NICE NG12, 2015 Suspected cancer: recognition and referral
The pan-London approach
11/11/2015
Dr Ishani Patel
1
Opening questions
•How many patients were diagnosed via the 2ww route?
•How many new diagnoses are made via A&E?
•Which cancers are most likely to present in this way?
•Why?
•Have you read the new guidelines?
•Your thoughts?
UK outcomes lag behind
45
Colorectal cancer one year survival
90
AUS
Lung Cancer one year survival
SWE
CAN
40
AUS
SWE
85
CAN
NOR
80
NOR
35
DEN
DEN
UK
75
UK
30
25
70
20
65
1995-99
AUS
100
2000-02
CAN
SWE
1995-99
2005-07
NOR
DEN
UK
2000-02
AUS
CAN
Breast cancer one year survival
SWE
2005-07
NOR
DEN
UK
Ovarian cancer one year survival
SWE
98
CAN
NOR
80
CAN
AUS
75
AUS
96
94
NOR
70
DEN
65
DEN
UK
UK
60
92
55
90
1995-99
AUS
2000-02
CAN
SWE
2005-07
NOR
DEN
UK
50
1995-99
AUS
2000-02
CAN
NOR
2005-07
DEN
UK
NG12, 2015
• Updated NICE guidelines for suspected cancer referrals was based
on primary care data and is symptoms based
• Reduced from 5-10% to a ≤3% PPV threshold
• Suspected cancer pathway referrals and urgent direct access
investigations
• Transforming cancer services team are working with London
Cancer Alliance and London Cancer
• Pan-London routes/forms/pathways consistent with NICE, with a
few exceptions and retention of past criteria
• Educational support alongside the forms – due to be for formal
use by March 2016
4
NG12, 2015
• There are 176 recommendations
• Emphasis on
Safety netting
Child safeguarding
Vulnerable adult safeguarding
• Most importantly…..
These recommendations are recommendations, not
requirements, and they are not intended to override
clinical judgement.
5
Pan-London Approach
• Forms that integrate with all IT systems
• Moving towards all electronic referrals (no more fax)
• Check boxes for safeguarding concerns, mobility, sensory
issues
• Weblink to guidelines within the form
• Autopopulate information from the record
• Bloods
• Imaging reports
• Guidance/prompts within the form where needed
• Patient information leaflets – translated into 11 languages
6
July 2015 edition
MrsTT
Mrs
•
•
•
•
•
•
65 year-old woman
PMHx Type 2 Diabetes
DHx Simvastatin, Metformin, Ramipril
SHx Lives with partner and teaches in local school
BMI 29
Last bloods on record are from 6 month ago
• Describes a month of worsening mid back pain and some persisting left thigh
pain for two months or so…. Brought on after a long walk in the Cotswolds
• Self cared with OTC analgesia
• Now beginning to affect her sleep
• No weight loss in fact (to her dismay) in fact trying to lose weight as she
hates taking so many pills for her long-term conditions!
What would you do next?
MrsTT
Mrs
Bloods
FBC shows mild leucopenia
Calcium on borderline
ESR borderline for age
Renal function normal
Bone scan/ MRI
Imaging
Vertebral fracture at T10
Femur x-ray normal
NICE
Mrs
T recommends
Offer a FBC, CALCIUM, ESR for patients aged > 60 with
1. Back pain
2. Persistent bone pain (> 6 weeks)
3. Unexplained fracture
Offer serum protein electrophoresis and Bence Jones Protein urine test
within 48 hours to patients aged > 60 with
1. Raised ESR
2. Presentation consistent with possible MYELOMA
Pan-London approach: Lowered age thresholds to > 40 years old
Investigation
Raised
plasma
viscosity
or
erythrocyte
sedimentation rate and presentation consistent
with myeloma
Possible cancer
Myeloma
Recommendation
Protein electrophoresis and
Bence-Jones protein urine test < 48 hours
Myeloma
Refer using suspected cancer pathway
Hypercalcaemia or leucopenia and presentation
consistent with myeloma, age ≥60 years
Protein electrophoresis or Bence-Jones protein
urine results suggest Myeloma
Haematological
Leukaemia
Myeloma
Lymphoma
Very urgent investigation:
Refer children and young people for
immediate specialist assessment for leukaemia if
they have:
• Unexplained petechiae
OR
• Hepatosplenomegaly.
Offer a very urgent full blood count (within
Urgent investigation:
Offer a full blood count, blood tests for
calcium and plasma viscosity or erythrocyte
sedimentation rate (ESR) to patients aged:
• 60 and over with:
– Persistent bone pain (particularly
OR back pain)
–
Unexplained fracture.
Immediate Specialist Assessment:
Consider very urgent referral (appointment
within 48 hours) in children and young people with:
• Unexplained lymphadenopathy
OR
• Splenomegaly.
Take in to account associated symptoms,
particularly:
• Fever
• Night sweats
• Shortness of breath
• Pruritus
• Weight loss.
Urgent referral:
48 hours) in children and young people with any of
the following unexplained signs or symptoms:
• Pallor
• Persistent fatigue
• Fever
• Persistent infection
• Generalised lymphadenopathy
• Persistent or unexplained bone pain
• Bruising
• Bleeding.
Consider a very urgent full blood count (within 48
hours) in adults with any of the following
unexplained signs or symptoms:
• Pallor
• Persistent fatigue
• Fever
• Persistent or recurrent infection
• Generalised lymphadenopathy
• Bruising
• Bleeding
• Petechiae
• Hepatosplenomegaly.
Accompanying notes:
Refer adults, children and young people with a
blood count or blood film reported as acute
leukaemia immediately.
Offer a very urgent protein electrophoresis
and a Bence-Jones protein urine test (within
48 hours) to patients aged:
• 60 and over with:
– Hypercalcaemia OR Leucopenia
AND
–
A presentation that is consistent
with possible myeloma.
Consider a very urgent protein electrophoresis
and Bence-Jones protein urine test (within
48 hours) if:
• Raised plasma viscosity or ESR at levels consistent
with myeloma
AND
• Presentation consistent with myeloma.
Urgent referral:
Urgently refer (appointment within two weeks) if
the results of protein electrophoresis or Bence- Jones
protein urine test suggest myeloma.
Consider urgent referral (appointment within
two weeks) in adults presenting with:
• Unexplained lymphadenopathy
OR
• Splenomegaly.
Take in to account associated symptoms,
particularly:
• Fever
• Night sweats
• Shortness of breath
• Pruritus
• Weight loss
• Alcohol-induced lymph node pain.
