Download Scottish referral guidelines for suspected cancer

Scottish referral guidelines for suspected cancer
May 2014
© Healthcare Improvement Scotland 2014
First published October 2013. Updated May 2014.
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www.healthcareimprovementscotland.org
Contents
1Introduction.....................................................................................................................................................................................1
1.1Background................................................................................................................................................................................................................1
1.2Purpose.......................................................................................................................................................................................................................2
1.3
Development of the guidelines..........................................................................................................................................................................2
1.3.1 Members of the guideline development team.............................................................................................................................................2
1.3.2 Methodology used..................................................................................................................................................................................................2
1.4
Achieving a balance................................................................................................................................................................................................3
1.5
Format of the guidelines.......................................................................................................................................................................................3
1.6
Referral timelines.....................................................................................................................................................................................................3
1.7
Dissemination of the guidelines........................................................................................................................................................................4
1.8
Audit and review of the guidelines...................................................................................................................................................................4
2
Common issues for cancer referrals............................................................................................................................................5
2.1
Patient issues.............................................................................................................................................................................................................5
2.1.1 Patients’ and carers’ needs ...................................................................................................................................................................................5
2.1.2 Impact of deprivation............................................................................................................................................................................................5
2.1.3 Demographic factors..............................................................................................................................................................................................5
2.1.4 Watch and wait.........................................................................................................................................................................................................5
2.1.5 Follow up....................................................................................................................................................................................................................5
2.2
Referral process........................................................................................................................................................................................................6
2.2.1 Use of the guidelines by all members of the primary care team...........................................................................................................6
2.2.2 Purpose of referral...................................................................................................................................................................................................6
2.2.3 Clinical decision support tools and structured documentation and proformas for referral .......................................................6
2.2.4 Downgrading of urgent referrals.......................................................................................................................................................................6
2.2.5 Feedback where no cancer is found.................................................................................................................................................................6
3Referral guidelines.........................................................................................................................................................................7
3.1
Lung cancer...............................................................................................................................................................................................................8
3.2
Breast cancer.............................................................................................................................................................................................................9
3.3
Lower gastrointestinal cancer.............................................................................................................................................................................11
3.4 Oesophago-gastric, hepatobiliary and pancreatic cancers......................................................................................................................12
3.5 Urological cancers...................................................................................................................................................................................................14
3.6 Skin cancers...............................................................................................................................................................................................................16
Reference list...............................................................................................................................................................................................17
Appendices..................................................................................................................................................................................................18
Appendix 1: Glossary...........................................................................................................................................................................................................18
Appendix 2: Members of guideline development team - steering group.......................................................................................................20
Appendix 3: Members of guideline development team - subgroups................................................................................................................21
Appemdix 4: Equality and diversity................................................................................................................................................................................23
1Introduction
1.1Background
Although cancer is a common problem with over 30,000 new cases being diagnosed in 2011 in Scotland (excluding
non-melanoma skin cancers), an individual general practitioner (GP) practice is likely to see about 31–32 new cases per
annum1. The average number of new cases per annum of individual cancer types for a GP practice with a list size of 5,518
patients is shown in Table 1. A GP practice is likely to see on average 4–5 new cases per annum of patients with each of
the most common cancers (lung, breast and colorectal cancer). An individual GP practice will also see only approximately
one new patient affected with either cancer of the bladder, kidney or oesophagus.
Table 1: Ten most common cancers in Scotland in 2011
Cancer
ICD-10 code
Total new cases
No. cases per 5,518 population per annum1,2
Trachea, bronchus and lung
C33-C34
5,069
5.32
Breast
C50
4,604
4.83
Colorectal
C18-C20
3,986
4.19
Prostate
C61
2,806
2.95
Malignant melanoma of skin C43
1,202
1.26
Head and neck
C00-C14, C30-C32 1,186
1.25
Non-Hodgkin’s lymphoma
C82-C85
1,001
1.05
Oesophagus
C15
836
0.88
Kidney
C64-C65
835
0.88
Bladder
C67
791
0.83
1. 5,518 represents an approximate estimate of the average list size per GP practice in Scotland as at October 2011
2. Rates are based on the total Scottish population of 5,254,800 as at 30 June 2011
Source: Scottish Cancer Registry, Information Services Division (ISD), April 2013; ISD Scotland, Practices and their Populations: http://www
isdscotland.org/Health-Topics/General-Practice/Practices-and-Their-Populations/
The task for the GP is to differentiate between patients whose symptoms may be due to cancer and the much larger number
of patients with similar symptoms arising from other causes. For certain symptoms, it may be entirely appropriate for a
GP to wait to see if the symptom resolves. Persistence or worsening of the symptom may alert the GP to the possibility
of cancer. Wherever possible these factors have been taken into account in the development of these guidelines.
