PRIORITIES AND CLINICAL EFFECTIVENESS FORUM

Transcription

1 PRIORITIES AND CLINICAL EFFECTIVENESS FORUM CANCER - GUIDELINES FOR URGENT REFERRAL OF PATIENTS WITH These guidelines are intended as a quick reference for GPs to ensure appropriate referral of those patients with suspected cancer. They are adapted from the NICE Clinical Guideline 27. To meet the national cancer waiting times, patients referred urgently should be seen with 2 weeks. The Trust will continue to audit the appropriateness and timeliness of these referrals and feedback to referring GPs. Page 1 of 16

2 I N D E X Title Page No Lung Cancer 3 Upper GI Cancer 4 Lower GI Cancer 5 Breast Cancer 6 Gynaecological Cancer 7 Urological Cancers 8 Haematological Cancers 9 Skin Cancers 10 Head and Neck cancers including Thyroid cancer 11 Brain and CNS Cancer 12 Bone Cancer and Sarcoma 13 Unknown primary Children s Cancers Page 2 of 16

3 LUNG CANCER Urgent Referral for Chest X-Ray Haemoptysis Unexplained or persistent (more than 3 weeks) - Cough - Chest/shoulder pain - Dyspnoea - Weight loss - Chest signs - Hoarseness - Finger clubbing - Features suggestive of metastasis from lung cancer (e.g. brain, bone, liver or skin) - Persistent cervical/supraclavicular lymphadenopathy Urgent referral to a Chest Physician Any of the following: Chest X-ray suggestive / suspicious of lung cancer (including pleural effusion and slowly resolving consolidation). Persistent haemoptysis in smokers/ex smokers over 40 years of age. Signs of superior vena cava obstruction (swelling of face / neck with fixed elevation of jugular venous pressure). Stridor (consider emergency referral). Normal chest X-ray where there is high suspicion of lung cancer. Page 3 of 16

4 UPPER G.I. CANCER Urgent Referral. Dysphagia food sticking on swallowing (any age) Dyspepsia at any age combined with one or more of the following alarm symptoms: - Weight loss - Proven anaemia - Vomiting Dyspepsia in a patient aged 55 years or more with one of the following high risk features: - onset of dyspepsia less than one year ago - continuous symptoms since onset Dyspepsia combined with at least one of the following known risk factors: - Peptic ulcer surgery over 20 years ago - Barrett s oesophagus - Pernicious anaemia - Known dysplasia, atrophic gastritis, intestinal metaplasia Jaundice- consider urgent ultrasound Upper abdominal mass Page 4 of 16

5 LOWER G.I. CANCER Urgent Referral It is recommended that these symptom and sign combinations when occurring for the first time should be used to identify patients for urgent referral under the two week standard: All Ages A definite palpable right sided abdominal mass A definite palpable rectal (not pelvic) mass Rectal bleeding WITH a change in bowel habit to looser stools and/or increased frequency of defecation persistent for 6 weeks. Over 60 Years Rectal bleeding persisting for 6 weeks or more without a change in bowel habit and without anal symptoms. Change of bowel habit to looser stools and/or increased frequency of defecation persistent for 6 weeks, even in the absence of rectal bleeding. Any Age Iron deficiency anaemia WITHOUT an obvious cause (HB<11 g/dl in men or <10 g/dl in postmenopausal women). Page 5 of 16

6 BREAST CANCER Urgent Referral Of any age with a discrete, hard lump with fixation, with or without skin tethering Who are female, aged 30 or older with discrete lump that persists after their period or presents after menopause Who are female, aged younger than 30: 1. with a lump that enlarges 2. with a lump that is fixed and hard 3. in whom there are other reasons to be concerned such as family history of any age, with previous breast cancer, who present with a further lump or suspicious symptoms with unilateral eczematous skin or nipple change that does not respond to topical treatment with nipple distortion of recent onset with spontaneous unilateral bloody nipple discharge who are male, aged 50 years or older with a unilateral, firm subareolar mass with or without nipple distortion or associated skin changes Conditions that require referral but not necessarily urgently Consider non urgent referral in: women aged younger than 30 years with a lump patients with breast pain and no palpable abnormality, when initial treatment fails and /or with unexplained persistent symptoms. [use of mammography in these patients is not recommended] Page 6 of 16

