Category: All Referrals

Lung, Suspicion of Cancer Referral

Scott McLaughlin
Lung Cancer

More than 90% of patients with lung cancer are symptomatic at the time of diagnosis. However, many symptoms associated with lung cancer (particularly cough and fatigue) are common presentations in primary care, associated with chronic diseases such as chronic obstructive pulmonary disease (COPD). It is therefore important that changes in symptoms are identified and acted upon.

Chest x-ray findings are abnormal in over 96% of symptomatic patients with lung cancer. In most cases where lung cancer is suspected, it is appropriate to arrange an urgent chest x-ray before urgent referral to a chest physician. However, a normal chest x-ray does not exclude a diagnosis of lung cancer. If the chest x-ray is normal but there is a high suspicion of lung cancer, patients should be offered urgent referral to a respiratory physician. In patients with a history of asbestos exposure, mesothelioma should be considered.

Urgent chest x-ray

Any haemoptysis

Unexplained/persistent (more than 3 weeks)

  • change in cough
  • dyspnoea
  • chest/shoulder pain
  • weight loss
  • chest signs
  • hoarseness
  • fatigue in a smoker over 50 years

Finger Clubbing

Features suggestive of metastatic disease

Cervical and/or persistent supraclavicular lymphadenopathy

Any person who has been referred for an urgent chest x-ray and has been found with consolidation should have a repeat chest x-ray no more than 6 weeks later to confirm resolution.

Urgent suspicion of cancer referral

Any symptoms or signs detailed above persisting for longer than 6 weeks despite a normal chest x-ray.

Chest x-ray suggestive/suspicious of lung cancer (including pleural effusion, pleural mass and slowly resolving consolidation)

Persistent haemoptysis in smokers/ex-smokers over 50 years of age

Mesothelioma

In mesothelioma, 80 – 90% of patients will have a history of asbestos exposure and it is essential that a career history is taken to identify any possible asbestos exposure.

Urgent suspicion of cancer referral

Individuals over 50 years with history of asbestos exposure and recent onset of:

  • chest pain
  • dyspnoea
  • unexplained systemic symptoms

Reference:
Scottish Referral Guidelines for Suspected Cancer. Scottish Government, August 2014
SIGN 137: Management of Lung Cancer
Lead Cancer Clinician: Dr Stuart Baird, Lead Physician for Lung Cancer NHS Lanarkshire
Review Date April 2017

Leg Ischaemia Guidelines

Scott McLaughlin

General Guidelines

Priority will be given to patients with critical limb ischaemia (rest pain, arterial ulcers, necrosis), symptomatic carotid stenosis and aortic aneurysm – who are likely to require surgical or radiological intervention.

Leg Ischaemia

Most patients with recent onset intermittent claudication will improve spontaneously – especially if they are encouraged to correct known risk factors. Furthermore timely attention to secondary prevention will reduce mortality and morbidity due to cardiac and cerebro-vascular disease in this high-risk group. Patients with mild to moderate intermittent claudication do not require invasive vascular interventions. If you have access to ABPI measurements, then that may help confirm the diagnosis.

Patients with severe intermittent claudication, not improved by a regime of smoking cessation, walking exercise, antiplatelet treatment, statin, weight reduction (as required) should be referred for vascular OP Clinic assessment.

Varicose Veins

NHS Lanarkshire does not offer treatment for thread veins or reticular veins or any cosmetic treatment for varicose veins.

Referral Criteria For Varicose Veins
(MANDATORY FIELDS AT LEAST ONE REQUIRED)

  • Open or healed varicose ulcer
  • Active varicose eczema (unresponsive to topical steroids and compression)
  • Recurrent superficial thrombophlebitis requiring NSAID therapy and compression
    • (* Phlebitis/thrombophlebitis is defined as acute onset, tender, hard, lumpy veins due to thrombosis. It is Not just painful veins. Standard treatment is NSAIDs and compression, not antibiotics. Patients should not be referred on first episode unless there is clinical evidence of thrombosis extending up to the groin)
  • A history of venous haemorrhage where there is a likelihood of further bleeding

Aortic Aneurysm

Patients with suspected aortic aneurysm, even without related symptoms, should be referred as an urgent case to the Vascular OP Clinic.
Patients with suspected symptomatic abdominal aortic aneurysm (i.e. recent onset or increasing back pain, acute tenderness of the aneurysm, distal embolism) should be referred as an emergency to the Receiving Surgical Team.

