Assessment of Suspected Cancer

Abstract

Early detection of cancer is crucial to improve patients' chances of survival. Unfortunately, early signs of cancer are often easier to see with the benefit of hindsight than they are at the time of presentation. Although cancer is common, cancer diagnosis is a relatively rare occurrence for an individual GP and referral from primary to secondary care is often triggered by a GP's awareness of ‘alarm symptoms’ or ‘red flags’ that are considered to predict malignant disease. It is important to have a lower threshold for investigating cancer in people with recognized risk factors for the disease, such as smoking. Failure to respond to treatment as expected (for example, a chest infection that does not settle with antibiotics), or symptoms that are getting progressively worse should raise suspicion of a possible diagnosis of cancer in any patient.

What does the GP curriculum say about the assessment of suspected cancer?

One of the great skills of a general practitioner is to recognize cancer illness in its early stages. Cancer is a clear concern for many patients who consult their doctor and it is a concern driven by common life experience.

In particular, a GP should be able to demonstrate the following:

Understanding of the current population trends in the prevalence of risk factors and cancer in the community

Knowledge of cancer referral guidelines and protocols, both local and national

Knowledge of the signs and symptoms of the early presentation of cancer

The ability to suspect a cancer diagnosis early in the disease process

Knowledge of the appropriate investigations of patients with cancer and of how they fit in with national guidelines

Understanding the processes of referral into secondary care and other care pathways

Knowledge of the ethical dimensions of treatment and investigation choices, including advanced directives (which may influence investigation choices in some patients)

The ability to learn from the clinical experience

Statement 12: ‘Cancer and Palliative Care’ contains outcomes relevant to the assessment of suspected cancer in general terms. Individual cancers are considered in their relevant topic statement (for example bowel cancer is covered in Statement 15.2: ‘Digestive problems’).

General rules of assessment

When assessing any patient with suspected cancer, your objectives are to:

Establish a constructive relationship with the patient to enable patient and doctor to communicate effectively and serve as the basis for any subsequent therapeutic relationship

Find out whether the patient has any predisposing factors to a diagnosis of cancer

Determine whether the patient has alarm symptoms that might suggest a diagnosis of cancer and, if so, what they are

Assess the patient's emotions and attitudes towards the problem and

Establish the best course of action

Use open questions at the start becoming directive when necessary—clarify, reflect, facilitate and listen. Ask about the presenting complaint. Take a chronological account noting specific symptoms and any history of similar symptoms. Be alert to a possible diagnosis of cancer when a patient presents with non-specific symptoms or signs such as:

Anorexia and/or weight loss for no apparent reason

Malaise or lethargy with no apparent cause

Fever or sweats

Generalized itching

Breathlessness

Bone pain

Lymphadenopathy

Recurrent infections or failure to recover from infections as expected

Specific alarm symptoms (‘red flags’) and signs are listed in Table 1 (Jones et al., 2007).

Table 1.

