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Gynaecological, Suspicion of Cancer Referral

August 7, 2017August 7, 2017 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)

Ovarian Cancer	Abnormal 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 Cancer	Any 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 Cancer	Any woman with clinical features (vaginal discharge, postmenopausal, postcoital and persistent intermenstrual bleeding) and abnormality suggestive of cervical cancer on examination of the cervix.
Vulval Cancer	Any unexplained vulval lump found on examination. Vulval bleeding due to ulceration.
Vaginal Cancer	Any 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 Template

August 7, 2017August 7, 2017 Scott McLaughlin

This is a dictation template to provide a reminder of the information required to complete the referral. The fields in red are mandatory and must be completed on the referral protocol.

Presenting Complaint

Main Presenting Complaint: [Text – 98 character maximum]

Reason for Referral: [Text]

World Health Organisation Performance Scale
Using the following as a guide, please select the most appropriate answer to describe the patients general health:

Options:

Asymptomatic
Symptomatic but completely ambulatory
Symptomatic, <50% in bed during the day
Symptomatic, >50% in bed, but not bedbound
Bedbound

Priority: Urgent Suspicion of Cancer

Date of Onset: [Date]

Will the patient accept any site for treatment:

Symptoms and Investigations

Symptoms

Unexplained weight loss:

Yes (If Yes, please provide brief details)
No

Unexplained iron deficiency anemia:

Yes (If Yes, please provide brief details)
No

Family history of oesophago-gastric cancer in more than two first degree relatives:

Yes (If Yes, please provide brief details)
No

Family history of familial adenomatous polyposis in any first degree relative:

Yes (If Yes, please provide brief details)
No

Barrett’s oesophagus:

Yes (If Yes, please provide brief details)
No

Pernicious anaemia:

Yes (If Yes, please provide brief details)
No

Gastric surgery over 20 years ago:

Yes (If Yes, please provide brief details)
No

Known dysplasia, atrophic gastritis, intestinal metaplasia:

Yes (If Yes, please provide brief details)
No

Upper abdominal epigastric mass:

Yes (If Yes, please provide brief details)
No

Iron deficiency anaemias:

Yes (If Yes, please provide brief details)
No

Clincal Examination

Jaundice:

Yes (If Yes, please provide brief details)
No

Upper abdominal mass:

Yes (If Yes, please provide brief details)
No

Investigations

FBC and ESR sent:

LFT, U&E sent:

Previous endoscopy done:

Upper GI cancer surgeon guideline

Gastrointestinal (Upper) Cancer, Endoscopy Template

August 7, 2017August 7, 2017 Scott McLaughlin

This is a dictation template to provide a reminder of the information required to complete the referral. The fields in red are mandatory and must be completed on the referral protocol.

Presenting Complaint

Main Presenting Complaint: [Text – 98 character maximum]

Reason for Referral: [Text]

World Health Organisation Performance Scale
Using the following as a guide, please select the most appropriate answer to describe the patients general health:

Options:

Asymptomatic
Symptomatic but completely ambulatory
Symptomatic, <50% in bed during the day
Symptomatic, >50% in bed, but not bedbound
Bedbound

Priority: Urgent Suspicion of Cancer

Date of Onset: [Date]

Will the patient accept any site for treatment:

Symptoms and Investigations

Symptoms

Unexplained weight loss:

Yes (If Yes, please provide brief details)
No

Unexplained iron deficiency anemia:

Yes (If Yes, please provide brief details)
No

Family history of oesophago-gastric cancer in more than two first degree relatives:

Yes (If Yes, please provide brief details)
No

Family history of familial adenomatous polyposis in any first degree relative:

Yes (If Yes, please provide brief details)
No

Barrett’s oesophagus:

Yes (If Yes, please provide brief details)
No

Pernicious anaemia:

Yes (If Yes, please provide brief details)
No

Gastric surgery over 20 years ago:

Yes (If Yes, please provide brief details)
No

Known dysplasia, atrophic gastritis, intestinal metaplasia:

Yes (If Yes, please provide brief details)
No

Upper abdominal epigastric mass:

Yes (If Yes, please provide brief details)
No

Iron deficiency anaemias:

Yes (If Yes, please provide brief details)
No

Clincal Examination

Jaundice:

Yes (If Yes, please provide brief details)
No

Upper abdominal mass:

Yes (If Yes, please provide brief details)
No

Investigations

FBC and ESR sent:

LFT, U&E sent:

Previous endoscopy done:

Upper GI cancer endoscopy guideline

Gastrointestinal (Upper) Cancer Surgeon

August 7, 2017August 7, 2017 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

Gastrointestinal (Upper) Cancer Endoscopy

August 7, 2017August 7, 2017 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.

