Referral guidelines for suspected cancer

Transcription

1 Referral guidelines for suspected cancer NICE guideline Second draft for consultation, September 2004 If you wish to comment on the recommendations, please make your comments on the full version of the draft guideline. CANCER REFERRAL: NICE guideline (September 2004) Page 1 of 80

2 Contents Key priorities for implementation Guidance Support and information needs of people with suspected cancer at the time of referral The diagnostic process Lung cancer Upper gastrointestinal cancer Lower gastrointestinal cancer Breast cancer Gynaecological cancer Urological cancers Haematological cancers Skin cancer Head and neck cancer Head and neck cancer (thyroid) Brain and CNS cancer Bone cancer and sarcoma Children s cancer Notes on the scope of the guidance Implementation in the NHS In general Audit Research recommendations Full guideline Related NICE guidance Clinical guidelines Cancer service guidance Technology appraisals Interventional procedures Review date...52 Appendix A: Grading scheme...53 CANCER REFERRAL: NICE guideline (September 2004) Page 2 of 80

3 Appendix B: The Guideline Development Group...57 Appendix C: The Guideline Review Panel...59 Appendix D: Technical detail on the criteria for audit...60 Calculation of compliance...62 Appendix E: Algorithms... Error! Bookmark not defined. CANCER REFERRAL: NICE guideline (September 2004) Page 3 of 80

4 Key priorities for implementation When referring patients with suspected cancer, primary healthcare professionals should assess the patient s need for continuing support whilst awaiting a specialist opinion, and should provide appropriate information about the possible diagnosis, what to expect from the service the patient will be attending, and how to obtain further information or help prior to the specialist appointment. In assessing the need of the patient for support, the primary healthcare professional should take account of the needs of people from different cultural groups, social factors, including family circumstances or isolation, and the needs of people of different ages. Primary healthcare professionals should take part in education, peer review and other activities to improve or maintain the clinical consulting skills they need to identify patients who may have cancer at an early stage and should be aware of the methods of communicating the possibility of cancer to the patient. Current guidelines (Royal College of Physicians, 1997) for advising patients and breaking bad news should be followed (taking into account the personal characteristics of the patient). Primary healthcare professionals should be familiar with the typical presenting features of most cancers, and be able to readily identify these features when patients consult with them. Primary healthcare professionals must be alert to the possibility of cancer when confronted by unusual symptom patterns or when patients who are thought to not have cancer fail to recover as expected. Discussion with a specialist should be considered if there is uncertainty about the interpretation of symptoms and signs, and whether a referral is needed. This may also enable the primary care professional to communicate their concerns and a sense of urgency to secondary healthcare professionals when symptoms are not classical. CANCER REFERRAL: NICE guideline (September 2004) Page 4 of 80

5 Cancer is uncommon in children, and its detection can present particular difficulties. Primary healthcare professionals should recognise that parents are the best observers of their children, and should listen carefully to their concerns. Professionals should also be willing to reassess the initial diagnosis or to seek a second opinion from a colleague if a child fails to recover as expected. The following guidance is evidence based. The grading scheme used for the recommendations (A, B, C, D or good practice point [GPP], and A [DS * ], B [DS], C [DS], and D [DS]) are described in Appendix A; a summary of the evidence on which the guidance is based is provided in the full guideline (see Section 5). * DS Diagnostic study CANCER REFERRAL: NICE guideline (September 2004) Page 5 of 80

6 1 Guidance 1.1 Support and information needs of people with suspected cancer at the time of referral Patients should be able to consult the primary healthcare professional of their choice whenever possible, including one of the same gender if preferred. [D] Before referral to specialist services or for further investigations, and after any test results have been received, primary healthcare professionals should discuss options (and their potential risks and benefits) with patients to improve their ability to share in decision-making and to make informed choices. [D] Adult patients who are being referred urgently because of suspected cancer should normally be told by the primary healthcare professional that they are being referred to a cancer service but, if appropriate, should be reassured that most people referred will not have a diagnosis of cancer, and alternative diagnoses should be discussed. [D] A patient who presents with symptoms suggestive of cancer should be referred by the primary healthcare professional directly to a team specialising in the management of the type of cancer, depending on local arrangements. [D] When referring a patient with suspected cancer to a specialist service for investigations, primary healthcare professionals should assess the patient s need for continuing support whilst awaiting a specialist opinion, and should provide information about the possible diagnoses in accordance with the patient s wishes for information. [D] Primary healthcare professionals should be aware of the methods of communicating the possibility of cancer to a patient, and be prepared to give the patient information on the likely diagnosis. [D] CANCER REFERRAL: NICE guideline (September 2004) Page 6 of 80