Haematology
Recommendation
Full blood count <
48 hours
Full blood count <
48 hours
Full blood count <
48 hours
Features
Possible Cancer
Recommendation
Features
Possible Cancer
Hepatosplenomegaly
Splenomegaly
(unexplained) taking into
account any fever, night
sweats, shortness of
breath, pruritus, or weight
loss
Leukaemia
Non-Hodgkin’s lymphoma
Full blood count < 48 hours
Consider suspected cancer
pathway referral
Fatigue (persistent)
in adults
Fever (unexplained)
Leukaemia
Infection
(unexplained and
persistent or
recurrent)
Leukaemia
Bruising, bleeding, or
petechiae (unexplained)
Lymphadenopathy
(generalised)
Lymphadenopathy
(unexplained) taking into
account fever, night
sweats, shortness of
breath, pruritus, weight
loss, or alcohol induced
lymph node pain
Leukaemia
Lymphadenopathy
or splenomegaly
(unexplained) with
fever, night sweats,
or pruritus
Lymphoma
Consider suspected
cancer pathway
referral
Pallor
Leukaemia
Lymphoma
Shortness of breath with
unexplained
lymphadenopathy or
splenomegaly
Persistent back pain or
bone pain or unexplained
fracture age ≥60 years
Lymphoma
Consider suspected cancer
pathway referral
Weight loss with
unexplained
lymphadenopathy
or splenomegaly
Full blood count <
48 hours
Consider suspected
cancer pathway
referral
Myeloma
Offer full blood count,
blood tests for calcium, and
either plasma viscosity
or erythrocyte
sedimentation rate
Leukaemia
Full blood count < 48 hours
Leukaemia
Full blood count < 48 hours
Lymphoma
Consider suspected cancer
pathway referral
Haematology
Haematology
Leukaemia in adults
Consider a very urgent full blood count (within 48 hours) to assess for leukaemia in adults with
any of the following:
•
•
•
•
•
•
•
•
•
pallor
persistent fatigue
unexplained fever
unexplained persistent or recurrent infection
generalised lymphadenopathy
unexplained bruising
unexplained bleeding
unexplained petechiae
hepatosplenomegaly.
Leukaemia in children and young people
Refer children and young people for immediate specialist assessment for leukaemia if they have
unexplained petechiae or hepatosplenomegaly.
Offer a very urgent full blood count (within 48 hours) to assess for leukaemia in children and
young people with any of the following:
•
•
•
•
•
•
•
•
pallor
persistent fatigue
unexplained fever
unexplained persistent infection
generalised lymphadenopathy
persistent or unexplained bone pain
unexplained bruising
unexplained bleeding.
13
Haematology
Non-Hodgkin's lymphoma in adults
• Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for
non-Hodgkin's lymphoma in adults presenting with unexplained lymphadenopathy or
splenomegaly. When considering referral, take into account any associated symptoms,
particularly fever, night sweats, shortness of breath, pruritus or weight loss.
Non-Hodgkin's lymphoma in children and young people
• Consider same day specialist assessment for non-Hodgkin's lymphoma in children and
young people presenting with unexplained lymphadenopathy or splenomegaly. When
considering referral, take into account any associated symptoms, particularly fever, night
sweats, shortness of breath, pruritus or weight loss.
Hodgkin's lymphoma in adults
• Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for
Hodgkin's lymphoma in adults presenting with unexplained lymphadenopathy. When
considering referral, take into account any associated symptoms, particularly fever, night
sweats, shortness of breath, pruritus, weight loss or alcohol-induced lymph node pain.
Hodgkin's lymphoma in children and young people
• Consider same day specialist assessment for Hodgkin's lymphoma in children and young
people presenting with unexplained lymphadenopathy. When considering referral, take
into account any associated symptoms, particularly fever, night sweats, shortness of
breath, pruritus or weight loss.
14
Skin
Malignant melanoma
Squamous cell carcinoma
Basal cell carcinoma
Urgent referral
Urgently refer (appointment within
two weeks) if:
• The patient presents with a suspicious pigmented
skin lesion that has a weighted 7-point checklist
score of 3 or more
OR
• Dermoscopy suggests malignant melanoma of
the skin.
Urgent referral:
•
Consider urgently referring (appointment
within two weeks) if patient has a skin lesion that
raises the suspicion of squamous cell carcinoma.
Urgent referral:
Only consider urgent referral (appointment
within two weeks) for patients with:
• A skin lesion that raises the suspicion of a basal cell
carcinoma if there is concern that a delay may
have an unfavourable impact, because
of factors such as lesion site or size.
Non-urgent referral:
Consider routine referral for patients with:
• A skin lesion that raises the suspicion of a basal cell
carcinoma.
Consider urgent referral (appointment within 2
weeks) for melanoma in patients with
a pigmented or non-pigmented skin lesion
that suggests nodular melanoma.
Accompanying notes:
The 7-point weighted checklist:
Major features (scoring 2 points each)
• Change in size
• Irregular shape
• Irregular colour
Minor features (scoring 1 point each)
•
•
•
•
Largest diameter of 7mm or more
Inflammation
Oozing
Change in sensation
Accompanying notes:
Squamous cell carcinomas are usually raised
lesions, a number of typical features have been
described: often ulcerated keratinised or crusting
lesions and growing typically on the head and neck
or back of hand. They occur commonly and are
higher risk in anyone who is immunocompromised or had a previous organ transplant.
Refer all new skin lesions in this group urgently.
Accompanying notes:
Features suggestive of a basal cell
carcinoma include:
• An ulcer with raised, rolled edge,
• Prominent fine blood vessels around the lesion,
• Nodules, often waxy or pearly in appearance.
Suspected basal cell carcinomas should only be excised
in primary care in accordance with the NICE guidance
on Improving outcomes for people with skin tumours
including melanoma (May 2010).
Specific sites of concern are sun-exposed areas such as
the scalp, face, hands and arms, particularly in fairhaired patients.
Skin
Pan-London approach are asking to consider risk factors
1.
2.
3.
4.
5.
Photo-damaged skin
Immunosuppression
Transplant
H/x skin cancer
FHx of skin cancer
What does lesion site or size refer to when determining a routine referral or a 2ww
for a BCC?
Pan-London: rapidly growing lesions near the eyelid, lip margin or nose refer to local
2ww service as higher risk of it being an SCC as well as needing rapid plastics
involvement
16
Brain and CNS
Brain and CNS cancer
Very urgent referral:
Consider very urgent referral (appointment
within 48 hours) in:
• Children and young people with newly abnormal
central neurological or cerebellar function.