Carotid Artery Disease

Patients with suspected carotid artery disease should be referred urgently if they present with symptoms of stroke, TIA, or amaurosis fugax.

HPS Notifiable Disease

Scott McLaughlin

This notification relates to Part 2 (Notifiable Diseases, Notifiable Organisms and Health Risk States) of the Public Health etc. (Scotland) Act 2008. A copy of the Act and Guidance for Registered Medical Practitioners can be found here

Registered Medical Practitioners should use it to notify the Health Board of Notifiable diseases and Health Risk States.

The disease list in the form should guide you as to which diseases are notifiable.

If the referral is urgent, please telephone your Health Protection Team at the Board on 01698 858232

Head and Neck, Suspicion of Cancer Referral

Scott McLaughlin

Head and Neck Cancers

The incidence of head and neck cancer is increasing and around 1,200 people are diagnosed with a head and neck cancer each year in Scotland, of which around 240 are thyroid cancers. The incidence of oropharyngeal cancer is increasing in the younger population, and appears to be associated with human papilloma virus (HPV) infection.

Risk factors for head and neck cancers (excluding thyroid) include: smoking, HPV, alcohol, poor diet, social deprivation, tobacco chewing habits (including Betel, Gutkha and Pan) and older age. The risk of developing nasopharyngeal cancer is higher in patients of Chinese origin and a higher index of suspicion should be used in these patients.

All patients with features suspicious of malignancy should be referred to a team specialising in the management of head, neck or thyroid cancers, depending on local arrangements

With the changing pattern of disease, age, non-smoking or non-drinking status should not be a barrier to referral.

Emergency Referral

Stridor

Urgent suspicion of cancer referral

Head and Neck Cancer
  • Persistent unexplained head and neck lumps for >3 weeks.
  • Ulceration or unexplained swelling of the oral mucosa persisting for >3 weeks.
  • All red or mixed red and white patches of the oral mucosa persisting for >3 weeks.
  • Persistent hoarseness lasting for >3 weeks (request a chest x-ray at the same time).
  • Dysphagia or odynophagia (pain on swallowing) lasting for >3 weeks.
  • Persistent pain in the throat lasting for >3 weeks.
Thyroid Cancer
  • Solitary nodule increasing in size.
  • Thyroid swelling in a pre-pubertal patient.
  • Thyroid swelling with one or more of the following risk factors:
    • neck irradiation
    • family history of endocrine tumour
    • unexplained hoarseness
    • cervical lymphadenopathy.

Reference:
Scottish Referral Guidelines for Suspected Cancer. Scottish Government, August 2014
SIGN Guideline 90 – Diagnosis and Management of Head and Neck Cancer
Clinical Lead Mr Andrew Carton, Head and Neck Surgeon, Monklands DGH
Review Date March 2017

Haematology, Suspicion of Cancer Referral

Scott McLaughlin
Haematological Cancers

Haematological cancers can present with a variety of symptoms. A combination of symptoms and signs, often non-specific, may suggest haematological cancer and warrant further examination, investigation and possible referral.

Leukaemia (acute and chronic)

Approximately 630 people are diagnosed with leukaemia in Scotland each year.1 Although all ages can be affected, around 70% of cases occur in people aged over 60 years. Symptoms and/or signs of bone marrow failure such as fatigue, pallor, bruising, bleeding and infections can occur. Fatigue and vulnerability to infection can result from most types of haematological cancer but are particularly severe in acute leukaemia. Some leukaemias may present with lymphadenopathy and/or hepatosplenomegaly. The most common form of leukaemia in adults is chronic lymphocytic leukaemia (CLL), which is often an indolent disease and an incidental finding.