Cancer remains a national clinical priority for the Scottish Government and NHSScotland. The Scottish Government
launched the ‘Detect Cancer Early’ initiative, in February 2012, to improve the overall 5-year survival for people diagnosed
with cancer in Scotland by achieving a 25% increase in the proportion of people diagnosed and treated in the first stage of
breast, colorectal and lung cancer by 2015. The earlier a cancer is diagnosed and treated, the better the survival outcomes.
Improving the percentage of early stage diagnoses will reduce premature deaths from cancer and subsequently have
a positive effect on overall life expectancy. One of the objectives of the programme is to work with GPs and the wider
primary care team to promote referral or investigation at the earliest reasonable opportunity for patients who may be
showing a suspicion of cancer while making the most efficient use of NHS resources and avoiding adverse impact on
access.
Scottish referral guidelines for suspected cancer • 1
1.2Purpose
The Scottish Referral Guidelines for Suspected Cancer were first published in 2002 and subsequently revised in 2007.
This version updates referral guidelines for the lung, breast and lower gastrointestinal cancer and takes account of new
research evidence and the findings of audits undertaken since the last revision. The recommendations here supersede
those in previous guidelines.
In line with the previous referral guidelines, the aim of these updated guidelines is to facilitate appropriate referral
between primary and secondary care for patients whom a GP suspects may have cancer. The guidelines should help
GPs, the wider primary care team, other clinicians and patients and carers to identify those patients who are most likely
to have cancer and who therefore require urgent assessment by a specialist. Equally it is hoped that the guidelines will
help GPs to identify patients who are unlikely to have cancer and who may appropriately be observed in a primary care
setting or who may require non-urgent referral to a hospital.
1.3Development of the guidelines
A multidisciplinary steering group was convened in 2012 to produce a relevant, evidence-based, clinically useful and
user-friendly document for practitioners in primary care. The first meeting was aimed at establishing the processes of
guideline development and making decisions about the scope of the guideline.
1.3.1.Members of the guideline development team
The members reflected the diverse range of stakeholders to which the guideline will apply, including clinicians from
both primary and secondary care, pharmacists, nurses, doctors in training, cancer networks and patient representatives.
The knowledge and experience of the team was important to bridge the gap between international expert opinion,
limited robust evidence, patient experience and clinical practice in NHSScotland. Membership of the steering group is
shown in Appendix 2.
The full group was supplemented by three subgroups, representing each tumour type for which the guidelines are being
updated. The subgroups consisted of specialists in the tumour types, GPs, nurses, pharmacists and representatives from
the relevant patient organisations. The subgroups reviewed the extant guidelines and the associated evidence tables.
Each subgroup met two times to reach consensus. Membership of the subgroups is shown in Appendix 3.
1.3.2Methodology used
The steering group agreed that the starting point for the revision process would be the existing referral guidelines,
enhanced by a review of evidence-based recommendations for referral from across the world. These recommendations
were identified from a search of the websites for a number of guideline-producing organisations in June 2012. This was
supplemented with a search for relevant guidelines in Medline and Embase. The search was updated in January 2013 to
ensure that all relevant guidelines were identified. Only guidelines published in English were considered.
2 • Scottish referral guidelines for suspected cancer
All the guidelines identified by the search were appraised for methodological quality using the Appraisal of Guidelines
for Research and Evaluation II (AGREEII) instrument. AGREEII is a validated tool used for the assessment of clinical practice
guidelines. It consists of 23 items organised into six quality domains that cover separate dimensions of guideline
quality. Each guideline is assigned an overall quality rating and a decision regarding whether the guideline would be
recommended for practice is also made. Each item is rated on a 7-point scale (1=strongly disagree to 7=strongly agree).
An overall summary of recommendations and quality rating for each guideline was compiled into evidence tables which
are available at www.healthcareimprovementscotland.org
The groups identified, reviewed and systematically considered differences in recommendations emerging from the
guidelines, in the light of their clinical and practical experience as well as their expert knowledge of the literature, while
taking account of the Scottish context. Where Scottish Intercollegiate Guidelines Network (SIGN) guidelines are in place
or are being revised, effort was made to ensure consistency between these guidelines and the related SIGN guideline.
1.4
Achieving a balance
Members of the subgroups were aware of the need to achieve a balance when setting criteria for urgent referral. If the
threshold is set too high, patients with a significant possibility of having cancer will be excluded. Furthermore the criteria
would be likely to be limited to patients with the most obvious symptoms, who may be most likely to have advanced
and/or incurable disease. Conversely, if the threshold is set too low, a large number of patients might be unnecessarily
referred urgently causing them avoidable anxiety and distress. This could overwhelm hospital clinics to the detriment
of patients with cancer and also to those with other serious illnesses.