7 1.1.7 Primary healthcare professionals should provide culturally appropriate care, recognising the possibility of different cultural meanings of the possibility of cancer, the relative importance of family decision-making and possible unfamiliarity with the concept of support outside the family. [D] Current guidelines (Royal College of Physicians, 1997) for advising patients and breaking bad news should be followed when this is necessary (taking into account the personal characteristics of the patient). [D] Patients (or in the case of children, parents or carers) should be involved in decision-making about referral as much as possible. [D] Consideration should be given by the primary healthcare professional to meeting the needs of carers and parents for information and support, and to meeting the particular needs of people whom they care for, such as children and young people, and people with special needs (for instance, people with learning disabilities or sensory impairment). [D] When cancer is suspected in a child, the referral decision and information to be given to the child should be discussed with the parents or carers (and the patient, if appropriate). [D] Primary healthcare professionals should discuss with patients (and parents and carers as appropriate, taking into account of the need for confidentiality) their preferences for being involved in decision-making about referral and further investigations, and ensure they have the time for this. Such discussions should include children, where they wish to be included and are capable of being so. [D] In situations where diagnosis or referral has been delayed, or there is significant compromise of the doctor/patient relationship, the primary healthcare professional should pay particular attention to the information and support needs of the patient and also involved carers. The patient CANCER REFERRAL: NICE guideline (September 2004) Page 7 of 80

8 should be enabled to consult a second primary healthcare professional if they wish. [D] The primary healthcare professional should be aware that some patients find being referred for suspected cancer particularly difficult because of their personal circumstances, such as age, family or work responsibilities, isolation or other health or social issues. [D] If the patient has additional support needs because of their personal circumstances, the specialist should be informed (with the patient s agreement). [D] The primary healthcare professional should be aware that men may have similar support needs as women but may be more reticent about using support services. [D] The information given to patients by the primary healthcare professional should cover, among other issues: where they are being referred to how long they will have to wait for the appointment how to obtain further information or help prior to the specialist appointment who they will be seen by what to expect from the service the patient will be attending what type of tests will be carried out, and what will happen during diagnostic procedures how long it will take to get a diagnosis or test results whether they can take someone with them to the appointment sources of information about the type of cancer concerned or suspected (where this is known) other sources of support, including those for minority groups. [D] All members of the primary healthcare team should have available to them information in a variety of formats on both local and national CANCER REFERRAL: NICE guideline (September 2004) Page 8 of 80

9 sources of additional support for patients who are being referred with suspected cancer. [D] The information and support needs of the patient after referral but before diagnosis should be considered by the primary healthcare professional. This should include inviting the patient to contact the primary healthcare professional again if they have more concerns or questions before they see a specialist. [D] 1.2 The diagnostic process Cancers often present with symptoms commonly associated with benign conditions. The primary healthcare professional should be ready to review the initial diagnosis in cases in which common symptoms do not resolve as expected. [D] Primary healthcare professionals should be familiar with the typical presenting features of most cancers, and be able to readily identify these features when patients consult with them. [D] Some cancers are very rare, and occasionally patients with common cancers present with atypical or non-specific features. Primary healthcare professionals must be alert to the possibility of cancer when confronted by unusual symptom patterns or when patients who are thought to not have cancer fail to recover as expected. In such circumstances, the primary healthcare professional should systematically review the patient s history and examination, and refer without delay if cancer is a possibility. [D] Cancer is uncommon in children, and its detection can present particular difficulties. Primary healthcare professionals should recognise that parents are the best observers of their children, and should listen carefully to their concerns. Primary healthcare professionals should also be willing to reassess the initial diagnosis or to seek a second opinion from a colleague if a child fails to recover as expected. [D] CANCER REFERRAL: NICE guideline (September 2004) Page 9 of 80

10 1.2.5 Primary healthcare professionals should take part in education, peer review and other activities to improve or maintain the clinical consulting skills they need to identify patients who may have cancer at an early stage and to communicate the possibility of cancer to the patient. [C] Primary healthcare professionals should undertake activities to maintain their clinical reasoning and diagnostic skills, such as continuing education and peer review. [C] If a primary healthcare professional has concerns about the interpretation of a patient s symptoms and/or signs, a discussion with a local specialist should be considered (for example, by telephone or ). [D] There should be arrangements in place locally so that letters about non-urgent referrals are assessed by the specialist, and the patient is seen more urgently if necessary. [D] There should be local arrangements to ensure a maximum waiting period for non-urgent referrals; the Guideline Development Group (GDG) suggests a maximum of 13 weeks. [D] There should be local arrangements to identify those patients who miss their appointments so that they can be followed up. [D] 1.3 Lung cancer Specific recommendations Urgent referral for a chest x-ray should be made when a patient presents with: [C] haemoptysis, or any of the following unexplained or persistent (that is, lasting more than 3 weeks) symptoms and signs: chest/shoulder pain dyspnoea weight loss CANCER REFERRAL: NICE guideline (September 2004) Page 10 of 80

