Cancer oncology

Tumour Markers
AFP	<40 mcg/l
CA 15-3	<30 kU/l
CA 19-9	<37 kU/l
CA 27-29	<38 kU/l
CA 125	<35 kU/l
CEA	<2.5 – 5 mcg /l
HCG	<2 mcg/l
Neuron Specific enolase	< 12.5 mcg/ml
PSA	<2.5 -6.5 mcg/l depending on age

aafp tumour markers

http://www.bmj.com/content/339/bmj.b3527.full

slideshare.net serum tumor markers

Paraneoplastic syndromes (oncology)

Paraneoplastic syndromes
SIADH secretion
Cushings
hypercalcaemia
polycythaemia
hypoglycaemia
thyrotoxicosis
gynaecomastica
dementia
peripheral neuropathy
cerebellar degeneration
Eaton Lambert syndrome
Acanthosis nigrans
Stiffmann syndrome
Icthyosis
Clubbing
Dermatomyositis

hacking-medschool/paraneoplastic-syndromes-endocrine\

Paraneoplastic syndromes Medscape

Paraneoplastic syndromes ninds.nih.gov

Paraneoplastic syndromes mayo clinic.com

Carcinogens

Known and Probable Human Carcinogens American Cancer Society

Carcinogens Kids against cancer

Carcinogens @ Scorecard

Red Flags in Suspected Cancer

Assessment of suspected cancer RCGP InnovAit

8 Cancer Red Flags Your Doc Should Never Ignore CBS News

Red flags in cancer

qcancer.org

qcancer.org/lung

qcancer.org/colorectal

qcancer.org/gastro-oesophageal

qcancer.org/pancreas

qcancer.org/ovary

http://www.bmj.com/content/344/bmj.d8009

qcancer.org/renal

QCancer @ NELM Nov 2011

NICE guidelines for suspected cancer

NICE CG27 Referral for suspected cancer Jun 2005

2 week wait for suspected cancer referrals Read Codes
8HHt	cancer referral
8Hn0	skin cancer
8Hn1	gynaecological cancer
8Hn2	breast cancer
8Hn3	children’s tumour
8Hn4	colorectal cancer
8Hn5	urological cancer
8Hn6	haematology malignancy
8Hn7	lung cancer
8Hn8	sarcoma
8Hn9	upper GI cancer
8HnA	brain tumour
8HnB	head and neck cancer

http://www.rcgp.org.uk/news/press_releases_and_statements/cancer_diagnosis_report.aspx

Nice CG 121 Apr 11 Lung Ca

Immediate referral
Consider immediate referral for patients with:
signs of superior vena caval obstruction (swelling of the face/neck with fixed elevation of jugular venous pressure)
stridor

Urgent referral
Refer urgently patients with:
persistent haemoptysis (in smokers or exsmokers aged 40 years and older)
a chest Xray suggestive of lung cancer (including pleural effusion and slowly resolving consolidation)
a normal chest Xray where there is a high suspicion of lung cancer
a history of asbestos exposure and recent onset of chest pain, shortness of breath or unexplained systemic symptoms where a chest Xray indicates pleural effusion, pleural mass or any suspicious lung pathology

Urgent chest Xray
Refer urgently for chest Xray (the report should be returned within 5 days) for patients with any of the following:
haemoptysis
unexplained or persistent (longer than 3 weeks):
chest and/or shoulder pain
dyspnoea
weight loss
chest signs
hoarseness
finger clubbing
cervical or supraclavicular lymphadenopathy
cough
features suggestive of metastasis from a lung cancer (for example, secondaries in the brain, bone, liver, skin)
underlying chronic respiratory problems with unexplained changes in existing symptoms

Upper gastrointestinal cancer

For patients under 55 years, referral for endoscopy is not necessary in the absence of alarm symptom
Patients being referred urgently for endoscopy should ideally be free from acid suppression medication, including proton pump inhibitors or H2 receptor agonists, for a minimum of 2 weeks