1.5Format of the guidelines
The guidelines covering the three tumour groups that have been revised are presented separately. There is not complete
uniformity in the layout of the guidelines as members of specific subgroups advised slightly different formats that
reflect the distinct nature of symptoms and patterns of disease. However, for each tumour group the guidelines include
information on:
zz key points about the pattern of the relevant cancer, and
zz guidelines for referral.
1.6
Referral timelines
The referral timelines used in the guidelines include:
zz urgent suspicion of cancer: the patient is seen within the Scottish Government target for urgent referrals
zz routine: all other referrals, and
zz primary care management.
All staff involved in the referral process should be aware of the difference and importance of using these terms.
Scottish referral guidelines for suspected cancer • 3
1.7Dissemination of the guidelines
The guidelines will be widely disseminated in a variety of formats. The current guidelines will be made available on both
the Scottish Government and the Healthcare Improvement Scotland websites.
1.8
Audit and review of the guidelines
Audit and monitoring of the guidelines in practice should generate a valuable amount of new information which will
be used to revise the guidelines in the future. It is strongly recommended that the Regional Cancer Networks undertake
prospective audit of the guidelines.
4 • Scottish referral guidelines for suspected cancer
2 Common issues for cancer referrals
2.1
Patient issues
2.1.1
Patients’ and carers’ needs
All healthcare professionals should be sensitive to the needs of patients, carers and relatives when cancer is suspected.
Good practice includes:
zz being sensitive to the patient’s wishes to be involved in decisions about their care
zz providing understandable information at a level appropriate to the patient’s wishes to be informed
zz providing information about any referral to other services in a variety of formats, whether to secondary or tertiary
care, including how long they might have to wait, who they are likely to see, and what is likely to happen to them
zz considering carefully the need for physical and emotional support while awaiting an appointment with a specialist
zz considering any carer’s needs for support and information, taking issues of confidentiality into consideration
zz taking the individual’s particular circumstances into account, for example age, family, work and culture
zz being aware of, and offering to provide access to, sources of information in various formats
zz maintaining a high standard of communication skills, including, for example, in the process of breaking bad news.
2.1.2
Impact of deprivation
Deprivation affects the incidence of and mortality associated with cancers. It also impacts materially on the ability of
patients to access healthcare services. It is essential that any consultation or other opportunity where a patient from a
deprived area presents with symptoms suggestive of possible cancer is used to full advantage.
2.1.3Demographic factors
As with deprivation, the increasing number of patients with long-term conditions and comorbidity pose major clinical
challenges and affect both the incidence of and mortality from cancer. Chronic disease management programmes afford
an opportunity to identify symptoms suggestive of possible cancer.
2.1.4Watch and wait
It is not always appropriate for a GP to refer a patient immediately with new symptoms or signs which could be cancer
(for example, 1 week of diarrhoea or a sore throat for 10 days) and an initial ‘watch and wait’ strategy may be appropriate.
It is also important for GPs to provide a ‘safety net’ and ensure patients know when to return if their condition does not
improve or change. However, in some cases, patients will be unwilling to watch and wait due to high levels of anxiety.
In such cases, the referring GP should ensure that this is detailed in the referral documentation.
2.1.5Follow up
It is good practice for the referrer to consider ways of supporting the patient to attend investigations or reviews and
addressing any concerns the patient may have about their referral. Reminders, such as text messaging, have been shown
to be effective in increasing the attendance rate for reviews.
Scottish referral guidelines for suspected cancer • 5
2.2
Referral process
2.2.1Use of the guidelines by all members of the primary care team
The guidelines are designed for use in any primary care setting, by any member of the clinical team. Local arrangements
should be in place in each NHS board area for pharmacists, NHS24, nursing staff and others to ensure rapid referral is
arranged. Most commonly this would be by making arrangements for the patient to see their GP urgently, clearly notifying
the concern about suspected cancer.
2.2.2
Purpose of referral
The ‘urgent suspicion of cancer’ referral pathway is designed to allow the rapid assessment and investigation of a patient
to determine the cause of their symptoms. For patients with persisting symptoms it is not acceptable to simply exclude
cancer without providing an assessment of the likely underlying cause. This may involve individual hospital specialities
making internal referrals to their colleagues to help determine the nature and cause of the patient’s symptoms. These
internal referrals should be undertaken with the minimum of delay and with good communication to both the patient
and GP. Where diagnostic tests are undertaken, the person requesting the test has a responsibility for acting on the result
and ensuring that the patient receives this.