Red flag symptoms for cancer

Red flag symptom	Condition	Action
New, unexplained headache	Brain tumour	Neurological examination including examination for papilloedema Refer urgently to neurology, neurosurgery or brain imaging if headache is: • Accompanied by features suggestive of raised intracranial pressure, for example vomiting, drowsiness, posture-related headache or pulse-synchronous tinnitus • Accompanied by other focal or non-focal neurological symptoms (for example black out or change in personality or memory) • Progressively severe headache • Persistent cancer and history of any cancer Consider non-urgent referral or discussion with a specialist if: A patient has unexplained headaches of recent onset: • Present for at least a month, and • Not accompanied by features suggestive of raised intracranial pressure.
Neurological symptoms	Central nervous system cancer	Undertake a neurological examination guided by the symptoms, but including examination for papilloedema Refer urgently to neurology if symptoms relate to the central nervous system, including: • Progressive neurological deficit • New-onset seizures • Mental changes • Cranial nerve palsy • Unilateral sensorineural deafness Refer urgently to an appropriate specialist: any patient previously diagnosed with any cancer who develops any of the following symptoms: • Recent-onset seizure • Progressive neurological deficit • New mental or cognitive changes • New neurological signs Consider urgent referral: for any patient with rapid progression of: • Subacute focal neurological deficit • Unexplained cognitive impairment, behavioural disturbance or slowness, or a combination of these • Personality changes confirmed by a witness and for which there is no reasonable explanation even in the absence of the other symptoms and signs of a brain tumour
Hoarseness	Lung or laryngeal cancer	Refer any patient with hoarseness persisting for with more than 3 weeks for an urgent chest X-ray. This is particularly important if the patient is a smoker, aged more than 50 years or is a heavy drinker. If there is a POSITIVE finding on chest X-ray: refer urgently to a team specializing in the management of lung cancer. If there is a NEGATIVE finding on chest X-ray: refer urgently to a team specializing in the management of head and neck cancer.
Thyroid swellings	Thyroid cancer	Refer immediately to a thyroid surgeon: patients with symptoms of tracheal compression including stridor due to thyroid swelling. Refer urgently to a thyroid surgeon: patients with a thyroid swelling associated with any of the following: • Solitary nodule increasing in size • History of neck irradiation • Family history of an endocrine tumour • Unexplained hoarseness or voice changes • Cervical lymphadenopathy • Very young (pre-pubertal) patient • Patient aged 65 years or more Investigation and referral of patients who do not require urgent referral: request thyroid function tests in patients with a thyroid swelling without stridor or any of the features listed above. Primary care initiation of investigations such as ultrasonography or isotope scanning is not recommended. Refer non-urgently to endocrinology: patients with hyper- or hypothyroidism and an associated goitre. Refer non-urgently to a thyroid surgeon: patients with goitre and normal thyroid function tests without any of the features listed above.
Head and neck symptoms and signs	Lymphoma, head and neck or stomach cancer	Refer urgently to suitable specialist: if a patient has: • An unexplained lump in the neck, of recent onset • A previously undiagnosed lump that has changed over a period of 3–6 weeks • Unexplained persistent swelling in the parotid or submandibular gland • Unexplained persistent sore or painful throat • Unilateral unexplained pain in the head and neck area for more than 4 weeks associated with otalgia (ear ache) but a normal otoscopy
Mouth symptoms	Oral cancer	Refer urgently to oral surgery: if a patient has • Mouth ulcers persisting for more than 3 weeks • Lumps in the mouth persisting more than 3 weeks • Red or white patches in the mouth—including suspected lichen planus—that are painful, swollen or bleeding. For patients with persistent symptoms or signs related to the oral cavity in whom a definitive diagnosis of a benign lesion cannot be made, refer or follow-up until the symptoms and signs disappear. If the symptoms or signs have not disappeared within 6 weeks, make an urgent referral. Refer urgently to a dentist: if any patient has unexplained tooth mobility lasting for more than 3 weeks. Refer non-urgently to oral surgery: if a patient has unexplained red and/or white patches of the oral mucosa that are not painful, swollen or bleeding—including suspected lichen planus. Refer to a dentist for routine monitoring: all patients with confirmed oral lichen planus (Fig. 1)
Upper gastrointestinal symptoms	Stomach, liver or pancreatic cancer	Helicobacter pylori status should not affect the decision to refer for suspected cancer. Consider checking a full blood count when referring, depending on local protocols, and to exclude iron deficiency anaemia in all patients presenting with new-onset dyspepsia. Urgent referral to a team specializing in upper gastro-intestinal malignancy: patients presenting with: • Dysphagia • Unexplained upper abdominal pain and weight loss, particularly if accompanied by back pain • Upper abdominal mass without dyspepsia • Obstructive jaundice (depending on clinical state)—consider urgent ultrasound scan as an alternative, if available. Consider urgent referral to a specialist in upper gastro-intestinal malignancy: patients presenting with: • Persistent vomiting and weight loss in the absence of dyspepsia • Unexplained weight loss or iron deficiency in the absence of dyspepsia • Unexplained worsening of dyspepsia and • Barrett's oesophagus • Known dysplasia, atrophic gastritis or intestinal metaplasia • Peptic ulcer surgery over 20 years previously Consider urgent specialist referral or referral for urgent endoscopy: patients of any age with dyspepsia and: • Chronic gastro-intestinal bleeding • Dysphagia • Progressive unintentional weight loss • Persistent vomiting • Iron deficiency anaemia • Epigastric mass • Suspicious barium meal result Urgent referral for endoscopy: any patient 55 years or more with persistent, recent-onset dyspepsia alone that cannot be explained, for example by non-steroidal anti-inflammatory use. GPs should not allow symptoms to persist for more than 4–6 weeks before referral.
