Cancer Flashcards
2 week suspected cancer referral pathway:
a) What are the red flags symptoms for lung and pleural cancers?
b) What are the investigations?
c) When do you refer using suspected cancer pathway?
a) RED FLAG symptoms: => Cough => Haemoptysis => Fatigue => SOB => Chest pain => Weight loss => Appetite loss => Persistent or recurrent chest infections => Finger clubbing => Persistent cervical lymphadenopathy over 3 weeks (urgent CXR) => Chest signs consistent with lung cancer => Thrombocytosis
b) URGENT CHEST X-RAY (within 2 weeks)
=> to assess for lung cancer in people aged > 40 years if they have 2 more of the above unexplained symptoms,
OR
=> if they have ever smoked and have 1 or more of the above unexplained symptoms
c) Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for lung cancer if they:
• have chest X-ray findings that suggest lung cancer
• are aged 40 and over with unexplained haemoptysis
• have stridor (immediate referral)
• signs of superior vena cava obstruction (immediate referral)
2 week suspected cancer referral pathway:
a) What are the red flags symptoms for Mesothelioma?
b) What are the investigations?
c) When do you refer using suspected cancer pathway?
a) RED FLAG symptoms: => Cough => Fatigue => SOB => Chest pain => Weight loss => Appetite loss => Finger clubbing => Chest signs compatible with pleural disease
b) URGENT CHEXT X-RAY (within 2 weeks) to assess for mesothelioma in people aged >40 years if:
- they have 2 or more of the above unexplained symptoms OR
- they have 1 or more of the above unexplained symptoms and have ever smoked OR
- they have 1 or more of the above unexplained symptoms and have been exposed to asbestos
c) Refer via 2 weeks pathway if they have chest X-ray findings that suggest mesothelioma
2 week suspected cancer referral pathway (Upper GI tract cancers):
a) What are the red flags symptoms for Oesophageal cancer?
b) What are the investigations?
c) When do you refer using suspected cancer pathway?
a) RED FLAGS symptoms
=> dysphagia > 3 weeks OR => age 55 and over with weight loss and - upper abdominal pain or - reflux or - dyspepsia
Urgent upper GI endoscopy (within 2 weeks) referral
Consider non-urgent upper GI endoscopy in people with haematemesis
Consider non-urgent upper GI endoscopy in people aged 55 or over with:
- treatment-resistant dyspepsia OR
- upper abdominal pain with low haemoglobin levels (iron deficiency anaemia) OR
- raised platelet count with any of the following:
- nausea
- vomiting
- weight loss
- reflux
- dyspepsia
- upper abdominal pain OR
• nausea or vomiting with any of the following:
- weight loss
- reflux
- dyspepsia
- upper abdominal pain
2 week suspected cancer referral pathway (Upper GI tract cancers):
a) What are the red flags symptoms for Pancreatic cancer?
b) What are the investigations?
c) When do you refer using suspected cancer pathway?
a) Red flag symptoms:
=> Age >60 years + weight loss + any of these symptoms • diarrhoea • back pain • abdominal pain • nausea • vomiting • constipation • new-onset diabetes • painless jaundice (Direct referral)
b) Urgent CT scan (within 2 weeks) or urgent USS if CT unavailable to assess for pancreatic cancer in people aged 60 years and above with weight loss and any of the above symptoms.
c) Refer via 2 week pathway for pancreatic cancer if they are aged 40 and over, and have painless jaundice
2 week suspected cancer referral pathway (Upper GI tract cancers):
a) What are the red flags symptoms for Stomach cancer?
b) What are the investigations?
c) When do you refer using suspected cancer pathway?
a) Red flag symptoms: => Dysphagia OR => aged 55 and over with weight loss and any of the following: - Upper abdominal pain - Reflux - Dyspepsia
b) Urgent upper GI endoscopy (within 2 weeks) with above findings
c) 2 week referral via cancer pathway for upper abdominal mass consistent with stomach cancer
Consider non-urgent upper GI endoscopy to assess for stomach cancer in people with
=> haematemesis OR
=> aged 55 and over with:
• treatment-resistant dyspepsia OR
- upper abdominal pain with low haemoglobin levels (iron deficiency anaemia) OR
- raised platelet count with any of the following:
- nausea
- vomiting
- weight loss
- reflux
- dyspepsia
- upper abdominal pain OR
• nausea or vomiting with any of the following:
- weight loss
- reflux
- dyspepsia
- upper abdominal pain
2 week suspected cancer referral pathway (Upper GI tract cancers):
a) What are the red flags symptoms for Gallbladder / Liver cancer?
b) What are the investigations?
a) Mass consistent with enlarged gallbladder or enlarged liver
b) Urgent USS (within 2 weeks)
2 week suspected cancer referral pathway (Lower GI tract cancers):
a) What are the red flags symptoms for Colorectal cancer?
b) What are the investigations?
c) When do you refer using suspected cancer pathway?