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

Gastro Intestinal (Upper) Cancer Endoscopy dictation template

ENT Cancer Referral

August 7, 2017August 7, 2017 Scott McLaughlin

Consider referral to ENT when the patient presents with any of the following signs or symptoms:

Hoarseness persisting for more than 3 weeks
High dysphagia persisting for more than 3 weeks
Unresolved neck masses for more than 3 weeks
- (** Also refer to Monklands or Hairmyres Hospital for ultrasound and or FNA **)
Persistent unilateral unexplained throat pain
Unilateral nasal obstruction particularly when associated with purlent discharge
Unexplained ear pain particularly with any of the above

Stridor should be referred as an emergency

Consider referral to Maxillofacial when the patient presents with any of the following signs or symptoms:

Ulceration of oral mucosa persisting for more than 3 weeks
Oral swellings persisting for more than 3 weeks
All red or red and white patches of the oral mucosa
Unexplained tooth mobility not associated with peridontal disease

Consider referral to Ophthalmology when the patient presents with any of the following signs or symptoms

Orbital masses

Consider referral to General Medicine when the patient presents with any of the following signs or symptoms

Cranial neuropathies

CCI Guidelines

The CCI Referral Guidelines can be found at ENT Referral Pathways.

Colorectal, Suspicion of Cancer Template

August 7, 2017August 7, 2017 Scott McLaughlin

This is a dictation template to provide a reminder of the information required to complete the referral. The fields in red are mandatory and must be completed on the referral protocol.

Presenting Complaint

Main Presenting Complaint: [Text – 98 character maximum]

Reason for Referral: [Text]

World Health Organisation Performance Scale
Using the following as a guide, please select the most appropriate answer to describe the patients general health:

Options:

Asymptomatic
Symptomatic but completely ambulatory
Symptomatic, <50% in bed during the day
Symptomatic, >50% in bed, but not bedbound
Bedbound

Priority: Urgent Suspicion of Cancer

Date of Onset: [Date]

Will the patient accept any site for treatment:

Symptoms and Investigations

Symptoms

Rectal bleeding:

Passage of mucus:

Tenesmus:

Anal Symptoms:

Change in bowel habit greater than 4 weeks:

Abdominal mass palpable:

Rectal lesion palpable:

Yes
No
Not Applicable

If not applicable, please state reason: [Text]

Iron deficiency anaemia:

Family history:

Please provide details of onset and duration of symptoms: [Text]

For ‘Low Risk’ patients, please provide their next review date: [Date]

Investigations

Please indicate if the following have been checked:

FBC and U&E sent:

TFT, CRP, and Faeces Culture sent (diarrhoea only):

Recent E-GFR:

Suspicion of Colorectal Cancer Guidelines

Colorectal, Suspicion of Cancer Referral

August 7, 2017August 7, 2017 Scott McLaughlin

Lower Gastrointestinal Cancer

Lower gastrointestinal symptoms are common presentations in primary care. Rectal bleeding for instance is estimated to affect 14,000 individuals per 100,000 population each year. There are large differences in the predictive value of rectal bleeding for cancer according to its association with other symptoms and signs and the age of the patient. For example, the positive predictive value of rectal bleeding alone is 2.4%, which rises to 8.5% in combination with an abnormal rectal examination.

Different management strategies should be adopted according to cancer risk so that those patients with transient lowrisk symptoms caused by benign disease avoid unnecessary investigation. The following guideline is recommended for managing patients with features associated with a possible diagnosis of colorectal cancer. Guidance for referral to regional genetics centres for those with a family history of colorectal cancer is available available at Scottish Government Health and Social Care website. In patients with ulcerative colitis, a plan for follow up should be agreed.

An abdominal and rectal examination and a full blood count should be performed on all patients with symptoms suggestive of colorectal cancer. These findings can facilitate appropriate triage in secondary care. A negative rectal examination, or a recent negative faecal occult blood result, should not rule out the need to refer. The carcinogenic embryonic antigen (CEA) test should not be used as a screening tool.

High-risk features Urgent suspicion of cancer referral
Bleeding	Repeated rectal bleeding without an obvious anal cause Any blood mixed with the stool
Bowel Habit	Persistent change in bowel habit especially to looser stools (more than 4 weeks)
Mass	Right-sided abdominal mass Palpable rectal mass
Iron deficiency anaemia In men of any age with unexplained iron deficiency anaemia and a haemoglobin of 11g/100ml or below. In non-menstruating women with unexplained iron deficiency anaemia and a haemoglobin of 10g/100ml or below.	Unexplained iron deficiency anaemia
Other	Past history of lower gastrointestinal cancer with any of the symptoms above

Primary care management

Low-risk features

Transient symptoms (less than 4 weeks)
Patients under 40 years in absence of high-risk features

Watch and wait (4 weeks)

Assessment and review
Consider bowel diary
Appropriate information, counselling and agreed plan for review with GP

Refer if symptoms persist or recur

Reference:
Scottish Referral Guidelines for Suspected Cancer. Scottish Government, August 2014
SIGN Guideline 126 – Diagnosis and Management of Colorectal Cancer
Lead Clinician Mr A Brown, NHS Lanarkshire
Review Date March 2017

Breast, Suspicion of Cancer Template

August 7, 2017August 7, 2017 Scott McLaughlin

This is a dictation template to provide a reminder of the information required to complete the referral. The fields in red are mandatory and must be completed on the referral protocol.