Lower gastrointestinal symptoms	Colorectal cancer	In a patient with equivocal symptoms who is not unduly anxious, it is reasonable to treat, watch and wait. Otherwise, referral depends on symptoms and age. Patients of any age: refer urgently to a team specializing in lower gastro-intestinal malignancy if the patient has: • Right lower abdominal mass consistent with involvement of large bowel • A palpable rectal mass (intraluminal, not pelvic; a pelvic mass outside the bowel warrants an urgent referral to a urologist or gynaecologist) • Unexplained iron deficiency anaemia (haemoglobin of 11 g/dl or less in a man or 10 g/dl or less in a non-menstruating woman) Patients 40 years or more: refer urgently to a team specializing in lower gastrointestinal malignancy if the patient reports rectal bleeding with a change of bowel habit towards looser stools and/or increased stool frequency persisting for more than 6 weeks. Patients 60 years or more refer urgently to a team specializing in lower gastrointestinal malignancy if the patient presents with: • Rectal bleeding persisting for 6 weeks or more without a change in bowel habit and without anal symptoms • Change in bowel habit to looser stools and/or more frequent stools persisting for 6 weeks or more without rectal bleeding
Breast lump	Breast cancer	Encourage all female patients to be breast aware (Box 1). Refer any patient who presents with symptoms suggestive of breast cancer urgently (to be seen within 2 weeks) to a team specializing in the management of breast cancer. In patients presenting with symptoms or signs suggestive of breast cancer, investigation prior to referral is not recommended. Suspicious symptoms are as follows: Refer urgently if the patient is: • Any age with a discrete, hard lump with fixation with or without skin tethering • Any age with a history of breast cancer presenting with a further lump or other suspicious symptoms • Aged 30 years or over with a discrete lump that persists after the next period, or presents after the menopause • Aged under 30 years with a lump that enlarges and is fixed and hard or in whom there are other reasons for concern such as family history Consider a non-urgent referral if: • A woman is aged under 30 years and has a lump which has no suspicious features and is not enlarging • A woman has breast pain and no palpable abnormality, when initial treatment fails and/or symptoms persist (use of mammography is not recommended)
Nipple changes	Breast cancer	Refer urgently if the patient has: • Unilateral eczematous skin or nipple change that does not respond to topical treatment • Nipple distortion of recent onset • Spontaneous unilateral bloody nipple discharge
Abnormal vaginal bleeding	Cervical or endometrial cancer	Perform a full pelvic examination, including speculum examination of the cervix, for patients with: • Alterations in the menstrual cycle • Intermenstrual bleeding • Post-coital bleeding • Post-menopausal bleeding • Vaginal discharge Refer urgently to a team specializing in gynaecological cancer: • Any patient with clinical features of cervical cancer on examination. A smear test is not required before referral and a previous negative result should not delay referral. • All patients with post-menopausal bleeding who are not taking hormone replacement therapy • Patients on hormone replacement therapy with persistent or unexplained postmenopausal bleeding after stopping hormone replacement therapy for 6 weeks • All patients taking tamoxifen with post-menopausal bleeding Endometrial thickness of over 4 mm on ultrasound scan needs further investigation. Consider urgent referral: if a patient has persistent intermenstrual bleeding and negative pelvic examination.
Vulval symptoms	Vulval cancer	Refer urgently to a team specializing in gynaecological cancer: • All patients with an unexplained vulval lump • All patients with vulval bleeding due to ulceration For patients with vulval pruritus or pain: A period of treat, watch and wait is reasonable. Active follow-up is recommended until symptoms resolve or a diagnosis is confirmed. If symptoms persist, refer to gynaecology. The referral may be urgent or non-urgent, depending on the symptoms and the degree of concern about cancer.
Abdominal or pelvic mass	Bowel, bladder, or gynaecological cancer	Refer for urgent ultrasound scan. If urgent ultrasound scan is not available, or the patient is unwell, refer for urgent consultant opinion
Haematuria	Urological cancer	Urgent referral to a team specializing in urological cancer. Refer patients: • Of any age with painless macroscopic haematuria • Aged 40 years or more with recurrent or persistent urinary tract infection associated with haematuria • Aged 50 years or more with unexplained microscopic haematuria For patients with symptoms suggestive of urinary tract infection and macroscopic haematuria, diagnose and treat the infection before considering referral. If infection is not confirmed, refer urgently. Non-urgent referral: Refer patients under 50 years of age with microscopic haematuria. If the patient has proteinuria, raised serum creatinine or reduced estimated glomerular filtration rate, refer to a renal physician. Otherwise, refer to urology.