Urgent Direct Access:
Consider urgent direct access MRI brain scan
(appointment within 2 weeks) in:
• Adults with progressive, sub-acute loss of central
neurological function.
Accompanying notes:
• A ‘normal’ scan
A normal investigation does not preclude the need
for ongoing follow up, monitoring and further
investigation. Furthermore, a seemingly ‘normal’
MRI scan may provide false reassurance in patients
who have neurological pathology that MRI scanning
is unable to detect.
• Approximately 10% of patients may be unsuitable
for, or unable to tolerate an MRI brain scan, e.g.
patients with pacemakers in-situ or those with
severe claustrophobia. In these patients a CT scan
may be more appropriate, taking potential radiation
exposure in to consideration.
• Incidental findings
A small percentage of MRI scans may yield
abnormalities in otherwise healthy individuals. This
may impact on these patients in a number of ways
including further investigation and the potential
impact on health insurance premiums. As incidental
findings are not an infrequent result of MRI
scanning, patients should have prior counselling and
information to make them aware of the potential
for such findings as a consequence of their
investigation.
• No definition of ‘progressive sub-acute loss of
central neurological function’ has been provided
for this update, but the 2005 NICE guidance for
suspected cancer includes signs
or symptoms that may cause concern, including:
progressive neurological deficit, new-onset
seizures, headaches, mental changes, cranial nerve
palsy.
• Headaches of recent onset accompanied by features
suggestive of raised intracranial pressure,
e.g. vomiting, drowsiness, posture-related
headache, pulse-synchronous tinnitus, or other
focal or non-focal neurological symptoms, such as
blackout or change in personality or memory.
• Consider urgent referral in patients with rapid
progression of: sub-acute focal neurological
deficit; unexplained cognitive impairment,
behavioural disturbance or slowness, or a
combination of these; personality changes
confirmed by a witness and for which there is no
reasonable explanation even in the absence
of the other symptoms or signs of a brain tumour.
Brain
Skin and CNS
Consider urgent (within 2 weeks) direct access MRI scan of the brain (or CT scan if MRI
is contraindicated) in adults with
•
•
•
•
•
progressive, sub-acute loss of central neurological function
new onset seizure
history of a malignancy with symptoms
personality change
blackout
• New onset headache with sinister features such as
• Vomiting
• Pulse-synchronous tinnitus
• Worse on supine position
• Awakens sleep
• Behavioural slowness
• Cognitive decline
18
Head and neck
Laryngeal cancer
Urgent referral:
Consider urgent referral (appointment within
two weeks) in patients:
• Aged 45 and over with either:
- Persistent unexplained hoarseness
OR
A dentist should consider urgent referral (appointment
within two weeks) for patients with either of the
following, which have been assessed by a dental
surgeon and concluded to be consistent with oral
cancer:
• A lump on the lip or the oral cavity
OR
- An unexplained lump in the neck.
Oral cancer
Urgent referral:
Consider urgent referral (appointment within
two weeks) for patients with:
• An unexplained ulceration in the oral cavity
lasting for more than 3 weeks
OR
• A persistent and unexplained lump in the neck
Consider urgent referral (appointment within
two weeks) for assessment by a dentist in patients
with either:
• An unexplained lump on the lip or in the
oral cavity
OR
• A red or red and white patch in the oral
cavity consistent with erythroplakia or
erythroleukoplakia.
• A red or red and white patch in the oral
cavity consistent with erythroplakia or
erythroleukoplakia.
Thyroid cancer
Urgent referral:
Consider urgent referral (appointment within
two weeks) in patients with:
• An unexplained thyroid lump.
Head and neck
•
Pan-London age thresholds lowered to 40+
•
Unexplained lump in the neck requires a concurrent chest x-ray to exclude lung cancer
or lymphoma
•
Unexplained = solitary thyroid lump (not bulky or all thyroid lumps!) or with suspicious
clinical features
•
Document risk factors
• Alcohol
• Tobacco
• HPV
• HIV/immuosuppresion
•
Area for dentists to refer
• Unexplained tooth mobility without periodontal disease
• Poor healing after dental extraction > 3/52
•
•
Pharyngeal cancers (23%) were omitted from the new guidance
Retention of old criteria from CG27, 2005 and WHO oral cancer guidelines
•
•
•
Persistent sore throat
Throat pain
Hoarseness (concurrent CXR)
20
Mr A
61 year old male
Office manager
Never smoked
You receive a OOH attendance note from local UCC
New onset dysuria and one episode of haematuria – immediate attended
UCC
• Urinalysis abnormal: leuk, nits, prot and blood +++
• Urine CTG sent – normal
• Urine culture sent - shows E.coli infection
• Patient was treated for a UTI at the time and asked to review results
with his GP
3 weeks later dysuria recurs but no visible haematuria
• Urinalysis indicates blood but no infection parameters
• Settles again after a second course of antibiotics
What next…..
Mr A
What would you do next…
• Abdomen ultrasound scan
• KUB AXR
• DRE, Full blood count and PSA
• Glucose, HbA1c, bone profile
• Routine referral to Urology
• GUM clinic
• Safety net and repeat urinalysis again even in the absence of
symptoms
NICE Recommends…
What would you do next…
• Abdomen ultrasound scan
• KUB AXR
• DRE, Full blood count and PSA
• Glucose, HbA1c, bone profile
• Routine referral to Urology
• GUM clinic
• Safety net and repeat urinalysis again even in the absence of
symptoms
NICE recommends  2ww
BLADDER
• Age 60+
• Unexplained non-visible haematuria with either
• Dysuria
• Raised WCC
BLADDER/RENAL
• Age 45+
• Unexplained visible haematuria without UTI
• Persisting visible haematuria after successful Rx for UTI
NICE recommends  2ww
PROSTATE
• SINGLE PSA above age-thresholds (BAUS)
AUDIT across London to discuss whether TWO PSAs may be a referral
criteria but at present aligning with NICE, NG12
Urological
Prostate cancer
Bladder cancer
Urgent referral:
Urgently refer men (appointment within two
weeks) if either:
• Their prostate feels malignant on digital rectal
examination (DRE)
OR
• Their prostate specific antigen (PSA) levels are
above the age-specific reference range.
Urgent referral:
Urgently refer patients (appointment within
two weeks) if they are:
• Aged 45 and over with either:
– Unexplained visible haematuria without
OR urinary tract infection
Non-urgent investigation:
Consider a PSA test AND DRE in men with any
of the following:
• Any lower urinary tract symptoms, such as
nocturia, urinary frequency, hesitancy,
urgency or retention
• Erectile dysfunction
• Visible haematuria.