11 chest signs hoarseness finger clubbing cervical/supraclavicular lymphadenopathy cough with any of the above recurrent attendance with unexplained persistent cough (4 weeks or more). A report should be made back to the referring primary healthcare professional within 5 days of referral Urgent referral to a member of the lung cancer multi-disciplinary team should be made for any of the following: [D] persistent haemoptysis in smokers/ex-smokers over 40 years of age a chest x-ray suggestive or suspicious of lung cancer (including pleural effusion and slowly resolving consolidation) Immediate referral to a member of the lung cancer multi-disciplinary team should be considered for the following: [A NICE] signs of superior vena caval obstruction (swelling of the face/neck with fixed elevation of jugular venous pressure) stridor. CANCER REFERRAL: NICE guideline (September 2004) Page 11 of 80

12 1.3.4 Patients in the following groups have a greater potential for developing lung cancer: [C] all current or ex smokers patients with chronic airway obstruction (COPD) people who have been exposed to asbestos people who have had a previous history of cancer (especially head and neck). Urgent referral for chest x-ray or to a chest physician should be made as for other patients (see 1.3.1) but may be considered sooner, for example, if symptoms or signs have lasted for less than 3 weeks. Investigations Unexplained changes in existing symptoms in patients with underlying chronic respiratory problems should prompt an urgent referral for chest x- ray. [D] If the chest x-ray is normal but there is a high suspicion of lung cancer or the symptoms persist, urgent referral should be made to a chest physician anyway. [D] Individuals with a history of asbestos exposure and recent onset of chest pain, shortness of breath or unexplained systemic symptoms should have a chest x-ray. If this indicates a pleural effusion, pleural mass, or any suspicious lung pathology, referral to a chest physician should be urgent. [C] 1.4 Upper gastrointestinal cancer A patient who presents with symptoms suggesting upper gastrointestinal cancer should be referred directly to a team specialising in the management of upper gastrointestinal cancer, depending on local arrangements. [D] CANCER REFERRAL: NICE guideline (September 2004) Page 12 of 80

13 1.4.2 Urgent referral or endoscopic investigation (to be seen within 2 weeks) is indicated for patients of any age with dyspepsia when presenting with any of the following: [C] chronic gastrointestinal bleeding dysphagia progressive unintentional weight loss persistent vomiting iron deficiency anaemia epigastric mass suspicious barium meal. (The definition of dyspepsia is taken from the NICE guideline called Dyspepsia: Management of dyspepsia in adults in primary care. Dyspepsia in unselected patients in primary care is defined broadly to include patients with recurrent epigastric pain, heartburn or acid regurgitation, with or without bloating, nausea or vomiting.) A patient aged 55 years or over presenting with dyspepsia and without alarm signs does not require routine referral for endoscopy. However, urgent endoscopy may be considered if symptoms persist despite Helicobacter pylori (H. pylori) testing and initial proton pump inhibitor (PPI) therapy, and when the primary healthcare professional s concern about the risk of cancer is heightened. [D] In a patient aged 55 years or over, features to be considered in assessing the risk of cancer include continuous symptoms, onset of symptoms of less than one year ago, pernicious anaemia, and previous gastric surgery or gastric ulcer. [D] Endoscopic investigation for inadequate therapeutic response to management of dyspepsia is not necessary in the absence of alarm symptoms. However, endoscopy should be considered in a patient aged 55 years or over when concern about the risk of gastric cancer is heightened (family history, pernicious anaemia, previous gastric surgery or gastric ulcer). [D] CANCER REFERRAL: NICE guideline (September 2004) Page 13 of 80

14 1.4.6 In a patient who has a change in the character of their dyspepsia, urgent referral should be considered if they have any of the following known risk factors: [C] Barrett s oesophagus known dysplasia, atrophic gastritis, intestinal metaplasia peptic ulcer surgery over 20 years ago A patient being referred urgently for endoscopy should be free from acid suppression medication, including either a PPI or H2 receptor antagonist (H2RA), for a minimum of two weeks. [C] In a patient presenting with dysphagia (interference with the swallowing mechanism that occurs within 5 seconds of having commenced the swallowing process), referral to the upper gastrointestinal cancer service should be urgent. [C] H. pylori status should not be considered in making decisions on referral for suspected cancer. [C] In a patient where the decision to refer has been made, a full blood count (FBC) may assist specialist assessment in the outpatient clinic. This should be in accordance with local practice. [D] All patients aged 45 years and over with new onset dyspepsia should be considered for full blood count (FBC) in order to detect iron deficiency anaemia. [D] In a patient without dyspepsia but with unexplained weight loss or iron deficiency anaemia, the possibility of upper gastrointestinal cancer should be recognised and the need for referral for further investigation considered. [C] An adult patient with persistent vomiting and weight loss in the absence of dyspepsia should be considered for upper gastro-oesophageal cancer, and, if appropriate, referral to the upper gastrointestinal cancer service should be urgent. [C] CANCER REFERRAL: NICE guideline (September 2004) Page 14 of 80