Prostatic symptoms or abnormal PSA	Prostate cancer	A digital rectal examination and a PSA test are recommended for patients with any of the following unexplained symptoms: • Inflammatory or obstructive lower urinary tract symptoms • Erectile dysfunction • Haematuria • Lower back pain • Bone pain • Weight loss, especially in the elderly Urgent referral to a team specializing in urological cancer: Consider discussion with a specialist and the patient (and/or carer) before referral for very elderly patients or those compromised by other co-morbidities. In all other cases, refer patients: • In whom a rectal examination reveals a hard, irregular prostate typical of prostate cancer. PSA result should accompany the referral. • In whom a rectal examination reveals a normal prostate, but there is a rising or raised age-specific PSA with or without other lower urinary tract symptoms. • With symptoms and high PSA levels. • For asymptomatic men with borderline, age-specific PSA results, repeat the PSA test after 1–3 months. If the PSA level is rising, refer the patient urgently.
Testicular or scrotal mass	Testicular cancer	Refer urgently to a team specializing in urological cancer, any patient with a swelling or mass in the body of the testis. Consider an urgent ultrasound in men with a scrotal mass that does not transilluminate and/or when the body of the testis cannot be distinguished.
Penile ulceration or masses	Penile cancer	Refer urgently to a team specializing in management of urological cancer, all patients with symptoms or signs of penile cancer. These include: • Progressive ulceration in the glans, prepuce or skin of the penile shaft • Mass in the glans, prepuce or skin of the penile shaft Lumps within the corpora cavernosa can indicate Peyronie's disease, which does not require urgent referral.
Haemoptysis, respiratory symptoms, or superior vena obstruction	Lung cancer	Refer for a same day consultant opinion or admit if: • Stridor • Superior vena cava obstruction (swelling of face and neck with fixed elevation of the jugular venous pressure) Refer urgently to a team specializing in management of lung cancer if: • Persistent haemoptysis in smokers or ex-smokers aged 40 years or more. • Chest X-ray suggestive of lung cancer including pleural effusion and slowly resolving consolidation • Normal chest X-ray where there is high suspicion of lung cancer • History of asbestos exposure and recent onset of chest pain, shortness of breath or unexplained systemic symptoms where a chest X-ray indicates pleural effusion, pleural mass or any suspicious lung pathology Refer for urgent chest X-ray if: • Haemoptysis • The patient has any of the following where unexplained or present for more than 3 weeks: • Cough • Chest or shoulder pain • Dyspnoea • Weight loss • Chest signs • Hoarseness (refer urgently to an ear, nose and throat surgeon if the chest X-ray is normal) • Finger clubbing • Cervical or supraclavicular lymphadenopathy • Features suggestive of metastases from a lung cancer—for example secondaries in the brain, bone, liver or skin Do not delay the referral for 3 weeks if there is a high risk of lung cancer, for example if the patient is a smoker or ex-smoker, has chronic obstructive pulmonary disease or has a previous history of cancer (especially head or neck cancer).
Skin changes	Melanoma, squamous cell cancer or basal cell cancer	Urgent referral: refer patients to a team specializing in treatment of skin cancer if: • A skin lesion suspected to be melanoma is present (Box 2). Avoid excision in primary care • The patient has a non-healing keratinizing or crusted skin tumour of over 1 cm diameter with significant induration on palpation and documented expansion over 8 weeks. These tumours are commonly found on the face, scalp or back of the hand. • The patient has had an organ transplant and develops a new or growing cutaneous lesion. Squamous cell carcinoma is common with immunosuppression and may be atypical and aggressive • A histological diagnosis of a squamous cell carcinoma is made following lesion excision or skin biopsy Refer routinely if: • Suspected basal cell carcinoma (usually on the face, and without significant expansion over 2 months) • Histological diagnosis of basal cell carcinoma following lesion excision • The patient has a persistent or slowly evolving unresponsive skin condition with uncertain diagnosis
Musculo-skeletal symptoms	Sarcoma or bone cancer	Refer for immediate X-ray: any patient with suspected spontaneous fracture. If the X-ray: • Indicates possible bone cancer, refer urgently • Is normal but symptoms persist, follow-up and/or request repeat X-ray or bone function tests, or refer Refer urgently: to a team specializing in treatment of bone cancer or sarcoma if a patient presents with a palpable lump that is: • Over 5 cm in diameter • Deep to fascia, fixed or immobile • Increasing in size • Painful • A recurrence after previous excision If a patient has HIV infection, consider Kaposi's sarcoma and make an urgent referral if suspected Urgently investigate: increasing, unexplained or persistent bone pain or tenderness, particularly pain at rest (and especially if not in the joint), or an unexplained limp. In older people metastases, myeloma or lymphoma, as well as sarcoma, should be considered.

