cancer – NHS Lanarkshire LanRefHelp

Urology, Suspicion of Cancer Referral

August 7, 2017August 7, 2017 Scott McLaughlin

Urological cancers

Prostate cancer

Prostate cancer is the most common cancer in males in Scotland, with approximately 2,800 new cases diagnosed every year. Risk increases with age and approximately 99% of cases are diagnosed in men aged over 50 years. Men are 2.5 times more likely to be diagnosed with prostate cancer, if their father or brother has had it. In the UK, the lifetime risk of prostate cancer in Black men (1 in 4) is double that of the lifetime risk of all men combined (1 in 8).

Men presenting with unexplained possible symptoms and signs suggestive of prostate cancer such as changes to urinary patterns, erectile dysfunction, haematuria, lower back pain, bone pain or weight loss should have a digital rectal examination and a prostate specific antigen (PSA) test with counselling. A PSA test should not be performed within 1 month of a proven urinary tract infection (UTI). It should be noted that the majority of men with prostate cancer have no symptoms at all.

Bladder and kidney cancer

Visible haematuria is the most common presenting symptom for both bladder and kidney cancer. Other presenting features include loin pain, renal masses, non-visible haematuria, anaemia, weight loss and pyrexia. Both cancers are uncommon, with around 800 new bladder and 860 new kidney cancers each year.

Testicular and penile cancer

Although scrotal swellings are a common presentation in general practice, testicular cancer is relatively rare, with around 200 new cases per annum, of which approximately 70% are between 15 and 45 years. Solid swellings affecting the body of the testis have a high probability (>50%) of being due to cancer. Cancer of the penis is rare, with around 60 new cases each year in Scotland, but its incidence is rising.

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

Urgent suspicion of cancer referral

Prostate cancer

Evidence from digital rectal examination of a hard, irregular prostate

Elevated or rising age-specific PSA. Rough guide to normal PSA levels:

men less than 60 years – less than 3ng/ml
men aged 60 – 69 years – less than 4ng/ml
men aged 70 years and over – less than 5ng/ml

Bladder and kidney cancer

Patients with painless visible haematuria
Patients with non-visible haematuria and symptoms suggestive of UTI but with sterile mid-stream urine (MSU)
Abdominal mass identified clinically or on imaging that is thought to arise from the urinary tract

Testicular and penile cancer

Swelling in the body of the testis
Suspicious scrotal mass found on imaging
Men considered to have epididymo-orchitis or orchitis which is not responding to treatment
Any non-healing lesion on the penis or painful phimosis

Non urgent referral

Elevated age-specific PSA where urgent referral will not affect outcome due to age or comorbidity
Asymptomatic persistent non-visible haematuria without obvious cause
Patients over 40 who present with recurrent UTI associated with any haematuria

Reference:
Scottish Referral Guidelines for Suspected Cancer. Scottish Government, August 2014
SIGN Guideline 85 – Management of transitional cell carcinoma of the bladder
Clinical Lead: Mr Rehan Khan, Consultant Urology Surgeon, NHS Lanarkshire
Review Date April 2017

Urology 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]

Prefered Hospital:

Hairmyres Hospital
Monklands Hospital
Wishaw General Hospital
First Available appointment

Clinical Examinations and Findings

Examinations and Findings

Frank haematuria in an adult (unexplained):

Yes (If Yes, please provide brief details)
No

Symptomatic, non-visible haematuria in a patient over 40 years old:

Yes (If Yes, please provide brief details)
No

Palpable renal mass with/without pain, with/without haematuria:

Yes (If Yes, please provide brief details)
No

Solid renal mass found on imaging:

Yes (If Yes, please provide brief details)
No

PSA outwith age related reference range:

Yes (If Yes, please provide brief details)
No

Clinically malignant prostate on PR exam and/or bone pain suspicious of metatastic prostate cancer:

Yes (If Yes, please provide brief details)
No

Swelling in body of testis or other suspicion of testis cancer:

Yes (If Yes, please provide brief details)
No

Suspected penile cancer:

Yes (If Yes, please provide brief details)
No

Investigations

Please indicate if any of these tests have been checked.

MSSU:

U&E and FBC:

PSA – after patient has been counselled:

Urology cancer guideline

Skin, Suspicion of Cancer Referral

August 7, 2017August 7, 2017 Scott McLaughlin

Skin Cancers

Approximately 12,000 people are diagnosed every year with skin cancer in Scotland, of which around 1,200 are malignant melanoma and 3,000 are squamous cell carcinomas (SCC). The incidence of skin cancer is rising.

Risk factors for all skin cancer types include excessive sunlight exposure, sun bed use, fair skin and susceptibility to sunburn. For melanoma, a large number of benign melanocytic naevi and family history are risk factors. For SCC, multiple small actinic keratoses, high levels of previous UV-A photochemotherapy and immuno-suppression are also risk factors. Patients with multiple atypical naevi and a strong family history may have an increased risk of developing skin cancer. Skin cancers are very infrequent in people with dark skin and in children under 15 years.

Guides for assessment include the 7-point checklist and the ABCD (Asymmetry, Border irregular, Colour irregular, Diameter increasing) checklist SIGN Guideline 72 (Withdrawn Feb 2015/Under Review) – Cutaneous Melanoma. Some melanomas will have no major features.

The dermoscope is a useful tool for trained clinicians screening pigmented lesions as it can increase diagnostic accuracy.

