Where you are:
FY2 doctor in the GP surgery.Who the patient is:
John is a 3rd year medical student who wants to learn about the approach to patients with suspected cancer.Other information you have:
None.What you must do:
Teach the medical student how to go about assessing and managing a patient that you suspect to have cancer.
QUESTIONS
Q – What are some of the symptoms to look out for?
Q – How long does patient have to wait before being seen by the specialist?
APPROACH
Colleague GRIPS (Informal)
- You must be John. Hi I’m Hashim one of the FY2s. Nice to meet you.
- I understand you want to learn about the approach to suspected cancer cases. Certainly, I’m more than happy to go over this with you today.
Rapport
- This rotation - How are you finding the GP rotation so far?
- General – How are you finding medical school generally?
- Offer support
– We may not have time to go over everything today, take my number and we can run some further sessions going forward.
– And if you need help or advice with anything else, don’t hesitate to get in touch and I’ll try my best to help.
Check understanding
- What do you know so far about the suspected cancer approach?
- Was there anything specifically about it you wanted us to cover today?
Overview
- History Taking
- Examinations
- Explaining the Provisional / Differential Diagnosis
- Management
– The referral
– Appropriate Investigations in the GP surgery
– Explaining what the specialist will do (AIT)
– Aftercare (FSL)
History Taking
- According to site of suspected cancer
– E.g. Suspected breast cancer - breast lump, breast skin changes, discharge or retraction in one nipple only, lump in the axilla. - Non-specific cancer symptoms (FLAWS)
– Weight loss / loss of appetite; fever and night sweats; lethargy and tiredness (TATT -
“tired all of the time”); lumps & bumps; anaemia (light-headedness, breathlessness,
palpitations). - Systemic Review (metastasis)
– Lung → cough; haemoptysis; breathlessness; chest pain.
– Brain → headache; seizures; N&V; visual disturbances.
– Bone → back or neck pain; bone pains; leg numbness; bowel / bladder disturbance.
– Liver → jaundice; abdominal swelling (localised - hepatomegaly, generalised - ascites). - PMAFTOSA (PMAF) - risk factor screening e.g. premalignant conditions, personal history of cancer, family history of specific cancer.
Am I making sense? Any questions so far?
- Psychosocial (risk factors, support network and effects)
– Life Habits (DESA) – diet, exercise, smoking, alcohol.
– Life Situation
➢ Home – important to know support network and if they have any dependants.
➢ Work e.g. factory worker, asbestos exposure.
– Life Effects – Activities of daily living (ADLs), Work, Relationships, Sleep, Mood, Hobbies.
ICE
Examinations
- Specific examinations
- Systemic examination (metastasis)
Explaining the Provisional / Differential Diagnosis
- If you are suspecting something malignant, air on the side of caution and give a differential diagnosis that includes alternative benign conditions. If you are concerned tell them you are concerned and give your reasons why.
– e.g. suspected bladder CA: blood in the urine can be caused by something benign like a waterworks infection or a kidney stone, but I am concerned that there is a possibility this could be caused by a cancer of the bladder. Bladder cancers can present with unexplained blood in urine in your age group and are known to be more likely in long-term smokers. - Offer to answer questions.
Note: Do not use a Breaking Bad News (SPIKES) approach for these consultations – SPIKES is generally reserved for confirmed (not suspected) cases.
Management
The Referral
- I will send an urgent referral through the Suspected Cancer Pathway. This means that
you will be seen by a specialist within 2 weeks.
Notes:
- Urgent referrals should be made within one working day. Clock starts from when specialist receives the referral, not when you send it. Include all appropriate information in the referral letter, stating clearly the referral priority i.e. urgent.
- For suspected cancers in children (0-15 years) and young people (16-24 years) → send a very urgent referral – to be seen within 48 hours).
Suspected Cancer Pathway
- Reassure – While this is a suspected cancer service, most people referred do not have a diagnosis of cancer.
- Support – You can take a companion with you to the appointment if you wish.
- Explore preferences – for being involved in decision‑making about referral options and further investigations including their potential risks and benefits.
Note: Discussion with a specialist (for example, by telephone or email) should be considered if there is uncertainty about the interpretation of symptoms and signs, and whether a referral is needed. This may also enable the GP to communicate their concerns and a sense of urgency to the specialist when symptoms are not classical.
Appropriate investigations in the GP surgery
- Sometimes it is appropriate to do urgent investigations at the GP surgery. Ideally the results should be available to the specialist when they see them, but this should not delay referral to the specialist.
Notes: For your information.
- Suspected ovarian cancer → urgent tumour marker: CA125; urgent ultrasound scan of the abdomen and pelvis.
- Suspected testicular cancer → urgent tumour markers (alpha-fetoprotein [AFP], human chorionic gonadotrophin [hCG], and lactate dehydrogenase [LDH] levels); direct access ultrasound scan.
- Suspected liver or gall bladder cancer → urgent direct access ultrasound scan
- Suspected pancreatic cancer → urgent direct access CT scan or urgent ultrasound scan if CT not available.
- Suspected leukaemia → very urgent full blood count (within 48 hours).
- Suspected colorectal cancer → offer quantitative faecal immunochemical testing (FIT).
- Suspected endometrial cancer → direct access ultrasound scan.
- Suspected soft tissue sarcoma - urgent direct access ultrasound scan
- Suspected bone sarcoma in children - very urgent direct access X‑ray (to be done within 48 hours)
- Suspected lung cancer or mesothelioma → urgent chest X‑ray
- Suspected brain/CNS tumour → urgent direct access MRI scan of the brain (or CT scan if MRI is contraindicated).
- Suspected multiple myeloma → very urgent protein electrophoresis and a Bence–Jones protein urine test (within 48 hours); full blood count and blood tests for calcium and plasma viscosity or ESR.
- Suspected Prostate cancer → prostate‑specific antigen (PSA) test.
Explain what the specialist will do (AIT)
- Specialist Assessment – history and examination
- Specialist Investigations to confirm the diagnosis
– These include tests that can’t be carried out in the GP surgery e.g. colonoscopy and biopsy.
– Explain how long it is likely to take to get a diagnosis or test results. - Treatment options if confirmed – will depend on staging and grading. Options may include surgery, curative or palliative chemotherapy and radiotherapy, biological and hormonal therapies.
Aftercare (FSL)
- Follow up – assess their need for continuing support while waiting for their referral appointment. Sometimes it may be appropriate to arrange a telephone call in a few days time.
– I appreciate that it’s a lot to take in and that you may later have questions or concerns that you can’t think of right now. I’d like to give you a call in 2 days’ time to see if there’s anything else you want to discuss before you see the specialist. - Safety netting - for Delayed or Missed appointment.
– If you don’t receive an appointment letter in the post / via the online Patient Portal Service to see the specialist within 1 week then let us know and we will chase up the appointment for you.
That’s quite a lot of information we’ve covered there… Would you like me to go over that again?
– If for whatever reason you miss your appointment, let us know as soon as possible so we can arrange another appointment for you.
Note: Most hospital policies are to discharge people who do not attend (DNA) their first appointment).
- Leaflet / Reading information
– Reputable websites or leaflets.
– Support Groups - If confirmed, we can get you in touch with Macmillan Cancer Support who can provide you with psychological and emotional support. There are lots of people living with cancer. Macmillan are there to make sure that nobody goes through cancer on their own.
Summarise