–
Visible haematuria that persists or recurs
after successful treatment of urinary tract
infection.
• Aged 60 and over with unexplained non-visible
haematuria and either:
– Dysuria
OR
– A raised white cell count on a blood test.
•
•
•
•
Consider alternative contributing
factors that may influence an
individual’s PSA ranges.
Urgent referral:
Consider urgent referral (appointment within two
weeks) in men with any of the following changes in the
testis:
• Non-painful enlargement
• Change in shape
• Change in texture.
Direct access ultrasound:
Consider a direct access ultrasound scan in men with
unexplained or persistent testicular symptoms.
Penile cancer
Non-urgent referral:
Consider referral in patients aged 60 and over
with recurrent or persistent urinary tract infection that
is unexplained.
Renal cancer
Accompanying notes:
Prostate-specific antigen ranges:
40–49 years 0–2.5ng/L
50–59 years 0–3.5ng/L
60–69 years 0–4.5nh/L
70–79 years 0–6.5ng/L
Testicular cancer
Urgent referral:
Urgently refer patients (appointment within two
weeks) if they are:
• Aged 45 years and over with either:
–
–
Unexplained visible haematuria without
urinary tract infection
Visible haematuria that persists or recurs
after successful treatment of urinary tract
infection.
Urgent referral:
Consider urgent referral (appointment within two
weeks) in men with any of the following, after exclusion
of sexually transmitted infection as a cause or after
treatment for a sexually transmitted infection has been
completed:
• A penile mass
• An ulcerated lesion
• Unexplained OR persistent symptoms affecting
the foreskin or glans.
Mr F
53 years old
Ex – smoker on the record
H/O pneumonia six months ago – had a post Rx CXR – normal
Wife asked him to get 3 week cough checked out as keeping her up at
night
Not in fact an ex-smoker! Smokes hash in a pipe
No haemoptysis fevers or weight loss
Chest clear
What do you do next…..
27
Mr F
What would you do next…..
• Chest x-ray
• FBC
• Spirometry
• 2ww
• Safety net and f/up in 3 weeks
• Reassure
• Smoking cessation advice
28
NICE recommends…
What would you do next…..
• Chest x-ray 
• FBC 
• Spirometry
• 2ww
• Safety net and f/up in 3 weeks
• Reassure
• Smoking cessation advice
29
NICE recommends….
Chest x-ray is normal
FBC shows elevated platelets
2ww referral 
In symptomatic patients, the majority of chest X-rays will be abnormal, but a
normal chest X-ray does not exclude diagnosis of lung cancer. This was shown in
the 2006 BJGP study of normal and abnormal chest x-rays in lung cancer
patients, 23% of lung cancer patients had a negative X-ray.
Pan-London – retaining shoulder and chest pain as criteria
30
Lung
Lung and pleural cancers
Urgent referral:
Urgently refer for lung cancer or mesothelioma
(appointment within two weeks) in patients with:
• Chest X-ray findings that suggest lung cancer or
mesothelioma
OR
• Patients aged 40 and over with unexplained
haemoptysis.
Urgent investigations:
Consider an urgent chest X-ray (to be
performed within two weeks) for lung cancer or
mesothelioma in patients aged 40 and over with
any of the following:
• Persistent or recurrent chest infection
• Finger clubbing
• Supraclavicular lymphadenopathy OR persistent
cervical lymphadenopathy
• Chest signs consistent with lung cancer or
pleural disease
• Thrombocytosis.
Urgent investigation:
Offer an urgent chest X-ray (to be performed
within two weeks) to assess for lung cancer
or mesothelioma in people:
• Aged 40 and over if they have never smoked
with 2 or more of the following unexplained
OR signs or symptoms
• Aged 40 and over and have previously smoked with
1 or more of the following unexplained signs or
symptoms
OR
• Any age if they have ever been exposed to
asbestos and have 1 or more of the following:
–
–
–
–
–
–
Cough
Fatigue
Shortness of breath
Chest pain
Weight loss
Appetite loss.
Accompanying notes:
In symptomatic patients, the majority of chest X-rays will
be abnormal, but a normal chest X-ray does not exclude
diagnosis of lung cancer. This was shown in the 2006 BJGP
study of normal and abnormal chest x-rays in lung cancer
patients, 23% of lung cancer patients had a negative X-ray.
Lung
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 or
• are aged 40 and over with unexplained haemoptysis.
Offer a chest X-ray to assess for lung cancer in people aged 40 and over if they have 2 or more of the following
unexplained symptoms, or if they have ever smoked and have 1 or more of the following unexplained symptoms:
• cough
• fatigue
• shortness of breath
• chest pain
• weight loss
• appetite loss.
Consider an urgent chest X-ray (to be performed within 2 weeks) to assess for lung cancer in people aged 40 and
over with any of the following:
• persistent or recurrent chest infection
• finger clubbing
• supraclavicular lymphadenopathy or persistent cervical lymphadenopathy
• chest signs consistent with lung cancer
• thrombocytosis.
32
Lung
Mesothelioma
Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for
mesothelioma if they have chest X-ray findings that suggest mesothelioma.
Offer a chest X-ray to assess for mesothelioma in people aged 40 and over, if:
• they have 2 or more of the following unexplained symptoms, or
• they have 1 or more of the following unexplained symptoms and have ever smoked, or
• they have 1 or more of the following unexplained symptoms and have been exposed to
asbestos:
• cough
• fatigue
• shortness of breath
• chest pain
• weight loss
• appetite loss.
Consider an urgent chest X-ray (to be performed within 2 weeks) to assess for mesothelioma in
people aged 40 and over with either:
• finger clubbing or
• chest signs compatible with pleural disease.
33
• 61 years old
• Ex – smoker
• New type 2 diabetes mellitus diagnosis on NHS health check
• BMI 30 and no FHx
• Lost a few kg in the past year
• Vague upper abdominal pain and occasional heartburn
• What do you do next…..
34
What do you do next….
• Abdomen US
• Abdomen CT
• Ca19/9
• FBC
• Ferritin/ TIBC
• Bone profile
• ESR
• Renal function
• Liver function
• Helicobacter pylori antigen test
• Upper GI Endoscopy
35
What do you do next….