7 GYNAECOLOGICAL CANCER Urgent Referrals With clinical features suggestive of cervical cancer on examination. A smear is not required before referral and a previous negative smear should not delay referral. Not on HRT with postmenopausal bleeding. On HRT with persistent or unexplained PMB after cessation of HRT for 6 weeks. Taking Tamoxifen with PMB. With unexplained vulval lump. With vulval bleeding due to ulceration. Persistent intermenstrual bleeding and negative pelvic examination. With palpable abdominal or pelvic mass on examination, thought to be of gynaecological origin that is not obviously fibroids. If available, could send for urgent ultrasound scan first to confirm gynaecological, but only if it doesn t significantly delay a referral. Page 7 of 16

8 UROLOGICAL CANCERS Urgent Referral Prostate With a hard, irregular prostate suggestive of prostate carcinoma. PSA should be measured and accompany the referral [unless this delays the referral]. An urgent referral is not needed if the prostate is simply enlarged and the PSA is in the age-specific reference range. With a normal prostate, but rising/raised age specific PSA. With symptoms and high PSA levels. PSA testing of asymptomatic men or screening for prostate cancer is not national policy. It is recommended that a PSA test, except in men clinically suspicious of prostate cancer should only be performed after full counselling and provision of written information. Refer to guidelines on PSA testing in primary care. Bladder and renal Of any age with painless macroscopic haematuria. Aged 40 years and older who present with recurrent or persistent urinary tract infection associated with haematuria. Aged 50 years and older who are found to have unexplained microscopic haematuria. With an abdominal mass identified clinically or on imaging that is thought to arise from the urinary tract. Testicular With a swelling or mass in the body of the testis. Penile Progressive ulceration or a mass in the glans or prepuce or skin of the shaft of the penis. Non-urgent referral Refer non-urgently patients under 50 with microscopic haematuria. Patients with proteinuria or raised serum creatinine should be referred to a renal physician. If there is no proteinuria and serum creatinine is normal, a non-- urgent referral to a urologist should be made. Page 8 of 16

9 HAEMATOLOGICAL CANCERS Combinations of the following symptoms and signs warrant full examination, further investigation [including FBC and film] and the urgency of any referral will depend on the symptom severity and the findings of investigations: - fatigue - breathlessness - alcohol induced pain - drenching night sweats - bruising - abdominal pain - fever - bleeding - lymphadenopathy - weight loss - recurrent infections - splenomegally - generalised itching - bone pain Immediate referral. With spinal cord compression or renal failure suspected of being caused by myeloma With a blood film/count reported as acute leukaemia Urgent referral Patients with persistent unexplained splenomegally. Page 9 of 16

10 SKIN CANCERS Melanoma Change is a key element in diagnosing malignant melanoma. For less suspicious lesions, undertake careful monitoring for change using the 7- point checklist for pigmented lesions: Major features of lesion: Minor features of lesion: - change in size - largest diameter 7 mm or more - irregular shape - inflammation - irregular colour - oozing - change in sensation - Lesions scoring 3 points or more, based on major features scoring 2 each and minor scoring 1 each, are suspicious and should be referred. Excision in general practice should be avoided. Squamous Cell Carcinoma Refer urgently patients: With non healing keratinizing or crusted tumours larger than 1 cm with significant induration on palpation. They are commonly found on the face, scalp or back of the hand with expansion noted over the proceeding weeks. Who are immunosuppressed and develop a new or growing cutaneous lesion. With histological diagnosis of squamous cell carcinoma. Non- urgent referral Basal cell carcinomas are slow growing and can be referred non- urgently. NB Send all excised skin specimens for pathological examination and if referring a patient in whom an excised lesion has been diagnosed as malignant, send a copy of the pathology report. Page 10 of 16

11 HEAD and NECK cancers including THYROID cancer Urgent Referral An unexplained lump in the neck, of recent onset, or a previously undiagnosed lump that has changed over a period of 3-6 weeks. An unexplained persistent swelling in the parotid or submandibular gland. An unexplained persistent sore or painful throat. Unilateral unexplained pain in the head and neck for more than 4 weeks, associated with otalgia but normal otoscopy. Unexplained ulceration of the oral mucosa or mass persisting for more than 3 weeks. Unexplained red and white patches [including suspected lichen planus] of the oral mucosa that are painful, swollen or bleeding. Urgent Chest X-ray referral: For any patient with hoarseness persisting for more than 3 weeks, particularly smokers aged 50 or over and heavy drinkers. If CXR positive refer urgently to team for lung cancer and if negative refer urgently to head and neck specialist. THYROID CANCER Immediate referral If symptoms of tracheal compression including stridor due to thyroid swelling. Urgent referral of patients with thyroid swelling associated with any of the following: A solitary nodule increasing in size A history of neck irradiation A family history of an endocrine tumour Unexplained hoarseness or voice changes Cervical lymphadenopathy Very young [pre-pubertal ] patient Patient aged 65 years and older Page 11 of 16