15 In an adult patient with unexplained upper abdominal pain and weight loss, with or without back pain, referral to the team specialising in upper gastrointestinal cancer should be urgent. [C] In patients with obstructive jaundice, referral should be immediate or urgent, dependent on the patient s clinical state. An urgent ultrasound investigation may be considered if available. [C] 1.5 Lower gastrointestinal cancer General recommendations The primary healthcare professional should recognise that the diagnosis of colorectal cancer on clinical grounds alone can be difficult. [D] In a patient with equivocal symptoms who is not unduly anxious, it is reasonable to use a period of treat, watch and wait as a method of management. [D] In a patient with unexplained symptoms related to the lower gastrointestinal tract, a digital rectal examination should always be carried out, provided this is acceptable to the patient. [C] A patient who presents with symptoms suggesting colorectal cancer should be referred directly to a team specialising in the management of lower gastrointestinal cancer, depending on local arrangements. [D] Specific recommendations In a patient aged 40 years or over reporting rectal bleeding with a change of bowel habit toward looser and/or increased stool frequency persisting for 6 weeks or more, referral should be urgent. [C] In a patient aged 60 years or over with rectal bleeding persisting for 6 weeks or more without a change in bowel habit, referral should be urgent. [C] CANCER REFERRAL: NICE guideline (September 2004) Page 15 of 80

16 1.5.7 In a patient aged 60 years or over with a change in bowel habit to looser and/or more frequent stools persisting for 6 weeks or more without rectal bleeding, referral should be urgent. [C] In a patient presenting with a lower abdominal mass consistent with involvement of the large bowel, referral should be urgent, irrespective of age. [C] In a patient presenting with a palpable rectal mass (intraluminal and not pelvic), referral should be urgent, irrespective of age. (A pelvic mass, outside the bowel, would warrant urgent referral to a general surgeon, urologist or gynaecologist.) [C] In a man of any age with unexplained iron deficiency anaemia and a haemoglobin of 11 gms/dl or below, referral to a GI team should be urgent.* (* Unexplained in this context means a patient whose anaemia has already been investigated and found not to be related to other sources of blood loss or blood dyscrasia.) [C] In a woman who is not menstruating with unexplained iron deficiency anaemia and a haemoglobin of 10 gms/dl or below referral to a gastrointestinal team should be urgent.* (* Unexplained in this context means a patient whose anaemia has already been investigated and found not to be related to other sources of blood loss or blood dyscrasia.) [C] Risk factors In a patient with ulcerative colitis or a history of ulcerative colitis, a plan for follow-up should be agreed with a specialist and offered to the patient as a normal procedure in an effort to detect colorectal cancer in this high risk group. [C] Currently, there is insufficient evidence to suggest that a positive family history of colorectal cancer can be used as a criterion to assist in the decision about referral of a symptomatic patient. [C] CANCER REFERRAL: NICE guideline (September 2004) Page 16 of 80

17 Interventions In a patient with equivocal symptoms, a full blood count (FBC) may help in identifying the possibility of colorectal cancer by demonstrating iron deficiency anaemia, which should then determine the urgency of referral or not, as the case may be. [C (DS)] In a patient for whom the decision to refer has been made, a full blood count (FBC) may assist specialist assessment in the outpatient clinic. This should be in accordance with local practice. [D] In a patient for whom the decision to refer has been made, no other examinations or investigations other than those referred to earlier are recommended, as this may delay appropriate referral. [D] 1.6 Breast cancer General recommendations The primary healthcare professional should recognise that the diagnosis of breast cancer on the basis of symptoms and signs alone can be difficult. [D] Primary healthcare professionals should convey optimism about the effectiveness of treatment and the outcome for breast cancer. For example, the five-year survival rate from breast cancer in the UK is 77%, and for screen-detected cancers, the five-year survival rate is 95.8%. [C] A patient who presents with symptoms suggesting breast cancer should be referred directly to a team specialising in the management of breast cancer, within appropriate local services. [D] Specific recommendations A woman s first suspicion that she may have breast cancer is often when she finds a lump in her breast. The primary healthcare professional should examine the lump with the patient s consent. The features of a lump that should make the primary healthcare professional strongly CANCER REFERRAL: NICE guideline (September 2004) Page 17 of 80

18 suspect cancer are a fixed, hard lump, with or without skin tethering. A patient presenting in this way requires urgent referral, irrespective of her age. [C] In a patient aged 30 or over with a discrete mass that persists after her next period, or presents after the menopause, referral should be urgent. [C] Breast cancer in women aged under 30 is rare, but does occur. A policy of referring all women urgently would not be appropriate, and nonurgent referral should be considered. However, in a patient aged under 30 with a lump that enlarges or has other features associated with cancer (fixed, hard), or in whom there are other reasons for concern such as family history, urgent referral would be appropriate. [C] The patient s history should always be taken into account. For example, it may be appropriate to agree referral within a few days in discussion with a specialist in a patient who reports a lump that has been present for several months. [D] In a patient presenting with a further lump or suspicious symptoms who has previously had histologically confirmed carcinoma-in-situ of the breast or breast cancer, referral should be urgent, irrespective of age. [C] In a patient who presents with unilateral eczematous skin or nipple change that does not respond to topical treatment, or with nipple distortion of recent onset, referral should be urgent. [C] In a patient who presents with spontaneous unilateral bloody nipple discharge, referral should be urgent. [C] Breast cancer in men is rare. However in a man aged over 50 years with a unilateral, firm subareaolar mass with or without nipple distortion or associated skin changes, referral should be urgent. [C] CANCER REFERRAL: NICE guideline (September 2004) Page 18 of 80