This table is based on information from the NICE guidance on referral for suspected cancer. Full guidance is available from the website http://www.nice.org.uk/.

Ovarian cancer is particularly difficult to diagnose. In patients with vague, non-specific, unexplained abdominal symptoms such as:

Bloating

Constipation

Abdominal pain

Back pain

Urinary symptoms

Carry out an abdominal palpation and consider a pelvic examination.

Ask about the medical history and in particular previous malignancy, radiotherapy or chemotherapy and conditions predisposing to cancer such as ulcerative colitis or abnormal smears. Enquire about family history of cancer and occupation. Certain occupations (such as asbestos worker) may predispose the patient to cancer. Check whether the patient is a smoker or drinks excessive amounts of alcohol. Tailor your examination to the symptoms reported and your suspected diagnosis.

Once you have finished your history and examination, summarize the history back to the patient and give an opportunity for the patient to fill in any gaps. Assess how the patient views the problem and ask what the patient thinks is wrong. Discuss your findings and agree on a plan of action.

Minor surgery for skin lesions:

All pigmented lesions that are not viewed as suspicious of melanoma but are excised should have a lateral excision margin of 2 mm of clinically normal skin and be deep enough to include subcutaneous fat

Send all excised skin specimens for pathological examination

When referring a patient in whom an excised lesion has been diagnosed as malignant, send a copy of the pathology report with the referral correspondence

Making referrals

Before referring for suspected cancer, consider how appropriate the referral is. If the patient is very elderly or has other co-morbidities (such as end-stage heart failure or dementia), it may not be in the patient's best interest to refer. Where possible discuss the pros and cons of referral with such patients before you reach a decision about referral. If the patient is unable to discuss the issue, take any advance directives into consideration and discuss the issue with the patient's family where possible.

All urgent referrals for suspected cancer should be made within one working day of the decision to refer. Hospitals should have arrangements in place to ensure that all patients referred with a diagnosis of suspected cancer are seen by a specialist within 2 weeks of the initial referral. Meeting these targets contributes to the overall rating of the hospital. The mechanism by which this occurs varies across the UK. In some areas it is possible to refer for ‘2-week wait’ appointments through the Choose and Book system. In other areas, a system of referral using a 2-week wait form is used. This may be a generic form for all suspected cancer diagnoses, or there may be different forms for each type of suspected cancer.

Figure 1.

Oral lichen planus—painless white streaks inside the cheek. Reproduced from dermnetnz.org 2007 with permission from New Zealand Dermatological Society incorporated.

Investigations for suspected cancer are stressful, so it is important to know about the level of social support that the patient has, even at this early stage. In many cases, the possibility of cancer has already gone through the patient's mind. A rapid appointment will raise levels of alarm still further. Therefore, it is important to explain to the patient why you are referring and what is likely to happen at the hospital. Not all patients want to know, so tread carefully and give the patient as much information as he or she wants.

Case history

Mrs Green is an ex-smoker. She came to see Dr Little as she had a chest infection. She had already been treated by another GP in the practice with a course of antibiotics but was no better. He gave her a different antibiotic and told her to come back if she was no better within a week. She did not improve, so Dr Little sent her for a chest X-ray. The chest X-ray showed a possible mass in the right hilum.

Dr Little explained to Mrs Green that the chest X-ray was not normal and that he needed to refer her for further investigation. She immediately asked what abnormal changes had been seen on the X-ray. He explained that there were changes present that could explain why she could not clear her chest infection. He went on to say that there were several possible causes for those changes but one of the possible causes was lung cancer. It was therefore essential to refer her urgently for this to be checked out. Mrs Green said that she had been worried about the possibility of cancer.

They agreed that Mrs Green would let him know when she had seen the consultant and keep him informed of what was going on. He continued to keep in contact with Mrs Green both in the surgery and by telephone. He offered her support and talked through her feelings about the uncertainties prior to diagnosis, tests she was going through, future treatment that she would face and support that was available.

Prostate-specific antigen testing for men

There is considerable demand for prostate-specific antigen (PSA) testing among men worried about prostate cancer. There is no prostate-screening programme in the UK but men can request a PSA test. The government has introduced a PSA ‘Informed Choice Programme’. Before performing a test it is important to counsel patients regarding the pros and cons of PSA assessment (Box 3).

Box 1.

Breast awareness

Breast awareness means knowing what your breasts look and feel like normally. Evidence suggests that there is no need to follow a specific or detailed routine such as breast self-examination, but you should be aware of any changes in your breasts.