NHS boards may wish to consider which diagnostic services GPs should have direct open access to. In these situations
the GP would be responsible for communicating the result to the patient and arranging any subsequent follow up.
2.2.3
Clinical decision support tools and structured documentation and proformas for referral
To achieve consistency, clinical decision support systems and structured proformas for referral would be helpful for use
in all clinical settings. Scottish Care Information (SCI) Gateway provides the means for electronic referrals, but clinical
decision support systems vary across NHSScotland.
2.2.4Downgrading of urgent referrals
On rare occasions it may be acceptable for the receiving hospital speciality to downgrade an urgent suspicion of cancer
referral to routine. This should never occur without first contacting the GP practice and allowing the GP the opportunity
to explain why an urgent referral was requested. Vital information may have been omitted from the referral or may
have become available since the referral was made. It is essential that the patient is kept informed about any change in
referral priority.
2.2.5Feedback where no cancer is found
The referring GP should receive timely feedback on the outcomes for all patients with an urgent suspicion of cancer
referral. Where negative results are found, this allows the GP to consider alternative courses of action. Likewise, information
about inappropriate referrals should be fed back to the referring GP detailing why it was felt to be inappropriate and
suggesting an alternative course of action.
6 • Scottish referral guidelines for suspected cancer
3Referral
guidelines
Scottish referral guidelines for suspected cancer • 7
3.1Lung cancer
More than 90% of patients with lung cancer are symptomatic at the time of diagnosis2. 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 cancer2. 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)
ŠŠ change in cough
ŠŠ dyspnoea
ŠŠ chest/shoulder pain
ŠŠ weight loss
ŠŠ chest signs
ŠŠ hoarseness
ŠŠ fatigue in a smoker aged 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 exposure2 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:
ŠŠ chest pain
ŠŠ dyspnoea
ŠŠ unexplained systemic symptoms
8 • Scottish referral guidelines for suspected cancer
3.2
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 www.sehd.scot.nhs.uk/mels/CEL2009_06.pdf
Lump
Urgent suspicion of cancer
referral
Routine referral
ŠŠ Any new discrete lump (in
ŠŠ Any new discrete lump in
patients over 35 years)
ŠŠ New asymmetrical nodularity
that persists at review after
menstruation (in patients over
35 years)
ŠŠ Unilateral isolated axillary
patients under 35 years with
no other suspicious features
Primary care management
Issue relevant advice leaflet
ŠŠ Women with longstanding
tender lumpy breast and
no focal lesion
ŠŠ New asymmetrical nodularity
ŠŠ Tender developing breasts
that persists at review after
menstruation (in patients
under 35 years)
in adolescents
lymph node in women
ŠŠ Cyst persistently refilling or
Nipple
symptoms
recurrent cyst
ŠŠ Bloodstained discharge
ŠŠ New nipple retraction
ŠŠ Persistent discharge sufficient ŠŠ Transient nipple discharge
to stain outer clothes
which is not bloodstained
ŠŠ Check prolactin levels
ŠŠ Nipple eczema if unresponsive
when discharge present
to topical steroids (such as
1% hydrocortisone) after a
minimum of 2 weeks
ŠŠ Longstanding nipple
retraction
ŠŠ Nipple eczema if eczema
present elsewhere
Skin changes
ŠŠ Skin tethering
ŠŠ Obvious simple skin
lesions such as sebaceous
cysts
ŠŠ Fixation
ŠŠ Ulceration
ŠŠ Peau d’orange
Abscess/
infection
ŠŠ Mastitis or breast inflammation ŠŠ Abscess or breast
which does not settle after one
course of antibiotics
inflammation even after
settled in patients over 35
years
ŠŠ Abscess* or inflammation
– try one course of
antibiotics to cover
staphylococcus and
streptococcus (also
consider possible
anaerobic infection as per
local guidelines)
Scottish referral guidelines for suspected cancer • 9
Urgent suspicion of cancer
referral
Pain
Routine referral
ŠŠ Unilateral persistent pain in
post menopausal women
ŠŠ Intractable pain that
interferes with the patient’s
lifestyle or sleep
Gynaecomastia
Primary care management
Issue relevant advice leaflet
ŠŠ Women with moderate
degrees of breast pain
and no discrete palpable
lesion
ŠŠ Exceptional aesthetics referral ŠŠ Examine and exclude
to plastic surgery pathway if
required
ŠŠ Exclude or treat any
endocrine cause prior to
referral
abnormalities such as
lymphadenopathy or
evidence of endocrine
condition
ŠŠ Review to exclude drug
causes
ŠŠ Measure hormones
(oestrogen, testosterone,
prolactin, human
chorionic gonadotropin
and alpha-fetoprotein)
ŠŠ Reassure
* Any acute abscess requires immediate discussion with secondary care.