19 Risk Factors In a patient presenting with features suggestive of breast cancer, increasing age should be the only risk factor taken into account in making a decision about urgent referral. The management of women who do not have features of breast cancer but have a family history of breast cancer is dealt with in the NICE guideline called The classification and care of women at risk of familial breast cancer. [C] Interventions In patients presenting with symptoms and/or signs suggesting breast cancer, investigation to establish the diagnosis of breast cancer prior to referral is not advised. [D] In patients presenting solely with breast pain, there is no evidence to support the use of mammography as a discriminatory investigation for breast cancer. Therefore its use in this group of patients is not recommended. [B (DS)] Specific support and information needs People of all ages who suspect they have breast cancer may have particular information and support needs. The primary healthcare professional should assess the person s need for information and support and respond sensitively. [D] Primary healthcare professionals should encourage all patients to be breast aware in order to reduce delay in the presentation of symptoms. [D] 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 (BSE), but women should be aware of any changes in their breasts. [ CANCER REFERRAL: NICE guideline (September 2004) Page 19 of 80

20 1.7 Gynaecological cancer General recommendations A patient who presents with symptoms suggesting gynaecological cancer should be referred directly to a team specialising in the management of gynaecological cancer, depending on local arrangements. [D] Specific recommendations A woman s first suspicion that she may have a gynaecological cancer may be when she experiences alterations in her menstrual cycle, intermenstrual bleeding, postcoital bleeding, postmenopausal bleeding or vaginal discharge. For a patient who presents with any of these symptoms, the primary healthcare professional should recommend a full pelvic examination including speculum examination of the cervix. [C] In a patient found on examination of the cervix to have clinical features which raise the suspicion of cervical cancer, referral should be urgent. A cytology test is not required before referral, and a previous negative cytology result is not a reason to delay referral. [C] Ovarian cancer is particularly difficult to diagnose on clinical grounds as the presentation may be with vague, non-specific abdominal symptoms alone (bloating, constipation, abdominal or back pain, urinary symptoms). In a woman who presents with any abdominal or urinary symptoms, abdominal palpation should be carried out. If there is significant concern, a pelvic examination should be considered, if appropriate and acceptable to the patient. [D] Any woman with a palpable abdominal or pelvic mass on examination which is not obviously uterine fibroids or of gastrointestinal or urological origin should have an ultrasound scan and then urgent referral to a gynaecological oncologist, depending on the findings. If urgent ultrasound is not available, the patient should be referred directly to the specialist gynaecologist. [C] CANCER REFERRAL: NICE guideline (September 2004) Page 20 of 80

21 1.7.6 A woman who presents with postmenopausal bleeding but is not on hormone replacement therapy (HRT) should be referred urgently. [C] A woman on hormone replacement therapy (HRT) who presents with persistent or unexplained postmenopausal bleeding after cessation of HRT for six weeks should be referred urgently. [C] Tamoxifen can increase the risk of endometrial cancer. A woman who presents with postmenopausal bleeding and who is taking tamoxifen should be referred urgently. [C] In a woman who presents with new onset non-specific abdominal symptoms and the primary healthcare professionals feels the diagnosis is irritable bowel syndrome, abdominal palpation should be performed. Management should include the offer of active follow-up until the symptoms resolve or a diagnosis is confirmed. [D] Vulval cancer frequently presents with a lump. A woman who presents with vulval symptoms should be offered a vulval examination, and if the patient has an unexplained vulval lump, referral should be urgent. [C] Vulval cancer can also present with vulval bleeding or ulceration. A patient with these features should be referred urgently to a gynaecological oncologist. [D] Vulval cancer may also present with pruritis or pain. For a patient who presents with these symptoms, it is reasonable to use a period of treat, watch and wait as a method of management, but this should include active follow-up until symptoms resolve or a diagnosis is confirmed. If symptoms persist, the referral may be urgent or non-urgent, depending on the symptoms and the degree of concern about cancer. [C] Risk factors There is an increased risk of endometrial cancer in those patients with a uterus who are taking unopposed oestrogen for hormone replacement CANCER REFERRAL: NICE guideline (September 2004) Page 21 of 80