Urgent referral for endoscopy /referral to specialist
Refer urgently for endoscopy, or to a specialist, patients of any age with dyspepsia and any of the following:
chronic gastrointestinal bleeding
dysphagia
progressive unintentional weight loss
persistent vomiting
iron deficiency anaemia
epigastric mass
suspicious barium meal result

Urgent referral
dysphagia
unexplained upper abdominal pain and weight loss, with or without back pain
upper abdominal mass without dyspepsia
Consider urgent referral for patients presenting with:
persistent vomiting and weight loss in the absence of dyspepsia
unexplained weight loss or iron deficiency anaemia in the absence of dyspepsia
Barrett’s oesophagus
known dysplasia, atrophic gastritis or intestinal metaplasia
peptic ulcer surgery over 20 years ago

Urgent endoscopy
Refer urgently for endoscopy patients aged 55 years and older with unexplained and persistent recent onset dyspepsia alone

Lower gastrointestinal cancer

Urgent referral
aged 40 years and older, reporting rectal bleeding with a change of bowel habit towards looser stools and/or increased stool frequency persisting 6 weeks or more
aged 60 years and older, with rectal bleeding persisting for 6 weeks or more without a change in bowel habit and without anal symptoms
aged 60 years and older, with a change in bowel habit to looser stools and/or more frequent stools persisting for 6w or more without rectal bleeding
of any age with a right lower abdominal mass consistent with involvement of the large bowel
of any age with a palpable rectal mass (intraluminal and not pelvic; a pelvic mass outside the bowel would warrant an urgent referral to a urologist or gynaecologist)
who are men of any age with unexplained iron deficiency anaemia and a haemoglobin of 11 g/100 ml or below
who are non-menstruating women with unexplained iron deficiency anaemia and a haemoglobin of 10 g/100 ml or below

Breast cancer (oncology)

<a href=”http://hacking-medschool.com/breast-cancer/”hacking-medschool.com/breast-cancer

Urgent referral
of any age with a discrete, hard lump with fixation, with or without skin tethering
who are female, aged 30 years and older with a discrete lump that persists after their next period, or presents after menopause
who are female, aged younger than 30 years:
with a lump that enlarges
with a lump that is fixed and hard
in whom there are other reasons for concern such as family history
of any age, with previous breast cancer, who present with a further lump or suspicious symptoms
with unilateral eczematous skin or nipple change that does not respond to topical treatment
with nipple distortion of recent onset
with spontaneous unilateral bloody nipple discharge
who are male, aged 50 years and older with a unilateral, firm subareolar mass with or without nipple distortion or associated skin changes

Nonurgent referral
women aged younger than 30 years with a lump
patients with breast pain and no palpable abnormality, when initial treatment fails and/or with unexplained persistent symptoms.

Gynaecological cancer

Urgent referral
Clinical features suggestive of cervical cancer on examination.
A smear test is not required before referral, and a previous negative result should not delay referral
Not on hormone replacement therapy with postmenopausal bleeding
On hormone replacement therapy with persistent or unexplained postmenopausal bleeding after cessation of hormone replacement therapy for 6 weeks
taking tamoxifen with postmenopausal bleeding
with an unexplained vulval lump
with vulval bleeding due to ulceration

Consider urgent referral for patients with persistent intermenstrual bleeding and negative pelvic examination

Refer urgently for an ultrasound scan
palpable abdominal or pelvic mass on examination that is not obviously uterine fibroids or not of gastrointestinal or urological origin. If the scan is suggestive of cancer, an urgent referral should be made.
If urgent ultrasound is not available, an urgent referral should be made

Urological cancer

Prostate
Refer urgently patients: with a hard, irregular prostate typical of a prostate carcinoma.