10 • Scottish referral guidelines for suspected cancer
3.3Lower 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 year2. 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 www.sehd.scot.nhs.uk/mels/HDL2001_24Guide.pdf. 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
ŠŠ Repeated rectal bleeding without an obvious anal cause
ŠŠ Any blood mixed with the stool
Bowel habit
Mass
ŠŠ Persistent change in bowel habit especially to looser stools (more than 4 weeks)
ŠŠ Right-sided abdominal mass
ŠŠ Palpable rectal mass
Iron deficiency anaemia
Other
ŠŠ Unexplained iron deficiency anaemia
ŠŠ Past history of lower gastrointestinal cancer with any of the symptoms above
Primary care management
Low-risk features
ŠŠ Transient symptoms (less than 4 weeks)
ŠŠ Patients over 40 years in absence of high-risk features
Watch and wait (4 weeks)
ŠŠ Assessment and review
ŠŠ Consider bowel diary
ŠŠ Appropriate information, counselling and agreed plan for review with GP
Refer if symptoms persist or recur
Scottish referral guidelines for suspected cancer • 11
3.4 oesophago-gastric, hepatobiliary and pancreatic cancers
Approximately 3,000 people are diagnosed with a primary oesophago-gastric, hepatobiliary or pancreatic cancer in
Scotland every year1.
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
ŠŠ Dysphagia (interference of the swallowing mechanism that occurs within 5 seconds of the swallowing process) or
odynophagia (pain on swallowing) at any age
ŠŠ New onset upper gastrointestinal pain or discomfort in people over 55 years
ŠŠ New or worsening upper gastrointestinal pain or discomfort combined with one or more of the following features:
{{unexplained
weight loss
{{unexplained
iron deficiency anaemia
ŠŠ Persistent vomiting more than 4 weeks.
ŠŠ 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
12 • Scottish referral guidelines for suspected cancer
Hepatobiliary and pancreatic cancer
ŠŠ Features of hepatobiliary or pancreatic cancer can be vague and non-specific, and may include:
{{unexplained
{{upper
obstructive jaundice
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
ŠŠ Dyspepsia under 55 years without accompanying symptoms or risk factors should be managed according to local
or national guidelines
Scottish referral guidelines for suspected cancer • 13
3.5 urological cancers
Prostate cancer
Prostate cancer is the most common cancer in males in Scotland, with approximately 2,800 new cases diagnosed every
year1. 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 year1.
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 years1. 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 rising1.
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
ŠŠ Evidence from digital rectal examination of a hard, irregular prostate
ŠŠ 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
ŠŠ Patients with painless visible haematuria
ŠŠ Patients with visible haematuria and symptoms suggestive of UTI but with sterile mid-stream urine (MSU)
ŠŠ Abdominal mass identified clinically or on imaging that is thought to arise from the urinary tract
14 • Scottish referral guidelines for suspected cancer
Testicular and penile cancer
ŠŠ Swelling in the body of the testis
ŠŠ Suspicious scrotal mass found on imaging
ŠŠ Men considered to have epididymo-orchitis or orchitis which is not responding to treatment
ŠŠ Any non-healing lesion on the penis or painful phimosis
Non urgent referral
ŠŠ Elevated age-specific PSA where urgent referral will not affect outcome due to age or comorbidity
ŠŠ Asymptomatic persistent non-visible haematuria without obvious cause
ŠŠ Patients over 40 who present with recurrent UTI associated with any haematuria
Scottish referral guidelines for suspected cancer • 15
3.6 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)1. 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 (www.sign.ac.uk/pdf/qrg72.pdf ). 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
ŠŠ Lesions which are suspicious for melanoma should not be removed in primary care. All excised skin specimens
should be sent for pathological examination.
ŠŠ Lesions suspicious of basal cell carcinomas (BCC) may not require urgent referral, except those invading potentially
dangerous areas.
ŠŠ A change in a mole should be examined and reviewed (in 2 weeks) in pregnant women and women who have had
a baby within 12 months.