22 therapy (HRT). A patient taking such treatment should be advised to stop or have the HRT changed to opposed oestrogen. [C] Investigation In a women who presents with symptoms and/or signs suggesting cervical cancer that are supported by findings on clinical examination, the decision should be urgent referral and not a cervical smear. [C (DS)] In a woman aged 50 or over who presents with non-specific abdominal symptoms without a palpable abdominal or pelvic mass at examination, and not obviously of gastrointestinal or urological origin, an abdominal and pelvic ultrasound should be considered to assist diagnosis. [D] Ovarian cancer antigen 125 (CA 125) is used in the assessment of women in gynaecology services, but cannot be recommended as a discriminatory investigation when making decisions on referral. [B (DS)] 1.8 Urological cancers In all male patients who present with symptoms of urinary outflow obstruction or impotence, a digital rectal examination (DRE) should be performed, with the patient s agreement. If a hard irregular prostate typical of cancer is identified, the patient should be referred without the need to undertake a prostrate-specific antigen (PSA) test. [C] All male patients aged 45 years or over who present with symptoms of urinary outflow obstruction or impotence, or have an abnormally enlarged prostate identified on a digital rectal examination (DRE), should be offered a prostrate-specific antigen (PSA) test after counselling and after exclusion of urinary tract infection (UTI). Ideally, the PSA test should be delayed for a week after DRE to avoid obtaining an inaccurate result. If the patient has an active UTI, the PSA test should be delayed until the infection has been treated. [C] In a male patient with symptoms of urinary outflow obstruction or an abnormally enlarged prostate on a digital rectal examination (DRE) CANCER REFERRAL: NICE guideline (September 2004) Page 22 of 80

23 suggestive of cancer and who also have a raised age-specific prostratespecific antigen (PSA) test, the management options should be discussed with the patient and an urgent referral to a urologist arranged if the patients agrees. [C] (The age-specific cut-offs recommended by the Prostate Cancer Risk Management Programme were given as follows: aged years > 3.0 ng/ml aged years > 4.0 ng/ml aged 70 years and over > 5.0 ng/ml.) All male patients aged 45 years or over with an abnormally enlarged prostate that is not typical of cancer on a digital rectal examination (DRE), but with a normal prostrate-specific antigen (PSA) test, should be followed up in primary care or offered a non-urgent referral. [D] In a male patient with symptoms of urinary outflow obstruction and no signs and a raised age-specific prostrate-specific antigen (PSA) test, the primary healthcare professional should discuss with the patient whether they would benefit from curative treatment and, if so, they should be referred urgently; otherwise, they should be referred non-urgently. [D] In a male patient whose first evidence of prostate cancer is the discovery of bone metastases, referral for assessment for palliative therapy should be discussed with the patient and should usually be urgent. [D] Male or female patients of any age who present with painless macroscopic haematuria should be referred urgently to a urologist. [D] In male and female patients with symptoms suggestive of a urinary tract infection who present with macroscopic haematuria, investigations should exclude infection before referral for consideration of urological cancer. [D] Female patients aged 40 years and over who present with recurrent or persistent urinary tract infection associated with haematuria should be CANCER REFERRAL: NICE guideline (September 2004) Page 23 of 80

24 referred urgently to a urologist. If haematuria is not present, referral may be non-urgent. [D] In male or female patients aged 50 years and over who are discovered to have unexplained microscopic haematuria (that is, strongly positive dipstick or laboratory proven), referral to a urologist should be urgent. [C] Urgent referral to a urologist is required for any male patient presenting with symptoms or signs of penile cancer, which include: [D] progressive ulceration a lump or mass occurring anywhere on the penis, but most commonly the glans or prepuce Any male patient with a swelling in the body of the testis should be referred urgently to a urologist. [C] In any patient with an abdominal mass identified either clinically or by incidental imaging that is thought to be arising from the urinary tract, a urological cancer should be considered and referral should be urgent. [D] An urgent ultrasound should be considered in male patients aged 55 years and under presenting with a scrotal mass when the body of the testis cannot be distinguished. The use of tumour marker tests (AFP/LDH/HCG) should be used to exclude germ cell malignancy irrespective of ultrasound results. [D] 1.9 Haematological cancers General recommendations CANCER REFERRAL: NICE guideline (September 2004) Page 24 of 80

25 1.9.1 Primary healthcare professionals should be aware that haematological cancers can present with a variety of symptoms which may have a number of different clinical explanations. [D] Specific recommendations Combinations of the following symptoms and signs may suggest haematological cancer and warrant full examination, further investigation (including a blood count and film) and possible referral. The urgency of referral depends on the severity of the symptoms and signs, and findings of investigations: [C] fatigue drenching night sweats fever weight loss generalised itching breathlessness bruising bleeding recurrent infections bone pain alcohol induced pain abdominal pain lymphadenopathy splenomegaly A patient with persistent unexplained splenomegaly requires urgent referral to a haematologist. [C] A patient with a blood count/film reported as acute leukaemia should be referred immediately. [D] Investigation of patients with persistent unexplained fatigue should include a full blood count, blood film and ESR (PV or CRP according to CANCER REFERRAL: NICE guideline (September 2004) Page 25 of 80