The breast awareness five-point code:

Know what is normal for you

Know what changes to look and feel for

Look and feel

Report any changes to your GP without delay

Attend for routine breast screening if you are aged 50 years or over

Changes to be aware of:

Size—if one breast becomes larger, or lower than is normal

Nipples—if a nipple becomes inverted (pulled in) or changes position or shape

Rashes—on or around the nipple

Discharge—from one or both nipples

Skin changes—puckering or dimpling

Swelling—under the armpit or around the collarbone (where the lymph nodes are)

Pain—continuous, in one part of the breast or armpit

Lump or thickening—different to the rest of the breast tissue.

What should I do if I notice a change? If you do notice a change in your breasts, see your GP as soon as you can. Your GP may ask you to come back at a different time in your menstrual cycle or send you to a breast clinic for a more detailed examination.

Remember that most breast changes are not cancer, even if they need follow-up treatment or further investigation.

Further information for patients:

Breast Cancer Care website: http://www.breastcancercare.org.uk/

NHS Cancer Screening ‘Be breast aware’ leaflet and other information website: http://www.cancerscreening.org.uk/breastscreen/breastawareness.html

Reproduced with permission from Breast Cancer Care

Box 2.

The seven-point check list for moles

Score 2 points for any major feature and 1 point for any minor feature. Any lesion scoring 3 points or more is suspicious—refer for consideration of skin biopsy.

Major signs:

Change in size—increase in size

Irregular colour

Irregular shape—irregular border, asymmetry and elevation

Minor signs:

Greater than or equal to 7 mm diameter

Inflammation

Oozing-including crusting or bleeding

Change in sensation—including symptoms of minor irritation or itch

Note: One feature is enough to prompt referral if you have a high level of suspicion. For low-suspicion lesions, monitor for change over 8 weeks.

Do the PSA test before doing a digital rectal examination. If that is not possible, delay the test for a week after the examination. Exclude urinary infection before PSA testing. Do not do a PSA test if the man has:

A proven urinary infection—treat the urinary infection and postpone the PSA test for at least a month

Ejaculated within previous 48 hours

Exercised vigorously in the previous 48 hoursv

Had a prostate biopsy within the previous 6 weeks

Abnormal PSA is a common reason for referral to a urologist. Its sensitivity and specificity are poor. Reasons for raised PSA are listed in Box 3. Cut-off values that should prompt urology referral are summarized in Table 2. Referral is not needed if the prostate is simply enlarged and the PSA is in the age-specific reference range.

Table 2.

PSA cut-offs that should prompt referral

Age (years)	Refer to urology if PSA (ng/ml)
50–59	≥3.0
60–69	≥4.0
≥70	>5.0

Note: Finasteride reduces PSA by ∼50%.

Suspected haematological malignancy

Haematological malignancy often presents with non-specific symptoms or signs. Have a high level of suspicion.

Refer immediately if:

Full blood count or blood film is reported as acute leukaemia

Suspected spinal cord compression

Suspected renal failure due to myeloma

Refer urgently to a team specializing in blood cancers: If a patient presents with persistent, unexplained splenomegaly

Investigations: Combinations of the following symptoms and signs warrant examination, further investigation with a full blood count, blood film and erythrocyte sedimentation rate (or C-reactive protein or plasma viscosity) and referral to a team specializing in haematological malignancy as needed:

Drenching night sweats and/or fever

Weight loss

Generalized itching—in addition check urea and electrolytes, creatinine, estimated glomerular filtration rate and thyroid function tests

Breathlessness—in addition check chest X-ray

Unexplained bleeding, bruising or purpura and/or symptoms suggesting anaemia

Recurrent infections

Persistent bone pain—in addition check X-ray, urea and electrolytes, creatinine, estimated glomerular filtration rate, liver profile, bone profile and PSA (in men)

Alcohol-induced pain

Abdominal pain

Splenomegaly—refer if persistent

Fatigue—repeat full blood count and erythrocyte sedimentation rate at least once if the condition remains unexplained and does not improve

Lymphadenopathy—if present for 6 weeks or more, lymph nodes are increasing in size, any lymph node is greater than 2 cm in diameter in size, widespread lymphadenopathy or associated weight loss, night sweats and/or splenomegaly, consider further investigation, discussion with specialist and/or referral

Box 3.

Taking the PSA test

What is prostate cancer? The prostate gland lies beneath the bladder. Each year in the UK ∼ 22 000 men are diagnosed with prostate cancer and 9500 die from the disease. It is rare in men below the age of 50 years, and the average age of diagnosis is 75 years. Slow-growing cancers are more common than fast-growing cancers and may not cause any symptoms or shorten life.