• Abdomen US
• Abdomen CT
• Ca19/9
• FBC (Hb and platelets)
• Ferritin/ TIBC
• Bone profile
• ESR
• Renal function
• Liver function
• Helicobacter pylori antigen test
• URGENT Upper GI Endoscopy
• ROUTINE Upper GI Endoscopy
36
Upper gastrointestinal
• Raised platelet count with any of the following:
Oesophageal and gastric
cancer
O - Oesophageal
–
–
–
–
–
–
G - Gastric
Urgent referral for endoscopy within two
weeks:
Urgently refer patients presenting with:
• Dysphagia (at any age) (OG)
OR
• Aged 55 and over with weight loss
AND
Upper abdominal pain
OR
Dyspepsia (OG).
Nausea
Vomiting
Reflux
Weight loss
Dyspepsia
Upper abdominal pain (OG)
OR
• Nausea or vomiting with any of the following:
–
–
–
–
Weight loss
Reflux
Dyspepsia
Upper abdominal pain (OG).
Pancreatic cancer
Gall bladder
Urgent direct access
Consider an urgent direct access ultrasound
scan (within two weeks) to assess for gall bladder
cancer in people with an upper abdominal mass
consistent with an enlarged gall bladder.
Liver cancer
Urgent direct access
Consider an urgent direct access ultrasound scan
(within two weeks) to assess for liver cancer in people
with an upper abdominal mass consistent with an
enlarged liver.
OR
Reflux
Consider urgent referral (appointment within two
weeks) for patients with an upper abdominal mass
consistent with stomach cancer (G).
Non-urgent direct access endoscopy:
Consider non-urgent direct access endoscopy for
patients presenting with:
• Haematemesis (at any age) (OG)
OR
• Aged 55 and over with:
– Treatment resistant dyspepsia (OG)
OR
– Upper abdominal pain and low
haemoglobin (OG)
Urgent referral:
Urgently refer patients (appointment within two
weeks) if aged 40 and over with jaundice.
Urgent direct access CT scan or an urgent
ultrasound scan if CT scan is not available:
Consider urgent direct access CT scan (within two
weeks) or ultrasound scan if CT scan is not
available for patients:
• Aged 60 and over, displaying weight loss
AND any of the following:
–
–
–
–
–
–
Diarrhoea
Back pain
Abdominal pain
Nausea/vomiting
Constipation
New-onset diabetes.
Accompanying notes:
Consider that 10% of pancreatic cancers are missed
by abdomen ultrasounds, whilst tumours smaller than
3cm will not be visible using an ultrasound. CT scans
have the advantage of staging at the same time.
Upper GI
Oesophageal cancer
Offer urgent direct access upper gastrointestinal endoscopy (to be performed within 2 weeks) to assess for oesophageal cancer in people:
• with dysphagia or aged 55 and over with weight loss and any of the following:
• upper abdominal pain
• reflux
• dyspepsia.
Consider non-urgent direct access upper gastrointestinal endoscopy to assess for oesophageal cancer in people with haematemesis.
Consider non-urgent direct access upper gastrointestinal endoscopy to assess for oesophageal cancer in people aged 55 or over with:
• treatment-resistant dyspepsia or upper abdominal pain with low haemoglobin levels 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.
38
Upper GI
Stomach cancer
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for people with an upper abdominal mass consistent
with stomach cancer.
Offer urgent direct access upper gastrointestinal endoscopy (to be performed within 2 weeks) to assess for stomach cancer in people:
• with dysphagia or aged 55 and over with weight loss and any of the following:
• upper abdominal pain
• reflux
• dyspepsia.
Consider non-urgent direct access upper gastrointestinal endoscopy to assess for stomach cancer in people with haematemesis.
Consider non-urgent direct access upper gastrointestinal endoscopy to assess for stomach cancer in people aged 55 or over with:
• treatment-resistant dyspepsia or upper abdominal pain with low haemoglobin levels 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.
39
Upper GI
Gall bladder cancer
Consider an urgent direct access ultrasound scan (to be performed within 2 weeks) to assess for gall bladder cancer in people
with an upper abdominal mass consistent with an enlarged gall bladder.
Liver cancer
Consider an urgent direct access ultrasound scan (to be performed within 2 weeks) to assess for liver cancer in people with an
upper abdominal mass consistent with an enlarged liver.
Pancreatic cancer
Refer for same day assessment for pancreatic cancer if they are aged 40 and over and have jaundice.
Consider an urgent direct access CT scan (to be performed within 2 weeks), or an urgent ultrasound scan if CT is not available, to
assess for pancreatic cancer in people aged 60 and over with weight loss and any of the following:
• diarrhoea
• back pain
• abdominal pain
• nausea
• vomiting
• constipation
• new-onset diabetes.
10% of pancreatic cancers are missed by abdomen ultrasounds, whilst tumours smaller
than 3cm will not be visible using an ultrasound. CT scans have the advantage of staging
at the same time
New onset diabetes can appear two years before an US detected pancreatic tumour is
possible
CT is the gold standard!
40
Bone and sarcoma
Bone sarcoma
Soft tissue sarcoma
Very urgent direct access:
Consider a very urgent direct access X-ray
(appointment within 48 hours) in any child or young
person with unexplained:
• Bone swelling
OR
• Bone pain.
Very Urgent referral:
Very urgent direct access:
Consider very urgent direct access ultrasound
scan (performed within 48 hours) for children and
young people with:
• An unexplained lump that is increasing in size.
Urgent direct access:
Consider very urgent referral in children and
young people (appointment within 48 hours) with:
• An X-ray that suggests the possibility of
bone sarcoma.
Urgent referral:
Consider urgent referral (appointment within
two weeks) in adults with:
• An X-ray that suggests the possibility of
bone sarcoma.
Consider urgent direct access ultrasound scan
(performed within two weeks) in adults with:
• An unexplained lump that is increasing in size.
Very urgent referral:
Consider very urgent referral (within 48 hours) in
children or young people with:
• Ultrasound scan findings that are suggestive of
soft-tissue sarcoma
OR
• Ultrasound scan findings that are uncertain and
clinical concern persists.
Urgent referral:
Consider urgent referral (within two weeks) in
adults with:
• Ultrasound scan findings that are suggestive of
soft-tissue sarcoma
OR
• Ultrasound scan findings that are uncertain
and clinical concern persists.
Sarcoma
Bone sarcoma in adults
Consider a suspected cancer pathway referral (for an appointment within
2 weeks) for adults if an X-ray suggests the possibility of bone sarcoma.
Bone sarcoma in children and young people
Consider same day specialist assessment for children and young people if an
X-ray suggests the possibility of bone sarcoma.