a) Refer adults using a suspected cancer pathway referral (for an appointment within 2 weeks) for colorectal cancer if:
• they are aged 40 and over + unexplained weight loss + abdominal pain OR
- they are aged 50 and over + unexplained rectal bleeding OR
- they are aged 60 and over with:
- iron-deficiency anaemia or
- changes in their bowel habit OR
• [FIT] tests show occult blood in their faeces
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for colorectal cancer in adults with a rectal or abdominal mass
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for colorectal cancer in adults under 50 years with rectal bleeding and any of the following unexplained symptoms: • abdominal pain • change in bowel habit • weight loss • iron-deficiency anaemia
b) Offer FIT test to assess for colorectal cancer in adults without rectal bleeding who:
• are aged 50 and over with unexplained: - abdominal pain or
- weight loss, OR
• are aged under 60 with:
- changes in their bowel habit or
- iron-deficiency anaemia, OR
• are aged 60 and over and have anaemia even in the absence of iron deficiency
2 week suspected cancer referral pathway:
a) What are the red flags symptoms for Breast cancer?
b) What are the investigations?
c) When do you refer using suspected cancer pathway?
Refer people (male or female) using a suspected cancer pathway referral (for an appointment within 2 weeks) for breast cancer if they are:
• aged 30 and over and have an unexplained breast lump ± pain OR
• aged 50 and over with any of the following symptoms in one nipple only:
- discharge
- retraction
• other changes of concern
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for breast cancer in people:
• with skin changes that suggest breast cancer or
• aged 30 and over with an unexplained lump in the axilla.
Consider non-urgent referral in people aged under 30 with an unexplained breast lump with or without pain
2 week suspected cancer referral pathway (Gynaecological cancers):
a) What are the red flags symptoms for Ovarian cancer?
b) What are the investigations?
c) When do you refer using suspected cancer pathway?
For women aged 18 and over:
- Urgent referral to a gynaecological cancer service if physical examination shows ascites and/or a pelvic / abdominal mass (which is not obviously uterine fibroids).
- Investigate in primary care if a woman (especially aged 50 or over) is having any of the following symptoms on a persistent or frequent basis (>12 times per month):
- persistent abdominal distension (referred as ‘bloating’)
- feeling full (early satiety) and/or loss of appetite
- pelvic or abdominal pain
- increased urinary urgency and/or frequency
- Unexplained weight loss
- Fatigue
- Changes in bowel habit / symptoms of IBS (IBS rarely presents for the first time in women of this age)
- Primary care investigations:
=> Serum CA125- If serum CA125 >35IU/ml => USS of abdomen and pelvis
- If USS suggests ovarian cancer => URGENT referral to gynaecological cancer service
=> Normal CA125 or normal USS after raised CA125 - monitor closely / investigate for other causes
=> If no other clinical causes, advise her to return to her GP if her symptoms become more frequent and persistent
2 week suspected cancer referral pathway (Gynaecological cancers):
a) What are the red flags symptoms for Endometrial cancer?
b) What are the investigations?
c) When do you refer using suspected cancer pathway?
- Refer women using a suspected cancer pathway referral (within 2 weeks) for endometrial cancer if they are:
=> aged 55 and over
=> post-menopausal bleeding (unexplained vaginal bleeding post menopause [>12 months after menstruation has stopped])
=> Consider a suspected cancer pathway referral (within 2 weeks) for endometrial cancer in women aged under 55 with post-menopausal bleeding
- Consider a USS to assess for endometrial cancer in women aged 55 and over with:
• unexplained symptoms of vaginal discharge who:
- are presenting with these symptoms for the first time OR
- have thrombocytosis OR
- report haematuria, OR
• visible haematuria and:
- low haemoglobin levels OR
- thrombocytosis, OR
- high blood glucose levels
2 week suspected cancer referral pathway (Gynaecological cancers):
a) What are the red flags symptoms for Cervical / vulval / vaginal cancer?
b) What are the investigations?
c) When do you refer using suspected cancer pathway?
- Cervical cancer:
Consider a suspected cancer pathway referral (within 2 weeks) for women if, on examination, the appearance of their cervix is consistent with cervical cancer - Vulval cancer:
Consider a suspected cancer pathway referral (within 2 weeks) for vulval cancer in women with an unexplained vulval lump, ulceration or bleeding. - Vaginal cancer:
Consider a suspected cancer pathway referral (within 2 weeks) for vaginal cancer in women with an unexplained palpable mass in or at the entrance to the vagina
2 week suspected cancer referral pathway (Urological cancers):
a) What are the red flags symptoms for Prostate cancer?
b) What are the investigations?
c) When do you refer using suspected cancer pathway?
- Refer people using a suspected cancer pathway (within 2 weeks) for prostate cancer if their prostate feels malignant on digital rectal examination.