What is the PSA test? PSA is a substance produced by the prostate gland. The PSA test is a blood test. If the levels of PSA in the blood are raised, it can give an early indication that prostate cancer is present. This test is now available to men who wish to be tested.

What if the test comes back normal? You are unlikely to have cancer. However, the PSA test can miss prostate cancer. If you have urinary symptoms, consult your G P.

What if the PSA levels are raised? The higher the level of PSA in the blood, the more likely it is to be cancer, but there are other causes of raised PSA levels too—for instance, enlargement of the prostate and prostate or urine infection. Roughly two-thirds of men with raised PSA levels will not have prostate cancer. Your GP will examine you to check your prostate gland and will either refer you to a specialist or repeat the PSA test in a few months.

What happens when you have been referred to a specialist? The specialist usually performs a prostate biopsy to determine if prostate cancer is present. This involves taking samples from the prostate through the back passage. Most men find this uncomfortable. Sometimes complications or infection may occur. Roughly two out of three men who have a prostate biopsy will not have prostate cancer. However, biopsies can miss some cancers and worry about prostate cancer may remain even after a clear result. Treatment depends on your age and the biopsy results.

So, should I have the PSA test? That is your decision.

Benefits of PSA testing

It may provide reassurance if the test result is normal

It may find cancer before symptoms develop

It may detect cancer at an early stage when treatments could be beneficial

If treatment is successful, the consequences of more advanced cancer are avoided

Downside of PSA testing

It can miss cancer and provide false reassurance

It may lead to unnecessary anxiety and medical tests when no cancer is present

It might detect slow-growing cancer that may never cause any symptoms or shortened life span

The main treatments of prostate cancer have significant side effects, and there is no certainty that the treatment will be successful

Further information about PSA testing and prostate cancer for patients:

National screening website: http://www.cancerscreening.nhs.uk

DIPEx Patient experience database website: http://www.dipex.org

Cancerbackup—Tel: 0808 800 1234, website: http://www.cancerbackup.org.uk/

Prostate cancer charity—Tel: 0800 074 8383, website: http://www.prostate-cancer.org.uk/

Prostate cancer support association—Tel: 0845 601 0766, website: http://www.prostatecancersupport.co.uk

Note: Patient information is reproduced from ‘PSA testing for prostate cancer’ and needs permission from the NHS Cancer Screening Programme.

Reproduced with permission from the NHS Cancer Screening Programme

Box 4.

Reasons for increased PSA

Prostate cancer

Benign prostatic hypertrophy

Acute or chronic prostatitis

Physical exercise

Acute urinary retention

Prostate instrumentation (includes prostate biopsy, urinary catheterization and rectal examination)

Old age

Note: PSA may be ‘normal’ when early prostate cancer is present.

Diagnosis of cancer in children

Diagnosis of childhood malignancy is a particular challenge in primary care. GPs rarely see children with cancer and the cancers that children may get are often unfamiliar to them. Always have a high index of suspicion and, if in doubt, refer for a specialist opinion. Referrals should be made to a paediatrician or specialist in children's cancer.

Some congenital or genetic syndromes may be associated with increased risk of childhood cancer (for example Down's syndrome is associated with leukaemia; neurofibromatosis is associated with central nervous system tumours).

Investigations: Check a full blood count and blood film if a child presents with

Pallor and/or fatigue

Unexplained irritability

Unexplained fever

Persistent or recurrent upper respiratory tract infections

Generalized lymphadenopathy

Persistent or unexplained bone pain (additionally consider X-ray)

Unexplained bruising

If the blood film or full blood count indicates leukaemia, make an urgent referral.

Abdominal distension: If persistent or progressive, examine the abdomen

If a mass is found, refer immediately

If the child is uncooperative and abdominal examination is not possible, or if examination is difficult, consider referral for urgent abdominal ultrasound

Refer for same day consultant opinion or admit: Any child with

Hepatosplenomegaly

Unexplained petechiae

Unexplained urinary retention

Reduced conscious level

Headache and vomiting that cause early morning waking, or occur on waking, as these are classic signs of raised intracranial pressure; less than 1% of children presenting with headache have a brain tumour

Children aged under 2 years with new-onset seizures (excluding febrile convulsion), bulging fontanelle, extensor attacks and/or persistent vomiting