Presenting Complaint

Main Presenting Complaint: [Text – 98 character maximum]

Reason for Referral: [Text]

World Health Organisation Performance Scale
Using the following as a guide, please select the most appropriate answer to describe the patients general health:

Options:

Asymptomatic
Symptomatic but completely ambulatory
Symptomatic, <50% in bed during the day
Symptomatic, >50% in bed, but not bedbound
Bedbound

Date of Onset: Date

Priority: Urgent Suspicion of Cancer

Is this a fast track referral of a previous breast cancer:

Is there a suspicion of bilateral disease:

Will the patient accept any site for treatment:

Protocol Specific Questions

HRT History:

Never
Previously
Current

Number of years on HRT: [Text]

Menopause Status:

Pre-Menopausal
Menopausal
Post-Menopausal
Male patient or not applicable

Last Menstrual Period: [Date]

Is there a family history of breast cancer:

If yes to previous question, please give relationship and age at diagnosis: [Text]

Previous Mammograms: [Text (please provide date and location or N/A)]

Previous Ultrasounds: [Text (please provide date and location or N/A)]

Previous Breast Clinic appointments: [Text (please provide date and location)]

Breast Examination

Left Breast

Is there any left breast abnormality present:

Left breast abnormality: [Text (Please accurately describe the location and type of abnormality)]

Left breast degree of suspicion:

Uncertain
Probably Benign
Probably Malignant

Right Breast

Is there any right breast abnormality present:

Right breast abnormality: [Text (Please accurately describe the location and type of abnormality)]

Right breast degree of suspicion:

Uncertain
Probably Benign
Probably Malignant

Suspicion of Breast Cancer Guidelines

Breast, Suspicion of Cancer Referral

August 7, 2017August 7, 2017 Scott McLaughlin

Breast Cancer

Breast symptoms are a relatively uncommon presentation in primary care. It is estimated that between 0.35% and 0.6% of all consultations in Scotland are for breast symptoms. Many of these consultations will be in young women, whereas the biggest risk factor, after gender, is increasing age. Incidence of breast cancer in women aged 30-35 is 33 per 100,000 population and approximately 81% of breast cancers occur in women over the age of 50.

Breast cancer accounts for 30% of cancers in women and around 4,400 people are diagnosed with breast cancer in Scotland each year; approximately 20 of these are men. The following recommendations seek to improve the referral and effective management of breast symptoms in women and men in primary care. Guidance for referral to regional genetics centres for those with a family history of breast cancer is available at Health Improvement Scotland website.

	Urgent suspicion of cancer referral	Routine Referral	Primary care management Issue relevant advice leaflet
Lump	Any new discrete lump (in patients over 35 years) New asymmetrical nodularity that persists at review after menstruation (in patients over 35 years) Unilateral isolated axillary lymph node in women Cyst persistently refilling or recurrent cyst	Any new discrete lump in patients under 35 years with no other suspicious features New asymmetrical nodularity that persists at review after menstruation (in patients under 35 years)	Women with longstanding tender lumpy breast and no focal lesion Tender developing breasts in adolescents
Nipple symptoms	Bloodstained discharge New nipple retraction Nipple eczema if unresponsive to topical steroids (such as 1% hydrocortisone) after a minimum of 2 weeks	Persistent discharge sufficient to stain outer clothes	Transient nipple discharge which is not bloodstained Check prolactin levels when discharge present Longstanding nipple retraction Nipple eczema if eczema present elsewhere
Skin Changes	Skin tethering Fixation Ulceration Peau d'orange		Obvious simple skin lesions such as sebaceous cysts
Abscess/infection	Mastitis or breast inflammation which does not settle after one course of antibiotics	Abscess or breast inflammation even after settled in patients over 35 years	Abscess* or inflammation - try one course of antibiotics to cover staphylococcus and streptococcus (also consider possible anaerobic infection as per local guidelines)
Pain		Unilateral persistent pain in post menopausal women Intractable pain that interferes with the patient's lifestyle or sleep	Women with moderate degrees of breast pain and no discrete palpable lesion
Gynaecomastia		Exceptional aesthetics referral to plastic surgery pathway if required Exclude or treat any endocrine cause prior to referral	Examine and exclude abnormalities such as lymphadenopathy or evidence of endocrine condition Review to exclude drug causes Measure hormones (oestrogen, testosterone, prolactin, human chorionic gonadotropin and alpha-fetoprotein) Reassure

* Any acute abscess requires immediate discussion with secondary care.

Reference:
Scottish Referral Guidelines for Suspected Cancer. Scottish Government, August 2014
SIGN Guideline 134 – Treatment of Primary Breast Cancer
Clinical Lead Dr Juliette Mitchell, Consultant Surgeon, Wishaw General Hospital
Review Date March 2017

Suspicion of breast cancer dictation template