Diagnosis of cancer

Question 1

Principles of cancer screening

Answer 1

Pick up pre-invasive/asymptomatic stages (symptoms occur when tumour bulk is higher or there are mets)

Aim: improve survival

Need a test that is sensitive + specific, identifies cancer before spread, curative treatments available for the early stages, affordable, acceptable to all social groups, good discriminatory index between benign + malignant

Question 2

What screening programmes are offered in the UK?

Answer 2

• Cervical every 3y aged 25-49 and every 5y 50-64, 65+ only if one of last 3 tests was abnormal
• Breast (mammogram) every 3y 50-70 (extending 47-73), after can self-refer
• Bowel: home testing kit every 2y ages 60-74, aged 55 one off flexi-sig
• Genetic screening for pt at risk e.g. BRCA1 FH

Question 3

Name some paraneoplastic syndromes and which cancers they are usually associated with
(NB there are loads in my CC notes)

Answer 3

• Lambert-Eaton syndrome (SCLC-impaired ACh release-proximal myopathy etc)
• Stiff Person syndrome (breast + lung)
• SIADH
• Ectopic ACTH secretion causing Cushing’s (SCLC)
• Hypercalcaemia (any but esp myeloma, renal, breast)
• Fever unknown origin
• Hypertrophic pulmonary osteoarthropathy (NSCLC)
• Acanthosis nigricans (gastric)
• Erythrocytosis (RCC< HCC, cerebellar)
• DVT, DIC (adenocarcinomas)
• Coagulopahthy of cancer
• Nephrotic syndrome (myeloma)
• Cachexia: chemokines + appetite loss
• Carcinoid syndrome: usually distal ileum/appendix, hot red flushing, severe diarrhoea, asthma attack

Question 4

What is the caveat to measuring tumour markers?

Answer 4

Can be normal in cancer
Raised/positive can be benign
Associated with multiple cancer types

Question 5

What are the main tumour markers and their cause?

Answer 5

• Monoclonal paraproteins - myeloma
• Alpha fetoprotein - HCC + non-seminoma gonad tumours
• Beta-hCG - choriocarcinomas, testicular germ cell, lung
• PSA - prostate
• CEA - GI cancers
• CA-125 - ovarian
• CA19-9 - GI esp pancreatic
• CA15-3 - breast
• M-band - myeloma, CLL
• Calcitonin - medullary thyroid carcinoma

Question 6

Histological features of malignant cells?

Answer 6

Pleiomorphic
More mitoses
Nuclear abnormalities of size/chromatin/the nucleolus
Evidence of tissue invasion
Differentiation: less differentiated=worse prognosis

Question 7

When is a 2ww referral indicated for lung cancer?

Answer 7

For a CXR

40+ with unexplained haemoptysis, with recurrent chest infection/chest signs/clubbing/supraclavicualr LN, or with 2 or more of other unexplained symptoms like cough fatigue WL SOB CP or asbestos exposure

Question 8

When is a 2ww referral indicated for upper GI cancers?

Answer 8

Oesophagus: dysphagia, upper ado pain/reflux/dyspepsia when 55+

Pancreas: 40+ with jaundice, or 60+ with WL and any of diarrhoea/back pain/abdo pain/N+V/constipation/new onset diabetes

Stomach: upper abdomen mass, dysphagia, 55+ with upper abdo pain/reflux/dyspepsia

Question 9

When is a 2ww referral indicated for colon cancer?

Answer 9

40+ unexplained WL + abdo pain

50+ unexplained PR bleeding

60+ iron def anaemia or change in bowel habit or a mass or blood in faeces

<50 with PR bleed + abdo pain/change bowel habit/WL/iron def anaemia

Question 10

When is a 2ww referral indicated for breast cancer?

Answer 10

30+ unexplained lump or axillary lump
50+ unilateral nipple symptoms
Any age with skin changes

Question 11

When is a 2ww referral indicated for gynae cancers?

Answer 11

Ascites/pelvic or abdo mass if not obviously fibroid
Persisting sx of ovarian ca like abdo distension, early satiety, pain, urinary sx
Post-menopausal bleeding
Unexplained new PV discharge if 55+
Based on cervical examination findings
Vulval/vaginal masses or ulceration or bleeding

Question 12

When is a 2ww referral indicated for urological cancer?

Answer 12

Prostate: If feels malignant on DRE; if have LUTS/erectile dysfunction check PSA and if high 2ww

Bladder: 45+ unexplained visible haematuria, 60+ unexplained non-visible haematuria + dysuria/high WCC

Renal: 45+ unexplained haematuria

Testicular: non tender enlargement or shape in shape or texture

Penile: mass or ulcerated lesion with STI excluded

Question 13

When is a 2ww referral indicated for skin cancer?

Answer 13

MM: if have a score of 3 based on major + minor features, or it looks like MM esp if suspect nodular
SCC: if looks like SCC
BCC: if concerns about site or size

Question 14

When is a 2ww referral indicated for H+N cancers?

Answer 14

Laryngeal - 45+ unexplained persistent hoarseness/lump
Oral: unexplained ulceration >3w, persistent unexplained neck lump
Thyroid: unexplained lump

Question 15

When is a 2ww referral indicated for blood cancers?

Answer 15

• Adult leukaemia: FBC within 48h if have pallor/persistent fatigue/unexplained fever/persistent infections/generalised LN/unexplained bruising/bleeding/petechiae/hepatosplenomegaly
• Child/YA leukaemia: immediate if have unexplained petechiae or hepatosplenomegaly
• Myeloma: hypercalcaemia/leukopenia when 60+
• Lymphoma: unexplained LN or splenomegaly, B sx, alcohol induced LN pain