Consider a very urgent direct access X-ray (to be performed within 48 hours) to
assess for bone sarcoma in children and young people with unexplained bone
swelling or pain.
BONE PAIN includes night pain, pain not responding to simple analgesia, bony
swelling and tenderness.
Plain radiographs may be ‘normal’ in patients with early bone sarcoma and if
there is bone pain and night pain not responding to simple analgesia consider
urgent MRI scan or referral to a sarcoma centre
42
Sarcoma
Soft tissue sarcoma in adults
Consider a 2ww to a sarcoma centre to assess an unexplained lump that 4.3cm
or larger (golf ball)
DO NOT ARRANGE AN URGENT ULTRASOUND AS MRI IS THE GOLD STANDARD
REFER TO SARCOMA CENTRE!
Soft tissue sarcoma in children and young people
Consider same day assessment for soft tissue sarcoma in children and young
people with an unexplained lump that is increasing in size.
Consider a same day assessment for children and young people if they have
symptoms or imaging results suggestive of soft tissue sarcoma or if findings are
uncertain and clinical concern persists.
43
Breast
Breast cancer
Urgent referral:
Urgently refer patients (appointment within
two weeks) if they are male or female:
• Aged 30 and over with an unexplained breast
lump (with or without pain)
OR
• Aged 50 and over with any unilateral
nipple changes of concern including discharge or
retraction.
Consider urgent referral (appointment within two
weeks) if:
• There are skin changes suggestive of breast
cancer
OR
• They are aged 30 and over with an unexplained
lump in the axilla.
Non-urgent referral:
Consider non-urgent referral in patients
under the age of 30 with an unexplained breast
lump (with or without pain).
Ms A
47 year-old Afro-Caribbean lady
Known type 2 diabetes – diet controlled
New onset unexplained vaginal discharge
Not sexually active for 6 months
Smears up to date
Regular periods
No IMB
What next….
45
NICE recommends…
What would you do next….
•
•
•
•
•
•
•
•
Pelvic and abdomen exam
Swabs/sexual health screen
Cervical smear
FBC
Urgent US pelvis
Non-urgent US pelvis
Ca125
2ww
46
NICE recommends…
What would you do next….
Pelvic and abdomen exam
Swabs/sexual health screen
Cervical smear
FBC
Urgent US pelvis
Non-urgent US pelvis
Ca125
2ww
NICE Recommends….
1. Full blood count  Elevate platelets/Low Hb DIRECT ACCESS
PELVIC US TO EXCLUDE ENDOMETRIAL CANCER
47
Gynaecology – Pan London
Endometrial cancer
• Refer women using a suspected cancer pathway referral (for an appointment within 2 weeks) for endometrial cancer if
they are aged 45 and over with post-menopausal bleeding (unexplained vaginal bleeding more than 12 months after
menstruation has stopped because of the menopause).
• Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for endometrial cancer in women aged
under 55 with post-menopausal bleeding.
• Consider a direct access ultrasound scan to assess for endometrial cancer in women aged 45 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
• low haemoglobin levels or thrombocytosis or high blood glucose levels (diabetes)
Cervical cancer
• Consider a suspected cancer pathway referral (for an appointment 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 (for an appointment within 2 weeks) for vulval cancer in women with an
unexplained vulval lump, ulceration or bleeding.
Vaginal cancer
• Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for vaginal cancer in women with an
unexplained palpable mass in or at the entrance to the vagina.
48
Gynaecology – Pan London
Ovarian cancer
Refer the woman urgently if physical examination identifies ascites and/or a pelvic or abdominal
mass (which is not obviously uterine fibroids)
• Carry out tests in primary care if a woman (especially if 45 or over) reports having any of the
following symptoms on a persistent or frequent basis – particularly more than 12 times per month:
• persistent abdominal distension (women often refer to this as 'bloating')
• feeling full (early satiety) and/or loss of appetite
• pelvic or abdominal pain
• increased urinary urgency and/or frequency.
Consider carrying out tests in primary care if a woman reports unexplained weight loss, fatigue or
changes in bowel habit.
Advise any woman who is not suspected of having ovarian cancer to return to her GP if her
symptoms become more frequent and/or persistent.
Carry out appropriate tests for ovarian cancer in any woman of 45 or over who has experienced
symptoms within the last 12 months that suggest irritable bowel syndrome (IBS), because IBS rarely
presents for the first time in women of this age.
• Measure serum CA125 in primary care and ultrasound scan of the abdomen and pelvis.
• If the ultrasound suggests ovarian cancer, refer the woman urgently for further investigation.
• For any woman who has 35 IU/ml or greater but a normal ultrasound refer 2ww
49
Gynaecological
Endometrial Cancer
Ovarian cancer
Urgent referral:
Urgently refer (appointment within two
weeks) if physical examination identifies any of
the following:
• Ascites
• Pelvic or abdominal mass (which is not obviously
uterine fibroids).
Urgent Investigation:
Arrange CA125 and/or ultrasound tests in
women (especially if 50 or over) with any of the
following on a persistent or frequent basisparticularly more than 12 times per month:
•
•
•
•
•
Persistent abdominal distension (bloating)
Early satiety and/or loss of appetite
Pelvic or abdominal pain
Increased urinary urgency and/or frequency
New onset symptoms suggestive of IBS (as IBS
rarely presents for the first time in women of this
age).
Consider CA125 and/or ultrasound tests if a woman
reports any of the following:
Urgent referral:
Urgently refer women (appointment within
two weeks) if they are:
• Aged 55 and over with:
–
Post-menopausal bleeding (unexplained
vaginal bleeding more than 12 months
after menstruation has stopped due to the
menopause).
Consider urgent referral (appointment within two
weeks) if they are:
• Aged under 55 with:
–
Post-menopausal bleeding.
Direct Access Ultrasound:
Consider direct access ultrasound in women:
• Aged 55 and over presenting with unexplained
symptoms of vaginal discharge who:
– Are presenting with these symptoms for the
first time
Report haematuria.
OR
Have thrombocytosis
Consider direct access ultrasound in women:
• Unexplained weight loss
• Fatigue
• Changes in bowel habit (though colorectal
cancer is a more common malignant cause).
• Aged 55 and over presenting with visible
haematuria and any of the following:
–
–
–
Low haemoglobin
Thrombocytosis
High blood glucose level.
Cervical cancer
Urgent referral:
Consider urgent referral (appointment within
two weeks) if:
• The appearance of the woman’s cervix is
consistent with cervical cancer.
Accompanying notes:
A smear test is not required before referral, and a
previous negative result should not delay referral.