26 local policy), and repeated if the patient s condition remains unexplained and does not improve. [B (DS)] Investigation of patients with persistent unexplained lymphadenopathy should include a full blood count, blood film and ESR (PV or CRP according to local policy). [B (DS)] The following additional features of lymphadenopathy should trigger investigation, follow-up and/or referral: [C (DS)] persistence for six weeks or more increasing size greater than 2 cm widespread nature associated splenomegaly, night sweats or weight loss Investigation of a patient with unexplained bruising, bleeding, and purpura or symptoms suggesting anaemia should include a full blood count, blood film, ESR (PV or CRP according to local policy) and clotting screen. [B (DS)] Persistent and unexplained bone pain in a patient should raise the suspicion of myeloma. If myeloma is suspected, paraproteins should be measured in blood and urine and urea and electrolytes, bone profile and X-ray requested. [B (DS)] A patient with spinal cord compression or renal failure suspected of being due to myeloma should be referred immediately. [C] A patient with bone pain that is persistent and unexplained should be investigated with full blood count and x-ray, urea and electrolytes, liver bone profile, PSA test (in males) and ESR (PV or CRP according to local policy). [C (DS)] CANCER REFERRAL: NICE guideline (September 2004) Page 26 of 80

27 1.10 Skin cancer All primary healthcare professionals should be aware of the weighted 7-point checklist for pigmented skin lesions. [C] All primary healthcare professionals who perform minor surgery should have received appropriate training in relevant aspects of skin surgery, including including cryotherapy, curettage, and incisional and excisional biopsy techniques. [D] Patients with persistent or slowly evolving unresponsive skin conditions in which the diagnosis is uncertain and cancer is a possibility should be referred. [D] All skin excisions and biopsies should be sent for pathological examination. [C (DS)] On making a referral of a patient in whom an excised lesion has been diagnosed as malignant, a copy of the pathology report should be sent with the referral correspondence, as there may be details (tumour thickness, excision margin etc) that will specifically influence future management. [D] Specific recommendations Melanoma Change is a key element in diagnosing malignant melanoma. For low suspicion lesions, careful monitoring for change over up to 8 weeks using the 7-point checklist (see ) should be undertaken by measurement with photographs and a marker scale and/or ruler. [D] All primary healthcare professionals should use the weighted 7-point checklist in the assessment of pigmented lesions to determine referral: [C] major features: change in size CANCER REFERRAL: NICE guideline (September 2004) Page 27 of 80

28 irregular shape irregular colour minor features: largest diameter 7 mm or more, inflammation, oozing, change in sensation A patient with a lesion suspected to be melanoma should be referred urgently, and excision in primary care should be avoided. [C] Squamous basal cell carcinomas CANCER REFERRAL: NICE guideline (September 2004) Page 28 of 80

29 Squamous cell carcinomas present as keratinizing or crusted tumours that may ulcerate. Where there is a suspicion that a skin lesion is a squamous cell carcinoma (SCC), particularly if hypertrophic, inflammed or rapidly growing, the patient should be referred urgently. [C] Slowly growing, non-healing lesions larger than 1 cm with significant induration on palpation, commonly on face, scalp or back of hand with a documented expansion over 8 weeks may be squamous cell carcinomas (SCC) and should be referred urgently. [C] Squamous cell carcinomas (SCC) are common in patients on immunosuppressive treatment, and transplant patients who develop new or growing cutaneous lesions should be referred urgently, as they are at risk of developing SCCs that may be atypical and aggressive. [C] Any patient with histological diagnosis of a squamous cell carcinoma (SCC) made in primary care should be referred urgently to a dermatologist. [C] Basal cell carcinomas are slow growing, usually without significant expansion over two months, and usually occur on the face. Patients with such lesions should be referred non-urgently. [C] Investigations All pigmented lesions that are not viewed as suspicious of melanoma but are excised should have a margin of 2 mm and cut to include subcutaneous fat. [B (DS)] 1.11 Head and neck cancer General recommendations Any patient with persistent symptoms or signs related to the oral cavity in whom a definitive diagnosis of a benign lesion cannot be made should be referred or followed up until the symptoms and signs disappear. [D] CANCER REFERRAL: NICE guideline (September 2004) Page 29 of 80

30 Primary healthcare professionals should advise all patients, including those with dentures, to have regular dental checkups. [D] Primary healthcare professionals who suspect head and neck cancer should make an urgent referral directly to the local head and neck designated cancer team. [D] Specific recommendations If oral lichen planus is suspected (unexplained red and white patches of the oral mucosa), the patient should be referred for prompt but nonurgent specialist assessment. Any patient with oral lichen planus should be monitored for oral cancer as part of routine dental examination. [C] A patient with unexplained ulceration of the oral mucosa persisting for more than 3 weeks should be referred urgently. [C] Any patient with hoarseness persisting for more than 6 weeks, particularly smokers aged over 50 and heavy drinkers, should be referred urgently for chest x-ray. Those with positive findings should be referred to a respiratory physician. Those with a negative finding should be referred to a head and neck team. [C] A patient with an unexplained lump in the neck which has recently appeared or a lump which has not been diagnosed before that has changed over a period of 4 6 weeks should be referred urgently to the head and neck cancer team. [C] A patient with dysphagia (difficulty in swallowing) should be referred urgently. [B] Adult patients with unexplained tooth mobility persisting for more than 3 weeks should be referred to a dentist urgently. [C] A patient with unresolved unilateral nasal mass/ ulceration/obstruction, particularly associated with purulent or bloody discharge, should be referred urgently. [C] CANCER REFERRAL: NICE guideline (September 2004) Page 30 of 80