Prostatespecific antigen (PSA) should be measured and the result should accompany the referral.
An urgent referral is not needed if the prostate is simply enlarged and the PSA is in the agespecific reference range) with a normal prostate, but rising/raised agespecific PSA, with or without lower urinary tract symptoms.
In patients compromised by other co-morbidities, a discussion with the patient or carers and/or a specialist may be more appropriatewith symptoms and high PSA levels

Age-specific cut-off PSA measurements recommended by the Prostate Cancer Risk Management Programme:
aged 50–59 >3.0 ng/ml
aged 60–69 >4.0 ng/ml
aged 70+ >5.0 ng/ml

There are no age-specific reference ranges for men over 80 years.
Nearly all men of this age have at least a focus of cancer in the prostate.
Prostate cancer only needs to be diagnosed in this age group if it is likely to need palliative treatment

Bladder and renal
Refer urgently patients: of any age with
painless macroscopic haematuria aged 40 years and older who present with recurrent or persistent urinary tract infection associated with haematuria aged 50 years and older who are found to have unexplained microscopic haematuria with an abdominal mass identified clinically or on imaging that is thought to arise from the urinary tract
Non-urgent referral
Refer nonurgently patients under 50 years of age with microscopic haematuria.
Patients with proteinuria or raised serum creatinine should be referred to a renal physician.
If there is no proteinuria and serum creatinine is normal, a nonurgent referral to a urologist should be made

Testicular
Refer urgently patients with a swelling or mass in the body of the testis

Penile
Refer urgently patients with symptoms or signs of penile cancer.
These include progressive ulceration or a mass in the glans or prepuce particularly, but can involve the skin of the penile shaft.
Lumps within the corpora cavernosa can indicate Peyronie’s disease, which does not require urgent referral

Haematological cancer / lymphoma / leukaemia

Refer a patient who presents with symptoms suggesting haematological cancer to a team specialising in the management of haematological cancer, depending on local arrangements
Be aware that haematological cancers can present with a variety of symptoms that may have a number of different clinical explanations
Combinations of the following symptoms and signs warrant full examination, further investigation (including FBC and film) and possible referral:
fatigue
drenching night sweats
fever
weight loss
generalised itching
breathlessness
bruising
bleeding
recurrent infections
bone pain
alcoholinduced pain
abdominal pain
lymphadenopathy
splenomegaly
The urgency of referral depends on the symptom severity and findings of investigations

Immediate referral
with a blood count/film reported as acute leukaemia
with spinal cord compression or renal failure suspected of being caused by myeloma

Urgent referral
Persistent unexplained splenomegaly

Skin cancer

SF30 Recommended BBC News

Skin cancer Rural Health West

Refer a patient presenting with skin lesions suggestive of skin cancer or in whom a biopsy has confirmed skin cancer to a team specialising in skin Refer patients with persistent or slowly evolving unresponsive skin conditions with uncertain diagnosis to a dermatologist
If you perform minor surgery you should have received appropriate accredited training in relevant aspects of skin surgery including cryotherapy, curettage, and incisional and excisional biopsy techniques, and should undertake appropriate continuing professional development

Melanoma
Change is a key element in diagnosing malignant melanoma. For lowsuspicion lesions, undertake careful monitoring for change using the 7point checklist (see below) for 8 weeks. Make measurements with photographs and a marker scale and/or ruler

7 point weighted checklist for assessment of pigmented skin lesions
major features of lesions:
change in size
irregular shape
irregular colour
minor features of lesions:
largest diameter 7 mm or more
inflammation
oozing
change in sensation
Lesions scoring 3 points or more (based on major features scoring 2 points each and minor features scoring 1 point each) in the 7point checklist above are suspicious.