Mediastinal, hilar or thoracic mass on chest X-ray

Refer for a same-day consultant opinion or refer urgently: Any child with

New-onset seizures

Cranial nerve abnormalities

Visual disturbances

Leg weakness—refer immediately if gait abnormalities or motor or sensory signs

Other motor/sensory signs

Abdominal mass

Skin nodules in a baby which could be metastatic neuroblastoma

Proptosis

Shortness of breath—particularly if not responding to bronchodilators

Full blood count suggesting malignancy

Urgent referral:

When a child presents three times or more with the same problem, but with no clear diagnosis

If a child has a white papillary reflex (leukocoria)—Figure 2

If a child is aged 2 or more and has a persistent headache, but you cannot carry out an adequate neurological examination in primary care

If a child is aged under 2 years with:

Abnormal increase in head size

Arrest or regression of motor development and/or altered behaviour

Abnormal eye movements and/or lack of visual following

Poor feeding or failure to thrive

New squint or change in visual acuity—urgency depends on other factors

If a child has an unexplained mass at any site that has one or more of the following features—the mass is:

Deep to the fascia

Non-tender

Progressively enlarging

Associated with a regional lymph node that is enlarging

More than 2 cm in diameter in size

If lymphadenopathy with one or more of the following features (particularly if there is no evidence of local infection and/or the lymphadenopathy is associated with general ill-health, fever or weight loss):

Non-tender, firm or hard lymph nodes

Lymph nodes of over 2 cm in size

Lymph nodes progressively enlarging

Any axillary nodes (in the absence of local infection or dermatitis)

Any supraclavicular nodes

If haematuria present

If persistent localized bone pain or swelling and X-ray showing signs of cancer

If unexplained deteriorating school performance or developmental milestones, or unexplained behavioural and/or mood changes

If rest pain or unexplained limp—consider X-ray and/or discussion with a paediatrician before or as well as referral

If family history of retinoblastoma and visual problems

Figure 2.

Loss of the red reflex in a child with retinoblastoma. Reproduced with permission from the University of Michigan.

Consider referral: When there is persistent parental anxiety, even when a benign cause is considered most likely.

Unexplained or persistent back pain: Examine the child and check a full blood count and blood film. Consider X-ray and/or discussion with a paediatrician. If no cause is found, refer urgently.

Significant event audit or critical event monitoring

Significant event audit is a recognized methodology for reflecting on important events in a practice and Quality and Outcomes Framework points are available for undertaking significant event audit (Education 7 and 10). New diagnoses of cancer are suitable topics for significant even audits to raise awareness of red flag symptoms and signs and to evaluate speed of diagnosis, referral and treatment. For it to be effective, it must be practised in a culture that avoids blame and involves all disciplines. There are three steps:

Decide on a topic and plan a meeting

At the end of the discussion, come to a decision about the case, for example well managed, need change in procedure

Prepare a report: The two acceptable formats for laying out these reports are described in Table 3

Table 3.

Methods of reporting significant event audits

Reporting method 1	Reporting method 2
Description of event—brief. Can be in note form. Learning outcome—aspects of high standard and those which could be improved. Where appropriate, include why the event occurred. Action plan—decisions taken. Describe reasons for decisions together with any other lessons learned from the discussion.	What happened? Why did it happen? Was insight demonstrated? Was change implemented?

Key points

Cancer is common and rapid diagnosis and referral is essential to maximize chances of survival.

GPs should watch for both general and specific red flags to alert them to a possible diagnosis of cancer and act on those findings.

Evaluation of the diagnosis and management of new cases of cancer in a practice can improve awareness of key symptoms alerting the doctor to a diagnosis of cancer and management for future patients. Significant event audit is a suitable methodology for doing this.

References

Cancer Research UK Available from: http://www.cancerresearchuk.org/[date last accessed 9.12.2007]

Jones

Latinovic

Charlton

Alarm symptoms in early diagnosis of cancer in primary care: Cohort study using General Practice Research Database. BMJ (Clinical research ed. 2007, May 19;334(7602):1040.

National Screening Prostate cancer informed choice programme, Available from: http://www.cancerscreening.nhs.uk/prostate/ [date last accessed 17.02.08]

NICE Referral guidelines for suspected cancer (2005) Available from: http://www.nice.org.uk/guidance/index.jsp?action=byID&r=true&o=10968 [date last accessed 17.02.08]

SIGN Number 61—Investigation of postmenopausal bleeding (2002) Available from: http://www.sign.ac.uk/guidelines/fulltext/61/index.html [date last accessed 17.02.08]

SIGN Number 67—Management of colorectal cancer (2003) Available from: http://www.sign.ac.uk/guidelines/fulltext/67/index.html [date last accessed 17.02.08]