Non Hodgkin’s lymphoma

Approximately 1,000 new cases of Non Hodgkin’s lymphoma are diagnosed in Scotland each year. Although all ages an be affected, around 70% of cases occur in patients aged over 60 years. Common symptoms or signs at presentation include fatigue, weight loss, night sweats, lymphadenopathy and hepatosplenomegaly.

Hodgkin’s lymphoma

Approximately 170 new cases of Hodgkin’s lymphoma are diagnosed in Scotland each year,1 with 50% of cases occurring in people under the age of 40 years. Clinical features at presentation are similar to those for Non-Hodgkin’s lymphoma but 95% of patients present with lymph gland involvement.

Myeloma

Approximately 400 new myeloma cases are diagnosed in Scotland each year. About 80% of cases occur in patients aged over 60 years.1 Clinical features at presentation include bone pain, symptoms of anaemia, renal impairment, and symptoms of hypercalcaemia (such as polyuria and polydipsia).

The presence of an isolated paraprotein or monoclonal gammopathy of unknown significance (MGUS) is not a cancer, and is a common incidental finding in the elderly (10% over 85 years). However, 12% of patients will develop myeloma or related disease within 10 years. All patients with MGUS should therefore be monitored to detect progression in paraprotein level. Some patients with a paraprotein are at more risk of developing myeloma than others, and this can often be predicted from results. Discussion with a haematologist is therefore encouraged if in any doubt.

For patients presenting with these non-specific symptoms, the GP should always consider checking the human immunodeficiency virus (HIV) status along with other routine investigations.

Routine tests and investigations should be repeated at least once if a patient’s condition remains unexplained.

If myeloma is suspected, urine as well as serum electrophoresis should be performed.

 

Arrangements for biopsy of persistent abnormal lymph glands vary locally.

All patients presenting with symptoms or signs suggesting haematological cancer should be referred to a team specialising in the management of haematological cancer, depending on local arrangements.

Urgent suspicion of cancer referral
  • Blood count film reported as suggestive of acute leukaemia or chronic myeloid leukaemia.*
  • Lymphadenopathy (>2cm) persisting for 6 weeks or increasing in size or generalised (HIV status should always be checked if generalised).
  • Hepatosplenomegaly in the absence of known liver disease.
  • Bone pain associated with a paraprotein and/or anaemia.
  • Bone x-rays reported as being suggestive of myeloma.
  • The following clinical features may also merit urgent referral:
    • fatigue
    • night sweat
    • weight loss
    • itching
    • bruising
    • recurrent infections
    • bone pain
    • polyuria and polydipsia (hypercalcemia)

* will normally be identified in the laboratory and communicated to the GP for management to be agreed.

Primary care management

  • CLL in an older person should be discussed with a local haematologist but many cases do not require detailed haematological review.
  • Asymptomatic monoclonal gammopathy may be followed up in primary care depending on local arrangements – consider discussion with a haematologist if any concern.

Reference:
Scottish Referral Guidelines for Suspected Cancer. Scottish Government, August 2014
Nice – Suspected cancer: recognition and referral 2015
Lead Clinician: Dr Lyndsay Mitchell, Consultant Haematologist, Monklands DGH
Review Date March 2017

Gynaecological, Suspicion of Cancer Referral

Scott McLaughlin
Gynaecological Cancers
Ovarian cancer

Over 90% of women with ovarian cancer are over the age of 40 years on diagnosis. Among women in Scotland with no family history the lifetime risk of developing ovarian cancer is estimated to be 1 in 55. Approximately 580 new cases of ovarian cancer are diagnosed in Scotland every year. Ovarian cancers are usually diagnosed late and approximately 30% of cases have a palpable pelvic mass. Symptoms are often non-specific abdominal symptoms but are characterised by their persistency and frequency.

Family history (both maternal and paternal) of breast or ovarian cancer can be used to identify women who have a higher risk of developing ovarian cancer. Guidance for referral to regional genetic centres for those with a family history is available at SIGN Website (SIGN 135) and Health Improvement Scotland website.

Endometrial cancer

Most patients (95%) with endometrial cancer present with postmenopausal bleeding. This cancer is uncommon in premenopausal women (< 5%). Approximately 639 new cases are diagnosed in Scotland each year. Risk factors for endometrial cancer include: tamoxifen, obesity, age over 45 years, nulliparity, family history of colon or endometrial cancer and exposure to unopposed oestrogens. A higher suspicion of risk should be used in these women.