Good practice points

Lesions which are suspicious for melanoma should not be removed in primary care. All excised skin specimens should be sent for pathological examination.
Lesions suspicious of basal cell carcinomas (BCC) may not require urgent referral, except those invading potentially dangerous areas.
Referrals should be accompanied by an accurate description of the lesion (including size, pain and tenderness) and photos if possible, subject to clinical governance arrangements, to permit appropriate triage.

A patient presenting with a skin lesion suggestive of cancer should normally be referred to a dermatologist, depending on local arrangements.

Urgent suspicion of cancer referral

Lesions on any part of the body which have one or more of the following features:

change in colour, size or shape in an existing mole
moles with ABCD (Asymmetry, Border irregular, Colour irregular, Diameter increasing or >6mm
new growing nodule with or without pigment
persistent (more than 4 weeks) ulceration, bleeding or oozing
persistent (more than 4 weeks) surrounding inflammation or altered sensation
new or changing pigmented line in a nail or unexplained lesion in a nail
slow growing, non-healing or keratinising lesions with induration (thickened base)
any melanoma or invasive SCC or high risk BCC diagnosed from biopsy
any unexplained skin lesion in an immuno-suppressed patient
BCC invading potentially dangerous areas, for example peri-ocular, auditory meatus or any major vessel or nerve

The department operates a photo triage system for Skin Cancer referrals. Please phone one of the numbers below to make an appointment for your patient with the Medical Photography department before making a referral. (Please do not delay the referral if there is a difficulty making the appointment)

Hairmyres Hospital: 01355 585497
Monklands Hospital: 01236 712129 or ask for Radio Page 527
Wishaw General Hospital: 01698 366443

Reference:
Scottish Referral Guidelines for Suspected Cancer. Scottish Government, August 2014
SIGN Guideline 72 (Withdrawn Feb 2015/Under Review) – Cutaneous Melanoma
Clinical Lead (Vacant)
Review Date April 2017

Skin 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

Expected Outcome:

Not specified
Diagnostic advice

Date of Onset: [Date]

Will the patient accept any site for treatment:

Lesions and Risks

Lesion Characteristics

Duration of lesion (months): [Text]

Site of lesion: [Text]

Size of lesion (mm): [Text]

Are there any changes to the lesion?

Lesion Specific Details

If Yes to the above question, Are there any changes to the lesion?, please answer the following:

Change in leasion size:

Is there irregular pigmentation:

Are there irregular borders:

Is the lesion inflamed:

Does the lesion itch or have altered sensation:

Is the lesion larger than others:

Does the lesion bleed or ooze:

Risk Factors

Has the patient had previous sunbed exposure:

Is the patient immunosuppressed:

Does the patient have a history of skin cancer:

Has the patient had a previous transplant:

Provisional Diagnosis

Provisional diagnosis:

Other
Melanoma
Basal cell carcinoma
Squamous cell carcinoma
Cutaneous lymphoma

Other (please specify): [Text]

Skin cancer guidelines

Lung, Suspicion of Cancer Referral

August 7, 2017August 7, 2017 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

Lung 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

What does the patient know: [Text]

Results

Chest X-ray:

Normal
Abnormal – Suspicion of cancer
Abnormal – other

Date of chest x-ray: [Date]

Blood sample for e-GFR taken within past 3 months:

Priority: Urgent Suspicion of Cancer

Date of Onset: [Date]

Will the patient accept any site for treatment:

Lung cancer referral guideline

Head and Neck, Suspicion of Cancer Referral

August 7, 2017August 7, 2017 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

August 7, 2017August 7, 2017 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

Haematological 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

History – Please add more details where required.

Fatigue:

Yes (If Yes, please provide brief details)
No

Night Sweats:

Yes (If Yes, please provide brief details)
No

Weight Loss:

Yes (If Yes, please provide brief details)
No

Itching:

Yes (If Yes, please provide brief details)
No

Breathlessness:

Yes (If Yes, please provide brief details)
No

Bruising:

Yes (If Yes, please provide brief details)
No

Recurrent Infections:

Yes (If Yes, please provide brief details)
No

Bone Pain:

Yes (If Yes, please provide brief details)
No

Polyuria and polydipsia (with normal glucose)

Yes (If Yes, please provide brief details)
No

Clinical Examinations

Hepatomegaly:

Yes (If Yes, please provide brief details)
No

Splenomegaly:

Yes (If Yes, please provide brief details)
No

Lymphadenopathy greater than 2cm over 6 weeks:

Yes (If Yes, please provide brief details)
No

Haematology cancer guideline

Gynaecology, 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

Persistant intermenstrual bleeding:

Persistent postcoital bleeding:

Postmenopausal bleeding (not on HRT):

Postmenopausal bleeding on combined continuous HRT or unscheduled bleeding on sequential HRT:

Persistent abdominal pain:

Abdominal distension:

Clinical Examination

Abdominal / Pelvic mass palpable by abdominal examination:

Yes (If Yes, please provide brief details)
No

Ascites

Cervical or vaginal lesion, suspicion of cancer:

Vulval lesion suspicion of cancer:

Investigation

Please indicate if any of the following have been checked

FBC and ESR sent:

CEA sent (if ovarian cancer suspected):

CA125 sent (if ovarian cancer suspected):

Ultrasound scan arranged:

Yes (If Yes, please provide brief details)
No

Gynaecology, Suspicion of Cancer Guideline