31 Investigations With the exception of persistent hoarseness (see ), investigations for head and neck cancer in primary care are not recommended as they can delay referral. [D] 1.12 Head and neck cancer (thyroid) Specific recommendations In patients presenting with symptoms of compression, including stridor due to thyroid swelling, immediate referral should be considered. [D] A thyroid swelling (goitre) associated with the following features are indications for urgent referral: [C] increasing in size patient with a history of previous neck irradiation unexplained hoarseness or voice changes cervical lymphadenopathy (usually deep cervical or supraclavicular region) the very young (pre-pubertal) a patient aged over 65 years in whom the swelling is diffuse and hard. Investigations Thyroid function tests should be requested by the primary healthcare professional. [D (DS)] Patients with hyper- or hypothyroidism and an associated swelling should be referred routinely to an endocrinologist. Thyroid cancer patients are usually euthyroid and if the features present are those listed in , then the patient should be referred urgently to a thyroid surgeon. CANCER REFERRAL: NICE guideline (September 2004) Page 31 of 80

32 Initiation of other investigations by the primary healthcare professional, such as ultrasonography or isotope scanning, is likely to result in unnecessary delay in making the diagnosis of cancer (IIb, B). [D] 1.13 Brain and CNS cancer General recommendations If a primary healthcare professional has concerns about the interpretation of a patient s symptoms and/or signs, a discussion with a local specialist should be considered. If rapid access to scanning is available, this investigation could also be considered. [D] Specific recommendations A patient with new, unexplained headaches or neurological symptoms should have a neurological examination guided by the symptoms, but including examination for papilloedema. [D] Any patient with symptoms related to the central nervous system (progressive neurological deficit, seizures, headaches, mental changes, unilateral deafness) in whom a definitive diagnosis of brain tumour cannot be excluded should be referred or followed up until the symptoms disappear. The development of new signs related to the central nervous system should be considered as potential indications for referral. [C] A patient with non-migrainous headaches of recent onset accompanied by features suggestive of raised intra-cranial pressure (for example, vomiting, drowsiness, woken by headache) or by other neurological symptoms should be referred urgently. [C] In a patient with non-migrainous and unexplained headache of recent onset, present for at least 1 month, but not accompanied by features suggesting raised intracranial pressure, discussion with a specialist or referral (usually non-urgent) should be considered. [D] A patient with a new, qualitatively different, unexplained headache that becomes progressively severe should be referred urgently. [C] CANCER REFERRAL: NICE guideline (September 2004) Page 32 of 80

33 Re-assessment and re-examination is required if the patient does not progress according to expectations. [D] Any patient with suspected recent onset seizures should be referred urgently to a specialist. [C] A detailed history should be taken from the patient and an eyewitness if possible to the attack to determine whether or not a seizure is likely to have occurred. [C] In a patient presenting with seizure, a physical examination, including cardiac, neurological, mental state, and developmental assessment, where appropriate, should be carried out. [C] Any patient previously diagnosed with any cancer who has a new onset seizure or other symptoms (progressive neurological deficit, seizures, headaches, mental changes, unilateral deafness) or neurological signs should be referred urgently to a specialist. [C] A patient with subacute progressive focal neurological deficit should be referred urgently. [B] A patient with a progressive cognitive impairment, behavioural disturbance or slowness should be referred urgently to a specialist for assessment. [C] A patient with a progressive cognitive impairment should be referred to a specialist for routine assessment. [C] If a patient presents with personality changes and is being considered for referral, a witness (carer, family member) should be asked to describe in detail what they have observed, if appropriate. [D] CANCER REFERRAL: NICE guideline (September 2004) Page 33 of 80

34 1.14 Bone cancer and sarcoma General recommendations 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. [C (DS)] The nature of the investigations will vary according to age of the patient and circumstances: sarcoma in adolescence metastases, myeloma or lymphoma in older people. Specific recommendations Bone tumours A patient with a suspected spontaneous fracture should be referred for an immediate x-ray. [B (DS)] If the x-ray suggests the possibility of cancer, the patient should be referred urgently (to a recognised bone cancer centre if possible). [C (DS)] If the x-ray is normal but symptoms persist, the patient should be followed up and/or a repeat x-ray or referral requested. [C (DS)] Soft tissue sarcomas A patient presenting with a palpable lump should be referred urgently if any one of the following features applies: [C] a painless lump which the patient reports is increasing in size lump size greater than about 5 cm lump deep to fascia, fixed or immobile lump close to the site of a previously excised lump pain. If there is any doubt about the need for referral, discussion with a specialist or service, depending on local arrangements, should be undertaken. CANCER REFERRAL: NICE guideline (September 2004) Page 34 of 80