Cervical cancer

Cervical cancer affects all adult age groups, with almost 50% of cases occurring between the ages of 30 and 50 years. The incidence of cervical cancer in Scotland is around 10.7 per 100,000 population and its estimated lifetime risk around 1 in 112. The majority of cases (80%) are diagnosed on speculum examination and up to 40% are screen detected. Typical symptoms include vaginal discharge, postmenopausal bleeding, postcoital bleeding and persistent intermenstrual bleeding. A cytology test is not required before referral, and a previous negative result is not a reason to delay referral.

Postcoital Bleeding

  • Check the cervical screening (smear) history and take a smear only if woman is a defaulter. NB A negative smear result could be a false negative in a woman with symptoms
  • Perform speculum and bimanual examination – urgent gynaecology cancer referral if suspicious
  • Take swabs (including chlamydia) and treat / refer GUM accordingly

Routine referral to gynaecology for:

  • any single heavy episode of postcoital bleeding at any age group
  • light postcoital bleeding persisting for over 4 weeks in over 35 age group
  • light postcoital bleeding persisting for over 12 weeks in under 35 age group

Vulval cancer

Most cases of vulval cancer occur in women over 65 years and 90% of patients have a visible tumour on clinical examination. Patients usually present with bleeding, discomfort, itch or a burning sensation. There are about 106 new cases of vulval cancer diagnosed every year in Scotland.

Vaginal cancer

Vaginal cancer is rare and comprises approximately 2% of gynaecological cancers. It is most commonly diagnosed in women above 60 years and is rare in women less than 40 years. Approximately 30 new cases of vaginal cancer are diagnosed in Scotland every year.

Good practice points

An abdominal palpation should be undertaken, CA125 blood serum level measured and urgent pelvic ultrasound scan carried out in:

  • any woman over 50 years who has experienced new symptoms within the last 12 months that suggest irritable bowel syndrome or
  • women (especially those over 50 years) with one or more unexplained and recurrent symptoms (most days) of:
  • abdominal distension or persistent bloating
  • feeling full quickly or difficulty eating
  • loss of appetite
  • pelvic or abdominal pain
  • increased urinary urgency and/or frequency
  • change in bowel habit.

A full pelvic examination, including speculum examination of the cervix, should be carried out in women presenting with:

  • significant alterations in their menstrual cycle
  • intermenstrual bleeding
  • postcoital bleeding
  • postmenopausal bleeding
  • vaginal discharge, or
  • pelvin pain.
  • A vulval examination should be carried out for any woman presenting with any vulval symptom.

If there is significant concern, awaiting the results of any investigation should not delay referral.

Urgent Suspicion of Cancer (Gynaecology)

Urgent Suspicion of Cancer (Gynaecology)

Ovarian CancerAbnormal ultrasound scan and/or CA125 level.
Ascites and/or ultrasound-confirmed pelvic or abdominal mass (that is not obviously uterine fibroids, gastrointestinal or urological in origin).
Endometrial CancerAny woman on hormone replacement therapy (HRT), presenting with persistent or unexplained postmenopausal bleeding, after cessation of HRT for 4 weeks.
Unscheduled vaginal bleeding in a patient taking tamoxifen
Postmenopausal bleeding.
Persistent intermenstrual bleeding, especially with other risk factors despite a normal pelvic examination.
A woman presenting with a palpable abdominal or pelvic mass on examination that is not obviously uterine fibroids, gastrointestinal or urological in origin should be referred urgently for ultrasound scan and, if significant concern, simultaneously to a specialist. Awaiting results of the ultrasound scan should not delay referral.
Cervical CancerAny woman with clinical features (vaginal discharge, postmenopausal, postcoital and persistent intermenstrual bleeding) and abnormality suggestive of cervical cancer on examination of the cervix.
Vulval CancerAny unexplained vulval lump found on examination.
Vulval bleeding due to ulceration.
Vaginal CancerAny suspicious abnormality of the vagina on speculum examination.

