NICE guideline on Suspected cancer: recognition and referral (2015) Education package for GPs and Nurse Practitioners Case scenarios

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

2 How to use the case scenarios The case scenarios can be used in a training session with the whole group or in smaller groups, or used by individual learners. Each scenario takes you step-by-step through the care of a fictional patient. Each question should be considered before viewing the answer on the next slide. You will need to refer to the NICE recommendations to help you decide how to manage each patient s condition.

3 Case scenario Mary [1] Mary is a 64 year-old woman who presents to you with vague, diffuse abdominal pain that has been persisting over a couple of weeks. She has never smoked and has no significant medical or family history. She is not taking any medication and is an infrequent attender. There has been no bleeding, change in appetite or bowel habit and there has been no weight loss. Examination and urine dipstick test is normal. What cancers should you suspect and what would you do?

4 Case scenario Mary [2] As Mary is over 50 with persistent abdominal pain, you should consider: ovarian cancer and carry out serum CA125 testing colorectal cancer and carry out occult blood in faeces testing You also carry out a full blood count as a standard test. Later that week, the blood test results come back to you: FBC - Hb 10.6g/dl, WCC 13, platelets 525 Ca125 is normal (< 35IU/ml) What do you do next?

5 Case scenario Mary [3] Mary has raised platelets and anaemia. You need to find out if she has iron-deficiency anaemia, so you test for serum ferritin. A few days later the following results come back to you: Mary s serum ferritin is low the occult blood in faeces testing is positive What do you do next?

6 Case scenario Mary [4] As Mary is aged over 60 with iron-deficiency anaemia and she also has occult blood in her faeces, you should refer her for a 2 week wait appointment for suspected colorectal cancer. As Mary is over 55 with abdominal pain, low haemoglobin levels and a raised platelet count, you should also consider oesophageal or stomach cancer and consider referring her for a non-urgent direct access upper gastrointestinal endoscopy at the same time.

7 Case scenario Tony [1] Tony is a 58 year-old man who presents to you with a 6 week history of urinary frequency and urgency and has occasionally noticed a small amount of blood in his urine. There is no significant medical history. What cancers should you suspect and what would you do?

8 Case scenario Tony [2] As Tony has lower urinary tract symptoms and visible haematuria, you should consider prostate cancer and do a prostate-specific antigen (PSA) test and digital rectal examination. As he is aged over 45 with visible haematuria, you should consider bladder cancer and renal cancer and check for a urinary tract infection. You carry out these tests and find: Digital rectal examination reveals a smooth moderately enlarged benign feeling prostate. PSA level is10 (age specific range is 0-4) MSSU reveals raised WCC and RBC 100 with E. coli UTI. What do you do next?

9 Case scenario Tony [3] You need to treat the UTI and repeat the MSSU to ensure that the infection has cleared. Then repeat the PSA test in 4-6 weeks. After treatment and on repeating the tests you find: MSSU is now normal RBC 20 PSA level is now 3.9 (age specific range is 0-4) What do you do next?

10 Case scenario Tony [4] Repeat the PSA test in 3-6 months. After 3 months: PSA level is now 5.4 (age specific range is 0-4) Repeat MSSU is normal Tony s lower urinary tract symptoms are only slightly improved. What would you do now?

11 Case scenario Tony [5] As Tony s PSA levels are above the age-specific reference range refer him for a 2 week wait appointment for suspected prostate cancer. What are some of the learning points from Tony s case? If you had chosen Dutasteride as treatment for his prostate symptoms what would have been the implications for PSA monitoring?

12 Case scenario Tony [6] Some of the learning points from Tony s case are: The first PSA level taken was 10 which was above the age specific range of 0-4. But this was misleading as Tony had a UTI, and the UTI should have been treated first before the PSA level was tested. After treating the UTI, the repeated PSA level was borderline at 3.9 and so it was good practice to repeat it in 3-6 months. Dutasteride reduces PSA levels by approximately 50%, so you would need to allow for this when measuring PSA.

13 Case scenario Yvonne [1] Yvonne is a 62 year-old woman who has come to see you for a new patient diabetes review having seen the nurse 2 weeks previously. Her diabetes was diagnosed opportunistically following a cardio-vascular risk appointment. Her BMI is 22. She mentions recent weight loss of 4kg in 5 weeks. She has never smoked. What cancers should you suspect and what would you do?

14 Case scenario Yvonne [2] As Yvonne is over 60 with weight loss and new-onset diabetes, you should consider pancreatic cancer and check for jaundice. As there is no jaundice you should refer her for an urgent direct access CT scan (or an urgent ultrasound scan if CT is not available). As she is over 55 with weight loss, you should consider oesophageal or stomach cancers and you should check whether she has a raised platelet count. As she is over 50 with weight loss, you should consider colorectal cancer and carry out testing for occult blood in faeces. You should also consider ovarian cancer and measure serum CA125.

15 Case scenario Yvonne [3] Continued Her platelet count, FOB test and serum CA125 are normal. However, CT of the abdomen confirms a suspicious lesion in the pancreas. What would you do now? What would you need to be aware of if you had sent her for an ultrasound scan instead of a CT scan?

16 Case scenario Yvonne [4] You should refer Yvonne for a 2 week wait appointment for suspected pancreatic cancer. Ultrasound scans can miss some pancreatic cancers, so you need to consider putting safety netting processes in place. For example, reviewing the patient again at a later date or having a discussion with a specialist where there is still concern.

17 Case scenario Michael [1] Michael is a 63 year-old electrician who presents with a 1 month history of gradual onset, non-mechanical back pain which is now disturbing his sleep. He reports a slight loss of appetite but no other significant symptoms and no weight loss. Examination of his spine reveals no general abnormality, although he is tender locally at L2. What cancers should you suspect and what would you do?

18 Case scenario Michael [2] As Michael is over 60 with persistent back pain, you should consider myeloma and carry out a full blood count, blood tests for calcium and plasma viscosity or erythrocyte sedimentation rate. You should also consider that Michael might have secondary bone cancer and carry out a chest X-ray to check for lung cancer and a PSA test and digital rectal examination to check for prostate cancer. The results of these tests are: The chest X-ray, PSA test and digital rectal examination are normal Erythrocyte sedimentation rate is 70 Calcium is What would you do now?

19 Case scenario Michael [3] As the erythrocyte sedimentation rate and presentation are consistent with possible myeloma, carry out a very urgent protein electrophoresis and a Bence-Jones protein urine test within 48 hours. The results of the protein electrophoresis and Bence-Jones protein urine test are abnormal. What would you do next?

20 Case scenario Michael [4] As the results of the protein electrophoresis and Bence-Jones protein urine test suggest myeloma, refer Michael for a 2 week wait appointment.

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

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