ŠŠ 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:
ŠŠ change in colour, size or shape in an existing mole
ŠŠ moles with Asymmetry, Border irregularity, Colour irregularity, Diameter increasing or >6mm
ŠŠ new growing nodule with or without pigment
ŠŠ persistent (more than 4 weeks) ulceration, bleeding or oozing
ŠŠ persistent (more than 4 weeks) surrounding inflammation or altered sensation
ŠŠ new or changing pigmented line in a nail or unexplained lesion in a nail
ŠŠ slow growing, non-healing or keratinising lesions with induration (thickened base)
ŠŠ any melanoma or invasive SCC or high risk BCC diagnosed from biopsy
ŠŠ any unexplained skin lesion in an immuno-suppressed patient
ŠŠ BCC invading potentially dangerous areas, for example peri-ocular, auditory meatus or any major vessel or nerve
16 • Scottish referral guidelines for suspected cancer
Reference list
1.
Information Services Division. Cancer incidence in Scotland (2011). 2013 [cited 12 Sept 2013]; Available at: http://
www.isdscotland.org/Health-Topics/Cancer/Publications/2013-04-30/2013-04-30-Cancer-Incidence-Report.
pdf?64773195982
2.
Scottish Executive. Scottish referral guidelines for suspected cancer. 2007 [cited 12 Sept 2013]; Available at: http://
www.sehd.scot.nhs.uk/mels/HDL2007_09.pdf
Scottish referral guidelines for suspected cancer • 17
Appendices
Appendix 1: Glossary
Actinic keratoses
Anaemia
Dry scaly patches of skin caused by damage from years of sun exposure
Condition where there is less than the normal number of red blood cells or less than the
normal quantity of haemoglobin in the blood
Atypical naevi
An unusual mole whose appearance is different (larger than average and irregular in shape)
from that of common moles
Auditory meatus
Either of the passages in the outer ear from the auricle to the tympanic membrane
Barrett’s oesophagus An abnormal change in the cells of the lower end of the oesophagus thought to be caused
by damage from chronic acid exposure
Benign tumour
A tumour that does not invade and destroy local tissue or spread to other sites in the body
Carcinogenic
Test used to measure the amount of this protein that may appear in the blood of some
embryonic antigen
people who have certain kinds of cancers, especially large intestine (colon and rectal)
test
cancer
Colorectal
Relating to or involving both the colon and the rectum
Consolidation
Condition where the alveolar (tiny air sacs in the lungs) space now contains fluid instead of
air
Dermoscope
Device used to examine moles through a thin layer of liquid to provide a highly accurate
assessment of what is going on directly below the skin’s surface
Dyspepsia
Pain or discomfort in the chest or stomach, sometimes accompanied by symptoms (such
as heartburn, bloating, belching, quickly feeling full after eating, nausea or vomiting), that
may develop soon after eating or drinking
Dysphagia
Interference of the swallowing mechanism that occurs within 5 seconds of the swallowing
process
Dyspnoea
Difficulty or pain in breathing
Epididymo-orchitis
Inflammation of the epididymis (the coiled tube that collects sperm from the testicle) and
or testis, usually due to infection
Epigastric pain
Pain that is localised to the region of the upper abdomen directly below the ribs
Familial adenomatous A rare, inherited condition that causes extra tissue (polyps) to form in the large intestine
polyposis
and in the upper part of the small intestine (duodenum)
Finger clubbing
Changes in the areas under and around the fingernails
Gastrointestinal
Relating to the stomach and intestines
Haematuria
Presence of blood in the urine
Non-visible haematuria: blood that can only be detected with laboratory testing
Haemoptysis
Helicobacter pylori
(H pylori)
Hepatobiliary and
pancreatic cancers
Visible haematuria: blood that is obvious with the naked eye
A condition in which someone coughs up blood from the lungs
A spiral shaped bacterium that lives on the gastric epithelium under the mucus layer of the
stomach and duodenum. The bacterium is thought to damage this mucus layer, which is
the stomach and duodenum's natural protection from gastric acids
Include cancers of the liver, gallbladder, bile ducts, and pancreas
Hoarseness
Abnormal voice changes
Incidence
Number of new cases of a condition in a defined population during a defined period and is
typically expressed as the number of new cases per 100,000 population per year (or other
18 • Scottish referral guidelines for suspected cancer
Jaundice
Yellowing of the skin and the whites of the eyes