Primary care management

  • Symptoms (see above) persisting or worsening for any woman who has a normal CA125 with normal ultrasound, assess for other clinical causes and investigate as appropriate or refer to appropriate secondary care services, depending on local arrangement.
  • Women presenting with vulval symptoms of pruritus or pain should be examined prior to initiation of any treatment and follow up should also include examination until symptoms are resolved or a diagnosis is confirmed.

Refer urgently or routinely, if symptoms persist, depending on the symptoms and the degree of concern about cancer.

Reference:
Scottish Referral Guidelines for Suspected Cancer. Scottish Government, August 2014
SIGN 135: Management of Epithelial Ovarian Cancer
Lead Clinician: Dr Sreedevi Gurram, Consultant Gynaecologist
Review Date April 2017

Gastrointestinal (Upper) Cancer Surgeon

Scott McLaughlin
Oesophago-gastric, hepatobiliary and pancreatic cancers

Approximately 3,000 people are diagnosed with a primary oesophago-gastric, hepatobiliary or pancreatic cancer in Scotland every year.

Common symptoms of oesophago-gastric cancer include weight loss, dysphagia, heartburn or pain, vomiting and anaemia. Common symptoms of hepatobiliary or pancreatic cancer include jaundice, abdominal mass, epigastric pain and weight loss. The risk of developing an oesophago-gastric cancer is higher in patients of East Asian origin and a higher suspicion of risk should be used in these patients.

An abdominal examination and appropriate blood tests (for example, full blood count, ferritin, urea and electrolytes test [U&Es] and liver function tests [LFTs]) should be performed on all patients with symptoms suggestive of these cancers. These findings can facilitate triage in secondary care. Referral should not be influenced by Helicobacter pylori (H pylori) status. Proton pump inhibitors should be avoided if possible prior to investigation. H2 antagonists may be used for symptomatic relief.

All patients with high-risk features should be referred to a team specialising in the management of oesophago-gastric, hepatobiliary or pancreatic cancers, depending on local arrangements.

Urgent suspicion of cancer referral

Oesophago-gastric cancer

Dysphagia (interference of the swallowing mechanism that occurs within 5 seconds of the swallowing process) or odynophagia (pain on swallowing) at any age.

New onset upper gastrointestinal pain or discomfort in people over 55 years.

New or worsening upper gastrointestinal pain or discomfort combined with one or more of the following features:

  • unexplained weight loss
  • unexplained iron deficiency anaemia

Persistent vomiting more than 4 weeks.

Upper gastrointestinal pain or discomfort combined with at least one of the following risk factors:

  • family history of oesophago-gastric cancer in more than two first-degree relatives
  • family history of familial adenomatous polyposis in any first-degree relative
  • Barrett’s oesophagus
  • pernicious anaemia
  • gastric surgery over 20 years ago
  • known dysplasia, atrophic gastritis or intestinal metaplasia
Hepatobiliary and pancreatic cancer

Features of hepatobiliary or pancreatic cancer can be vague and non-specific, and may include:

  • unexplained obstructive jaundice
  • upper abdominal or epigastric mass
  • unexplained back pain (consider other cancer causes such as malignant spinal cord compression)
  • unexplained weight loss
  • any suspicious abnormality, in the hepatobiliary tract, found on imaging (such as biliary dilatation or pancreatic/liver lesion)

Primary care management

Dyspepsia under 55 years without accompanying symptoms or risk factors should be managed according to local or national guidelines.

Good Practice Points

There should be a low threshold for considering investigation (perhaps with discussion about appropriate imaging with a radiologist) or routine referral for patients presenting with:

  • late onset diabetes in a weight-losing patient
  • non responsive dyspepsia following initial test and treat
  • post prandial pain or early satiety
  • new onset irritable bowel syndrome symptoms in middle age
  • steatorrhoea or fat malabsorption

Reference:
Scottish Referral Guidelines for Suspected Cancer. Scottish Government, August 2014
SIGN Guideline 87 – Management of oesophageal and gastric cancer
Clinical Lead Mr Hakim BenYounes, Chief of Medical Services, NHS Lanarkshire
Review Date March 2017