(If you strongly suspect cancer any one feature is adequate to prompt urgent referral)
Refer urgently patients:
with a lesion suspected to be melanoma. (Excision in primary care should be avoided)

Refer urgently patients:
with nonhealing keratinizing or crusted tumours larger than 1 cm with significant induration on palpation. They are commonly found on the face, scalp or back of the hand with a documented expansion over 8 weeks
who have had an organ transplant and develop new or growing cutaneous lesions as squamous cell carcinoma is common with immunosuppression but may be atypical and aggressive
with histological diagnosis of a squamous cell carcinoma

Nonurgent referral
Basal cell carcinomas are slow growing, usually without significant expansion over 2 months, and usually occur on the face. If basal cell carcinoma is suspected, refer nonurgently

Head and neck cancer including thyroid cancer

Refer a patient who presents with symptoms suggestive of head and neck or thyroid cancer to an appropriate specialist or the neck lump clinic, depending on local arrangements

Urgent referral
Refer urgently patients with:
an unexplained lump in the neck, of recent onset, or a previously undiagnosed lump that has changed over a period of 3 to 6 weeks
an unexplained persistent swelling in the parotid or submandibular gland
an unexplained persistent sore or painful throat
unilateral unexplained pain in the head and neck area for more than 4 weeks, associated with otalgia (ear ache) but a normal otoscopy
unexplained ulceration of the oral mucosa or mass persisting for more than 3 weeks
unexplained red and white patches (including suspected lichen planus) of the oral mucosa that are painful or swollen or bleeding
For patients with persistent symptoms or signs related to the oral cavity in whom a definitive diagnosis of a benign lesion cannot be made, refer or follow up until the symptoms and signs disappear. If the symptoms and signs have not disappeared after 6 weeks, make an urgent referral

Referral to a dentist
Refer urgently to a dentist patients with unexplained tooth mobility persisting for more than 3 weeks
Monitor for oral cancer patients with confirmed oral lichen planus, as part of routine dental examination.
Advise all patients, including those with dentures, to have regular dental checkups

Referral for a chest Xray
Refer urgently for chest Xray patients with hoarseness persisting for more than 3 weeks, particularly smokers aged older than 50 years and heavy drinkers
If there is a positive finding, refer urgently to a team specialising in the management of lung cancer. If there is a negative finding, refer urgently to a team specialising in head and neck cancer

Nonurgent referral
Refer nonurgently a patient with unexplained red and white patches of the oral mucosa that are not painful, swollen or bleeding (including suspected lichen planus)

Thyroid cancer
• Refer immediately patients with symptoms of tracheal compression including stridor due to thyroid swelling
• Refer urgently patients with a thyroid swelling associated with any of the following:
? a solitary nodule increasing in size
? a history of neck irradiation
? a family history of an endocrine tumour
? unexplained hoarseness or voice changes
? cervical lymphadenopathy
? very young (prepubertal) patient
? patient aged 65 years and older

Brain / CNS tumours

iTunes U Brain Tumours Rock Valley College

Support Cells in Nervous System
microglial	phagocyte
oligodendroglial	CNS myelination	oligodendrocytoma
schwann	PNS myelination	schwannoma – acoustic neuroma
astrocyte	PNS myelination	astrocytoma
ependymal	lines ventricles helps circulation of CNS	ependyoma

CNS Tumours

astrocytoma

glioblastoma muliforme

meningioma

schwannoma (acoustic neuroma)

medulloblastoma

ependymoma

Urgent referral
progressive neurological deficit
new onset seizures
mental changes
cranial nerve palsy
unilateral sensorineural deafness in whom a brain tumour is suspected
headaches of recent onset accompanied by features suggestive of raised ICP:
vomiting
drowsiness
posture-related headache
pulse-synchronous tinnitus

other focal or non-focal neurological symptoms, for example blackout, change in personality or memory
a new, qualitatively different, unexplained headache that becomes progressively severe
suspected recentonset seizures (refer to neurologist)
Consider urgent referral (to an appropriate specialist) in patients with rapid progression of:
subacute focal neurological deficit
unexplained cognitive impairment, behavioural disturbance or slowness, or a combination of these
personality changes confirmed by a witness and for which there is no reasonable explanation even in the absence of the other symptoms and signs of a brain tumour

Nonurgent referral
Consider nonurgent referral or discussion with specialist for:
unexplained headaches of recent onset:
present for at least 1 month
not accompanied by features suggestive of raised ICP

Mobile phone use and brain tumours BMJ Oct 2011