12 BRAIN and CNS cancer Urgent Referral Symptoms related to the CNS, including: -progressive neurological deficit -new-onset seizure -headaches -mental changes -cranial nerve palsy -unilateral sensorineural deafness in whom a brain tumour is suspected. headaches of recent onset accompanied by features suggestive of raised intracranial pressure, for example: -vomiting -drowsiness -posture-related headache -pulse-synchronous tinnitus -or by other focal or non-focal neurological symptoms, for example blackout, change in personality or memory a new, qualitatively different, unexplained headache that becomes progressively severe suspected recent onset seizures Consider urgent referral with rapid progression of: subacute focal neurological deficit unexplained cognitive impairment, behavioural disturbance or slowness personality changes of no reasonable explanation NB. Refer urgently any patient with previously diagnosed cancer developing any of the following: recent onset seizure progressive neurological deficit persistent headaches new mental or cognitive changes new neurological signs Page 12 of 16

13 BONE CANCER and SARCOMA Urgent Referral A soft tissue mass with one or more of the following characteristics: - Size > 5 cms - Painful - Increasing in size - Deep to fascia, fixed or mobile - Recurrence after previous excision Referral for immediate X-ray any patient with suspected spontaneous fracture. If the X-ray indicates possible bone cancer, refer urgently. Urgent investigation is indicated in unexplained or persistent bone pain or tenderness, particularly pain at rest. Page 13 of 16

14 Guideline for referral of a patient with an unknown primary Definition of unknown primary A strong suspicion of metastatic cancer (ie radiologically proven) where the primary disease site is unknown. Tissue diagnosis is not necessary. NUMBERS INVOLVED We think about 50 per year in total but this includes those identified as unknown primary during admission. Work is currently being carried out by public health to look into possibly of establishing a single person or team responsible for all patients with an unknown primary and therefore one referral route. In the absence of a single point of access, the following referrals are recommended based on the likely diagnosis: FEMALE MALIGNANT ASCITES GYNAE CONSULTANT LUNG METS LUNG CONSULTANT LIVER METS UPPER GI CONSULTANT CEREBRAL METS LUNG CONSULTANT CHEST AND LIVER METS COMBINED LUNG CONSULTANT BONE METS (MALE) UROLOGIST BONE METS (FEMALE) BREAST SURGEON All the referrals should of course be made through the 2 week wait Choose and Book appointments. Page 14 of 16

15 CHILDREN S CANCERS Urgent Referral Abnormal blood count: If reported as requiring urgent further investigation. Petechiae/Purpura: These findings are always an indication for urgent investigation. Fatigue: In a previously healthy child when combined with either of the following: - generalised lymphadenopathy - hepatosplenomegaly Bone Pain: especially if it is: - diffuse or involved the back - persistently localised at any site - requiring analgesia - limiting activity Lymphadenopathy: is more frequently benign in younger children but referral us advised if one or more of the following characteristics are present, particularly if there is no evidence of previous local infection - non tender, firm/hard and > 2 cms in maximum diameter - progressively enlarging - associated with other signs of general ill health, fever and/or weight loss - involves axillary nodes (in the absence of any local infection or dermatitis) or supraclavicular nodes - seen as a mediastinal or hilar mass on chest x-ray Headache: of recent origin with one or more of the following features: - increasing in severity or frequency - noted to be worse in the mornings or causing early wakening - associated with vomiting - associated with neurological signs (e.g. squint, ataxia) - associated with behavioural change or deterioration in school performance. - when persistent and you cannot carry out an adequate neurological examination Page 15 of 16

16 Soft Tissue Mass: any mass which occurs in an unusual location should be considered suspicious particularly if associated with one or more of the following characteristics: - shows rapid or progressive growth - size > 3 cms in maximum diameter - fixed or deep to fascia - associated with regional lymph node enlargement NB. There are associations between Down s syndrome and leukaemia, between neurofibromatosis and CNS tumours and between other rare syndromes and some cancers. Be alert to the potential significance of unexplained symptoms in children with such syndromes. Page 16 of 16