- Consider a prostate-specific antigen (PSA) test and digital rectal examination to assess for prostate cancer in people with:
• any lower urinary tract symptoms, such as nocturia, urinary frequency, hesitancy, urgency or retention or
• erectile dysfunction or
• visible haematuria - Consider referring people with possible symptoms of prostate cancer above, using a suspected cancer pathway referral (within 2 weeks) for prostate cancer if their PSA levels are above the threshold for their age. Take into account any comorbidities
Below 40 years: Use clinical judgement
40 to 49 years: More than 2.5 mcg/l
50 to 59 years: More than 3.5 mcg/l
60 to 69 years: More than 4.5 mcg/l
70 to 79 years: More than 6.5 mcg/l
Above 79: Use clinical judgement
2 week suspected cancer referral pathway (Urological cancers):
a) What are the red flags symptoms for Bladder cancer?
b) What are the investigations?
c) When do you refer using suspected cancer pathway?
Refer within 2 weeks if:
i) Aged 45 and over with:
=> unexplained visible haematuria without UTI
=> visible haematuria that persists or recurs after successful treatment of UTI
OR
ii) Aged 60 and over with:
=> unexplained non-visible haematuria and either dysuria or raised WBC
*non-urgent referral in people aged 60 and over with recurrent or persistent unexplained UTI
2 week suspected cancer referral pathway (Urological cancers):
a) What are the red flags symptoms for Renal cancer?
b) What are the investigations?
c) When do you refer using suspected cancer pathway?
Refer within 2 weeks if:
Aged 45 and over with:
=> unexplained visible haematuria without UTI
OR
=> visible haematuria that persists or recurs after successful treatment of UTI
2 week suspected cancer referral pathway (Urological cancers):
a) What are the red flags symptoms for Testicular / Penile cancer?
b) What are the investigations?
c) When do you refer using suspected cancer pathway?
- Testicular cancer: Refer within 2 weeks if:
=> Non-painful enlargement or change in shape or texture of testis
=> USS with unexplained or persistent testicular symptoms - Penile cancer: Refer within 2 weeks if:
=> Penile mass or ulcerated lesion (STI excluded as cause)
=> Persistent penile lesion after treatment of STI
*consider referral for penile cancer with unexplained or persistent symptoms affected the foreskin or glans
2 week suspected cancer referral pathway (SKIN cancers):
a) What are the red flags symptoms for malignant melanoma?
b) What are the investigations?
c) When do you refer using suspected cancer pathway?
- Refer within 2 weeks if score of 3 or more:
Major features (2 points):
- Change in size
- Irregular shape
- Irregular colour
Minor features (1 points):
- Largest diameter 7mm or more
- Inflammation
- Oozing
- Change in sensation
- Refer within 2 weeks if dermas copy suggests melanoma
2 week suspected cancer referral pathway (SKIN cancers):
a) What are the red flags symptoms for SCC and BCC?
b) What are the investigations?
c) When do you refer using suspected cancer pathway?
- SCC => 2 week referral if skin lesion suspicious of SCC
- BCC:
i) Routine referral if BCC suspicion (ulcer with raised rolled edge; prominent fine blood vessels around a lesion; pearly / waxy nodule on the skin
ii) 2 week referral only if delay may lead to significant impact due to lesion side or size
2 week suspected cancer referral pathway (Head & Neck cancers):
a) What are the red flags symptoms for Laryngeal and Thyroid cancer?
b) What are the investigations?
c) When do you refer using suspected cancer pathway?
- Laryngeal cancer - 2 week referral if:
Aged 45 and over with:
=> persistent unexplained hoarseness
OR
=> unexplained lump in the neck
- Thyroid cancer -2 week referral with unexplained thyroid lump
2 week suspected cancer referral pathway (Head & Neck cancers):
a) What are the red flags symptoms for Oral cancer?
b) What are the investigations?
c) When do you refer using suspected cancer pathway?
2 week referral if:
=> unexplained ulceration in the oral cavity for more than 3 weeks
OR
=> persistent and unexplained lump in the neck
Urgent referral within 2 weeks if:
=> lump on the lip or in the oral cavity
OR
=> red / red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia
Patient & family support and safety netting:
- Discuss with patient their preference for being involved in decision making about referral including potential risks and benefits
- Reassure patients as appropriate. Explain that most people will not have a diagnosis of cancer being referred and discuss alternatives / diagnoses
- Info given to patients & families should include:
=> where the person is being referred to
=> how long they will have to wait for the appt
=> how to obtain further info about type or cancer suspected and help before specialist appt
=> what to expect from the service the patient is attending
=> what type of tests may be carried out and what will happen during diagnostic procedures
=> how long till a diagnosis is made / test results
=> whether they can take someone to the appt
=> who to contact if they don’t receive appt confirmation
=> other sources of support i.e. Macmillan - offers with emotional, physical and financial support
- Safety-netting:
=> Ensure results on investigations are reviewed and acted upon. Possible false negatives on x-rays or FIT tests
=> Warn patient of new symptoms development or worsening symptoms then to get in contact
=> Also get in contact if continues to worry and is seeking mental / emotional support - Arrange follow up in an agreed frame-time