Lymphadenopathy
A chronic, abnormal enlargement of the lymph nodes
Melanocytic naevi
Moles that arise as a result of proliferation of melanocytes, the cells in the skin that produce
pigment
Metaplasia
The transformation of one type of tissue into a different kind
Metastasis
Spreading of malignant disease from one part of the body to another through the
bloodstream or the lymphatic vessels
Mesothelioma
Cancer of the mesothelial cells, which are the cells that make up the membrane (lining) that
covers the outer surface of most of the body organs
Obstructive jaundice
A yellowish discolouration of the skin, the conjunctival membranes over the sclerae (whites
of the eyes), and other mucous membranes caused by hyperbilirubinaemia (increased
levels of bilirubin in the blood) as a result of interruption to the drainage of bile in the
biliary system
Odynophagia
Pain on swallowing
Oesophago-gastric
cancer
Cancer of the stomach and cancer of the oesophagus, also known as the gullet
Peri-ocular
Situated around the eye
Phimosis
A condition where the foreskin is too tight to be pulled back over the head of the penis
(glans)
Photochemotherapy
A type of ultraviolet radiation treatment used for severe skin diseases
Pleural effusion
Collection of fluid between a lung and the chest wall
Positive predictive
value
The probability that a person with a positive test result has, or will get, the disease
Primary care
Primary-level health, disability, social and community services care provided by a range of
health workers including general practitioners, nurses, pharmacists and allied health care
professionals
Prostate specific
antigen (PSA) test
A test which measures the blood level of PSA, a protein that is produced by the prostate
gland
Rectal
Relating to, or situated near the rectum
Sebaceous cyst
A benign or harmless growth which forms when the release of sebum (a fluid produced by
sebaceous glands in the skin), is blocked
Secondary care
Public hospitals, hospital-based services and specialist services
Squamous cell
carcinomas (SCC)
An uncontrolled growth of abnormal cells arising in the squamous cells, which compose
most of the skin’s upper layers (the epidermis)
Stridor
A sharp high pitched sound made when air passes an obstruction in the upper airway
(larynx)
Supraclavicular
Pertaining to the area above the clavicle or collar bone
Symptoms and signs
What the patient reports or what is observed that may indicate a condition or disease
Persistent: refers to signs or symptoms that continue to occur beyond a period of time that
would normally be indicative of a self-limiting condition
Unexplained: refers to signs or symptoms where no diagnosis has been made to identify
the cause after the patient has been assessed by a healthcare practitioner
Urea and electrolytes
test
A test which includes the measurement of the urea, sodium, potassium, CO2 and chloride
concentrations in venous blood
Urinary tract infection Develops when part of the urinary tract becomes infected, usually by bacteria
(UTI)
Scottish referral guidelines for suspected cancer • 19
Appendix 2: Members of guideline development team - steering group
Bob Grant
Peter Hutchison
Alistair Dorward
Ann Graham
Dawn Crosby
Douglas Rigg
Elaine Anderson
Hilda Emengo
Jacquie Dougall
(from September 2013)
Jim Little
(until September 2013)
Lisa Cooper
Lorraine Sloan
Moira Adams
Paul Baughan
Robert Atkinson
Sally Arnison
Sara Twaddle
Shirley Fife
Steven Beaven
Chair
Deputy Chair, General Practitioner, NHS Dumfries and Galloway
Consultant Respiratory Physician, NHS Greater Glasgow and Clyde
Junior Doctor, NHS Lothian
Head of Service Strategy and Policy, Teenage Cancer Trust
General Practitioner, NHS Greater Glasgow and Clyde
Consultant Breast Surgeon, NHS Lothian
Health Services Researcher, Healthcare Improvement Scotland
Cancer Delivery Programme Manager, Scottish Government
Cancer Delivery Programme Manager, Scottish Government
Clinical Team Leader, NHS24
Primary and Community Care Programme Manager, MacMillan UK
Patient and carer representative
General Practitioner, NHS Forth Valley
Patient and carer representative
Pharmacist, NHS Lothian
Director of Evidence (Interim), Healthcare Improvement Scotland
Consultant Cancer and Palliative Care Nurse, NHS Lothian
General Practitioner, NHS Tayside
20 • Scottish referral guidelines for suspected cancer
Appendix 3: Members of guideline development team - subgroups
Lung cancer guideline team
Bob Grant
Alistair Dorward
Chris Miller
Colin Selby
Diana Borthwick
Douglas Rigg
Jayne Oliver