Vulval cancer
Urgent referral:
Consider urgently referring (appointment within
two weeks) women with any of the following
unexplained vulval signs or symptoms:
• A vulval lump
• Ulceration
• Bleeding.
Vaginal cancer
Urgent referral:
Consider urgent referral (appointment within two
weeks) in women with an unexplained palpable mass in
or at the entrance to the vagina.
NG12: Colorectal
Symptom Profile in
primary care
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Rectal bleeding PLUS
diarrhoea for 6 weeks
(>40)
Rectal bleeding for 6
weeks (>60)
CIBH for 6 weeks (>60)
Mass (any age)
Iron deficiency anaemia
(Male Hb<11g/dl; female
Hb<10g/dl)
Loss of weight and
abdominal pain (>40)
Rectal bleeding (>50)
Iron-deficiency anaemia
(>60)
CIBH (>60)
Rectal bleeding, plus a
second symptom (<50)
Unexplained abdo pain or
weight loss (<50)
CIBH (<60)
Iron-deficiency anaemia
(<60)
Non-iron deficiency
anaemia (>60)
Other symptoms
Under 2005
Guidance
Refer
Under 2015
guidance
Refer
Approximate risk
of cancer
5% or more
3-5%
Refer
Test for
occult blood
1-3%
Safety net
51
Lower gastrointestinal
Colorectal cancer
Urgent referral:
Urgently refer (appointment within two weeks)
for colorectal cancer in patients:
• Aged 40 and over with:
–
Unexplained weight loss AND abdominal
pain
• Aged 50 and over with:
– Unexplained rectal bleeding
• Aged 60 and over with either:
– Iron deficiency anaemia
OR
– Alteration in bowel habit
• An unexplained positive Faecal Occult Blood
Test (FOBT).
Consider urgent referral (appointment within 2
weeks) for colorectal cancer in patients:
• Any age with:
–
A rectal or abdominal mass
• Aged under 50 with rectal bleeding AND any of the
following unexplained signs or symptoms:
–
–
–
–
Abdominal pain
Altered bowel habit
Weight loss
Iron deficiency anaemia.
Faecal Occult Blood Testing
In the absence of rectal bleeding, offer FOBT to
patients:
• Aged 50 or over with unexplained:
–
Abdominal pain
OR
Weight loss
–
• Aged under 60 with either:
–
Changes in bowel habit
OR
Iron-deficiency anaemia
–
• Aged 60 and over with:
– Anaemia even in the absence of iron deficiency.
Anal cancer
Urgent referral:
Consider urgent referral (appointment within
two weeks) in patients with either:
• An unexplained anal mass
OR
• Unexplained anal ulceration.
Colorectal – pan London
LONDON IS NOT SUPPORTING USE OF FOBT!
RECTAL BLEEDING
•
Aged 50 years or over with rectal bleeding
•
Aged Less than 50 years but MUST have one or more of the following
Abdominal pain
Change in bowel habit
Weight loss
Iron deficiency anaemia
CHANGE IN BOWEL HABIT - aged 60 or over
IRON DEFICIENCY ANAEMIA - aged 60 or over
ABDOMINAL PAIN AND WEIGHT LOSS – aged 40 or over
Abnormal physical examination
•
Abdominal mass thought to be large bowel cancer (any age)
•
Palpable rectal mass (any age)
•
Anal mass (unexplained and any age)
•
Anal ulceration (unexplained and any age)
Anal cancer
• Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for anal cancer in people
with an unexplained anal mass or unexplained anal ulceration.
53
Children and TYA
Symptoms of concern in children and young people
Take into account the insight and knowledge of parents and carers when considering making a referral for suspected cancer in a
child or young person. Consider referral for children if their parent or carer has persistent concern or anxiety about the child's
symptoms, even if the symptoms are most likely to have a benign cause.
Leukaemia in children and young people
Refer children and young people for immediate specialist assessment for leukaemia if they have unexplained petechiae or
hepatosplenomegaly. [new 2015]
Offer a very urgent full blood count (within 48 hours) to assess for leukaemia in children and young people with any of the
following:
• pallor
• persistent fatigue
• unexplained fever
• unexplained persistent infection
• generalised lymphadenopathy
• persistent or unexplained bone pain
• unexplained bruising
• unexplained bleeding
Hodgkin's lymphoma in children and young people
Consider a very urgent referral (for an appointment within 48 hours) for specialist assessment for Hodgkin's lymphoma in
children and young people presenting with unexplained lymphadenopathy. When considering referral, take into account any
associated symptoms, particularly fever, night sweats, shortness of breath, pruritus or weight loss.
Brain tumour/cancers
Consider a very urgent referral (for an appointment within 48 hours) for suspected brain or central nervous system cancer
in children and young people with newly abnormal cerebellar or other central neurological function.
54
Children and TYA
Soft tissue sarcoma
Consider a very urgent direct access ultrasound scan (to be performed within 48 hours) to assess for soft tissue
sarcoma in children and young people with an unexplained lump that is increasing in size.
Consider a very urgent referral (for an appointment within 48 hours) for children and young people if they have
ultrasound scan findings that are suggestive of soft tissue sarcoma or if ultrasound findings are uncertain and
clinical concern persists.
Bone sarcoma
Consider a very urgent referral (for an appointment within 48 hours) for specialist assessment for children and
young people if an X-ray suggests the possibility of bone sarcoma.
Consider a very urgent direct access X-ray (to be performed within 48 hours) to assess for bone sarcoma in
children and young people with unexplained bone swelling or pain.
Neuroblastoma
Consider very urgent referral (for an appointment within 48 hours) for specialist assessment for neuroblastoma
in children with a palpable abdominal mass or unexplained enlarged abdominal organ.
Retinoblastoma
Consider urgent referral (for an appointment within 2 weeks) for ophthalmological assessment for
retinoblastoma in children with an absent red reflex.
Wilms' tumour
Consider very urgent referral (for an appointment within 48 hours) for specialist assessment for Wilms' tumour in
children with any of the following:
• a palpable abdominal mass
• an unexplained enlarged abdominal organ
• unexplained visible haematuria
55
Children and TYA
Suspected cancer (part 1—children and young adults): visual overview of updated NICE guidance Hamilton et
al, BMJ 2015; 350:h3036
56
You know more than most that cancer doesn’t just affect the people you
support physically. It can affect everything – their relationships, finances
and careers.
We want to work with you to help you provide the best support possible for
people affected by cancer and their families. So as well as offering resources to
support you in your role, we can provide information to the people you support,
so they know they’ll never have to face cancer alone.
