

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 (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

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

39. Non-lymphadenomatous neck 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 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

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. Weber without lateralization Weber lateralizes left Weber lateralizes right Rinne both ears AC>BC Normal/bilateral sensorineural loss Sensorineural loss in right Sensorineural loss in left Rinne left BC>AC Conductive loss in left Combined loss : conductive and sensorineural loss in left Rinne right BC>AC Combined loss : conductive and sensorineural loss in right Conductive loss in right Rinne both ears BC>AC 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

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 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

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. OVARIAN CANCER Bloating Abdominal PainPelvic or Abdominal Pain Nausea/ Poor Appetite/Feeling Full/ Flatus/Belching Trouble Eating or Feeling Too Full Quickly Constipation and/or DiarrhoeaConstipation Urinary Symptoms eg. frequency Fatigue Upset Stomach/HeartburnUpset Stomach Back Pain Abdominal Swelling (with Weight Loss?)Abdominal Swelling with Weight Loss Muscle painsPain During Sex Menstrual Changes It is uncommon for IBS to first develop in women over the age of 50

51. 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

52. 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 »

53. 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

54. 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

55. 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

56. PANCOAST TUMOUR AT RIGHT APEX

57. Summary of the Session A Mole – Possible Malignant Melanoma Lump on the Leg – Possible Sarcoma Leg Pain – Osteosarcoma or Osgood-Schlatter’s 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)

58. Identifying and Referring Patients with Suspected Cancer CLINICAL RECORD REVIEW

59. 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

60. 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.

61. 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

62. 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

63. 2 nd 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.

64. Weight Chart

65. 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

66. 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

67. Weight Chart

68. 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

69. 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.