Lorraine Dallas
Louise Gorman
Luke Daines
Sarah Muir
Chair
Consultant Respiratory Physician, NHS Greater Glasgow and Clyde
Pharmacist, NHS Forth Valley
Consultant Respiratory Physician, NHS Fife
Lung Clinical Nurse Specialist, Edinburgh Cancer Centre
General Practitioner, NHS Greater Glasgow and Clyde
General Practitioner, NHS Forth Valley
Director of Information and Support, The Roy Castle Lung Cancer Foundation
General Practitioner, NHS Forth Valley
Junior Doctor
General Practitioner, NHS Forth Valley
Breast cancer guideline team
Bob Grant
Ann Graham
David Stevenson
Elaine Anderson
Elizabeth Smyth
Hilary Campbell
Moira Adams
Pam Chisholm
Peter Hutchison
Philippa Whitford
Rosalie Dunn
Sarah Muir
Chair
Junior Doctor, NHS Lothian
General Practitioner, NHS Forth Valley
Consultant Breast Surgeon, NHS Lothian
Consultant Breast Surgeon, NHS Grampian
Head of Scotland Services, Breast Cancer Care
Patient and carer representative
Lead Pharmacist, Lothian Palliative Care Network
General Practitioner, NHS Dumfries and Galloway
Consultant Breast Surgeon, NHS Ayrshire and Arran
General Practitioner, NHS Lanarkshire
General Practitioner, NHS Forth Valley
Lower gastrointestinal cancer guideline team
Bob Grant
Ann Graham
Emma Anderson
Helen MacLeod
Hugh Brown
James Mander
Janice Oman
Michael Fyall
Paul Horgan
Rhoda Abel
Robert Atkinson
Steven Beaven
Chair
Junior Doctor, NHS Lothian
Scotland Operations Manager, Bowel Cancer UK
General Practitioner, Central and Eastern Cheshire Primary Care NHS Trust
General Practitioner, NHS Ayrshire and Arran
Consultant Colorectal Surgeon, NHS Lothian
Pharmacist, NHS Forth Valley
General Practitioner, NHS Forth Valley
Consultant Colorectal Surgeon, NHS Greater Glasgow and Clyde
General Practitioner, NHS Forth Valley
Patient and carer representative
General Practitioner, NHS Tayside
Scottish referral guidelines for suspected cancer • 21
Oesophagogastric, hepatobiliary and pancreatic cancer guideline team
Bob Grant
Peter Hutchison
Alastair MacMillan
Allan Lapsley
David Stevenson
Irfan Ahmed
Kate Cunningham
Lindsay Campbell
Louise Gorman
Neil Pryde
Sami Shimi
Stuart Paterson
Chair
Deputy Chair, General Practitioner, NHS Dumfries and Galloway
Consultant Gastrointestinal Surgeon, NHS Fife
Chair, Oesophageal cancer has reached everywhere (OCHRE)
General Practitioner, NHS Forth Valley
Consultant Upper HPB Surgeon, NHS Grampian
Campaign Director, OCHRE
Managed Clinical Network National Manager for Sarcoma, HPB and Neuro Cancers
General Practitioner, NHS Forth Valley
General Practitioner, NHS Fife
Consultant Gastrointestinal Surgeon, NHS Tayside
Consultant Gastroenterologist, NHS Forth Valley
Urological cancer guideline team
Bob Grant
Peter Hutchison
Adam Gaines
Alan McNeil
Alistair Haw
Chris Miller
David Stevenson
Hugh Brown
Justine Royle
Michael Fyall
Steven Beaven
Chair
Deputy Chair, General Practitioner, NHS Dumfries & Galloway
Director, Prostate Scotland
Consultant Urologist, NHS Grampian
Campaigns and Media Manager - Scotland, Prostate Cancer UK
Pharmacist, NHS Forth Valley
General Practitioner, NHS Forth Valley
General Practitioner, NHS Ayrshire and Arran
Consultant Urologist, NHS Lothian
General Practitioner, NHS Forth Valley
General Practitioner, NHS Tayside
Skin cancer guideline team
Bob Grant
Peter Hutchison
Alex Holme
Colin Fleming
David Stevenson
Douglas Rigg
Leigh Smith
Louise Gorman
Mark Darling
Neil Pryde
Chair
Deputy Chair, General Practitioner, NHS Dumfries and Galloway
Consultant Dermatologist, NHS Lothian
Consultant Dermatologist, NHS Tayside
General Practitioner, NHS Forth Valley
General Practitioner, NHS Forth Valley
Chair, Melanoma Action and Support Scotland (MASSCOT)
General Practitioner, NHS Forth Valley
Consultant Dermatologist, NHS Greater Glasgow and Clyde
General Practitioner, NHS Fife
22 • Scottish referral guidelines for suspected cancer
Appendix 4: Equality and diversity
The Scottish Government and Healthcare Improvement Scotland are committed to equality and diversity in respect of
the nine equality groups defined by age, disability, gender reassignment, marriage and civil partnership, pregnancy and
maternity, race, religion, sex, and sexual orientation.
The guideline development process has been assessed and the guideline is expected to have a positive impact on certain
age groups (depending on the tumour type) and more deprived populations in Scotland. The completed equality and
diversity checklist is available on www.healthcareimprovementscotland.org
Scottish referral guidelines for suspected cancer • 23