Together, we can help make sure people affected by cancer get the support they
need to feel more in control – from the moment they’re diagnosed, through
treatment and beyond.
Our cancer support specialists, benefits advisers and cancer nurses are available to
answer any questions your patients might have through our free Macmillan Support
Line on 0808 808 00 00 (Monday to Friday, 9am – 8pm).
To find out more about our work and services,
visit macmillan.org.uk/professionals
Macmillan Cancer Support, registered charity in England and Wales (261017), Scotland (SC039907) and the
Isle of Man (604). MAC15454_DESKTOP
PATIENT INFORMATIN LEAFLET
http://londoncancer.org/media/48492/2wkreferral-patient-leaflet.pdf
http://londoncancer.org/media/124336/patientinformation-for-urgent-referrals.pdf
Final case….
69 year old lady
Acute swelling left calf consistent with a DVT
NO triggers
DVT Ax – Doppler confirms – Haematology initiates NOAC
What next…..
58
Final case….
What next…… could be a sign of an underlying malignancy
1.
2.
3.
4.
Urogenital
Breast
Colorectal
Lung cancer
Carry out an assessment for additional symptoms, signs or findings that may help
to clarify which cancer is most likely and offer urgent investigation or a suspected
cancer pathway referral (for an appointment within 2 weeks).
59
Cancer of unknown primary
Some symptoms or symptom combinations may be features of several different cancers. For some of
these symptoms, the risk for each individual cancer may be low but the total risk of cancer of any
type may be higher. This section includes recommendations for these symptoms.
Symptoms of concern in adults
For people with unexplained weight loss, which is a symptom of several cancers including colorectal,
gastro-oesophageal, lung, prostate, pancreatic and urological cancer:
• Carry out an assessment for additional symptoms, signs or findings that may help to clarify which
cancer is most likely and offer urgent investigation or a suspected cancer pathway referral (for an
appointment within 2 weeks).
For people with unexplained appetite loss, which is a symptom of several cancers including lung,
oesophageal, stomach, colorectal, pancreatic, bladder and renal cancer:
• Carry out an assessment for additional symptoms, signs or findings that may help to clarify which
cancer is most likely and offer urgent investigation or a suspected cancer pathway referral (for an
appointment within 2 weeks).
For people with deep vein thrombosis, which is associated with several cancers including urogenital,
breast, colorectal and lung cancer:
• Carry out an assessment for additional symptoms, signs or findings that may help to clarify which
cancer is most likely and consider urgent investigation or a suspected cancer pathway referral (for
an appointment within 2 weeks).
60
Cancer of unknown primary
• Unexplained weight loss
colorectal, gastro-oesophageal, lung, prostate, pancreatic and urological
cancer
• Unexplained appetite loss
lung, oesophageal, stomach, colorectal, pancreatic, bladder and renal
cancer
• Deep vein thrombosis
urogenital, breast, colorectal and lung cancer
Carry out an assessment for additional symptoms, signs or findings that may help
to clarify which cancer is most likely and offer urgent investigation or a suspected
cancer pathway referral (for an appointment within 2 weeks).
61
Non-specific features of cancer
Suspected cancer (part 2—adults): visual overview of updated NICE guidance Hamilton et al, BMJ 2015;
350:h3044
62
Primary care investigations and results
Suspected cancer (part 2—adults): visual overview of updated NICE guidance Hamilton et al, BMJ 2015;
350:h3044
63
Symptoms based infogram
Assessing and referring adult cancers. Image from Suspect cancer (part 2- adults) BMJ 2015;350:h3044
Guidance
Patient Support, Safety
Netting and Diagnostic
Access Guidance
The following guidance is taken from pages 114–117 of
the NICE 2015 guidance for suspected cancer referral, it
includes recommendations on patient support, safety
netting and the diagnostic process:
• Explain to people who are being referred with
suspected cancer that they are being referred to a
cancer service. Reassure them, as appropriate,
that most people referred will
not have a diagnosis of cancer, and discuss
alternative diagnoses with them.
• When referring a person with suspected cancer to a
specialist service, assess their need for continuing
support while waiting for their referral
appointment. If the person does have additional
support needs because of their personal
circumstances, inform the specialist (with the
person’s agreement).
• Advise those patients who may not meet
immediate referral criteria to re-consult their
GP if symptoms persist or progress.
• If direct access for some tests is unavailable in
your area, seek an alternative urgent referral
pathway.
• You will note that some symptoms from the 2005
NICE guidance for suspected cancer referral have
been removed from the guidance update,
although there may be no explicit
recommendations, refer appropriately if clinical
concern persists.
• Give the person information on the possible
diagnosis (both benign and malignant) in
accordance with their wishes for information
(see also the NICE guideline on patient
experiences in adult NHS services). Macmillan has
more than 500 free booklets available at
be.macmillan.org.uk, covering different types of
cancer, treatments and side effects. They also offer
information and guidance on the day-to- day issues
of living with cancer.
• The information given to people with suspected
cancer and their families and/or carers should
cover, among other issues:
–
–
How to obtain further information about the
type of cancer suspected or help before the
specialist appointment
What type of tests may be carried
out, and what will happen during
diagnostic procedures.
• Provide information that is culturally and
linguistically appropriate as well as taking in
to account the patient’s level of ability.
Macmillan’s most commonly requested cancer
information is available online to download
in a selection of different languages.
Macmillan’s Online Community is a network of
people affected by cancer which anyone can join
to get support from others going through a similar
experience.
Resources
1. National Institute for Health and Care Excellence. Suspected cancer: recognition and referral,
2015.
www.nice.org.uk/guidance/NG12
http://www.nice.org.uk/guidance/ng12/evidence/full-guidance-65700685
2. NICE Suspected cancer: recognition and referral tumour site recommendations
http://www.nice.org.uk/guidance/NG12/chapter/1-recommendations
3. BMJ Suspected cancer (part 1—children and young adults): visual overview of updated NICE
guidance
http://www.bmj.com/content/350/bmj.h3036
4. BMJ Suspected cancer (part 2—adults): reference tables from updated NICE guidance
http://www.bmj.com/content/350/bmj.h3044
5. Macmillan Rapid Referral Guidelines
http://www.macmillan.org.uk/Documents/AboutUs/Health_professionals/PCCL/Rapidreferralguidelin
es.pdf
66
Transforming Cancer Services Team for London
SECSU.tcstlondon@nhs.net
Dr Ishani Patel
ishanipatel@nhs.net
Ishani.patel@btinternet.com
67