My name is Fernando Florido and I am a GP in the United Kingdom. In this podcast I go through a section of the NICE guideline NG12 “Suspected cancer recognition and referral”, last updated in December 2021. This episode will summarise the section “recommendations by site of cancer” covering breast cancer as well as gynaecological and urological cancers.

This podcast will be saved on a website.

NICE guideline NG12 can be found here:

https://www.nice.org.uk/guidance/ng12/chapter/Recommendations-organised-by-site-of-cancer

Age specific PSA threshold table:

Table 1 Age-specific PSA thresholds for people with possible symptoms of prostate cancer

Age (years) Prostate-specific antigen threshold (micrograms/litre)

Below 40 Use clinical judgement

40 to 49 More than 2.5

50 to 59 More than 3.5

60 to 69 More than 4.5

70 to 79 More than 6.5

Above 79 Use clinical judgement

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Welcome to a new episode of the Clinical Guidelines in Primary Care podcast. My name is Fernando Florido and I am a GP in the United Kingdom. This is the second episode of the cancer guidelines series. This episode will summarise the section “recommendations by site of cancer” of the NICE guideline NG12 “Suspected cancer recognition and referral”. In this podcast, I will cover breast cancer as well as gynaecological and urological cancers. I hope that you enjoy the episode.

Starting with Breast cancer

We must refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for breast cancer if they are:

·      aged 30 and over and have an unexplained breast lump with or without pain or

·      aged 50 and over with any of the following symptoms in one nipple only:

o  discharge 

o  retraction 

·      other changes of concern. This has been left particularly vague so we must use our clinical judgment here.

We should also consider a suspected cancer pathway referral in people:

·      with skin changes that suggest breast cancer or

·      aged 30 and over with an unexplained lump in the axilla.

Finally, we should consider non-urgent referral in people aged under 30 with an unexplained breast lump with or without pain. However, breast cancer can happen in patients under 30 so you are particularly worried for any reason, you can always upgrade the referral to urgent.

Now we are going to move to Gynaecological cancers and the first one to consider is

Ovarian cancer

and these recommendations apply to women aged 18 and over.

We need to make an urgent referral to a gynaecological cancer service if physical examination identifies ascites and/or a pelvic or abdominal mass (which is not obviously uterine fibroids). 

We must carry out tests in primary care, particularly the measurement of serum CA125  if a woman, especially if aged 50 or over, reports having any of the following symptoms on a persistent or frequent basis – particularly more than 12 times per month:

·      persistent abdominal distension (often referred to as 'bloating')

·      feeling full and/or loss of appetite

·      pelvic or abdominal pain

·      increased urinary urgency and/or frequency. 

We must also measure CA125 if a woman experiences symptoms within the last 12 months that suggest irritable bowel syndrome or IBS, because IBS rarely presents for the first time in women of this age.

We should consider carrying out tests in primary care, particularly the measurement of serum CA125  if a woman reports unexplained weight loss, fatigue or changes in bowel habit. 

Once the CA125 has been measured as per these recommendations, we must do the following:

If the value is 35 IU/ml or greater, we must arrange an ultrasound scan of the abdomen and pelvis. 

And, if the ultrasound suggests ovarian cancer, we will obviously need make an urgent referral to a gynaecological cancer service. 

However, for any woman who has a serum CA125 which is less than 35 IU/ml, or CA125 of 35 IU/ml or greater but a normal ultrasound:

·      we will need to assess her carefully for other clinical causes of her symptoms and investigate if appropriate

·      and, if no other clinical cause is apparent, we will need to advise her to return to primary care if her symptoms become more frequent and/or persistent. 

In summary:

We must do an urgent cancer referral there is ascites or a pelvic or abdominal mass. 

We must measure CA125  if a woman, especially if aged 50 or over, reports frequent or persistent symptoms such as:

·      'bloating'

·      feeling full or loss of appetite

·      pelvic or abdominal pain

·      increased urinary urgency and/or frequency. 

·      Or if IBS symptoms have developed within the last 12 months.

In addition we should consider CA125 if there is:

·      Weight loss

·      Fatigue

·      Changes in bowel habit

If the value is 35 or greater, we must arrange an ultrasound scan and act accordingly if abnormal. 

If the CA125 is less than 35 or is greater with a normal ultrasound we must continue to investigate or monitor the patient until the cause if found

The next cancer to consider is Endometrial cancer

We must refer women using a suspected cancer pathway referral if they are aged 55 and over with post‑menopausal bleeding (or unexplained vaginal bleeding more than 12 months after menstruation has stopped because of the menopause), although we should also consider in women aged under 55.

We need to consider a direct access ultrasound scan in women aged 55 and over with:

·      unexplained vaginal discharge who:

o  are presenting with these symptoms for the first time or

o  have thrombocytosis or

o  report haematuria, or

·      visible haematuria and:

o  low haemoglobin levels or

o  thrombocytosis, or

o  high blood glucose levels. This is because there is a link between hyperglycaemia and endometrial cancer and hyperglycaemia is considered an independent risk factor for this type of cancer.

In summary, do a cancer referral if there is postmenopausal bleeding and do an USS if the women is over 55 and have a vaginal discharge or haematuria with other symptoms such as thrombocytosis, low haemoglobin or hyperglycaemia.

For Cervical cancer it is very straightforward.

We need to consider a suspected cancer pathway referral if, on examination, the appearance of their cervix is consistent with cervical cancer. 

In terms of Vulval and vaginal cancer

We need to consider a suspected cancer pathway referral for vulval cancer in women with an unexplained vulval lump, ulceration or bleeding and  for vaginal cancer if there is an unexplained palpable mass in or at the entrance to the vagina. 

We will now move to the Urological cancers

In terms of Prostate cancer

We must refer men using a suspected cancer pathway referral if their prostate feels malignant on digital rectal examination. 

We need to consider a prostate‑specific antigen (PSA) test and digital rectal examination to assess for prostate cancer in men with:

·      any lower urinary tract symptoms, such as nocturia, urinary frequency, hesitancy, urgency or retention or

·      erectile dysfunction or

·      visible haematuria. 

And we need to consider referring using a suspected cancer pathway referral if their PSA levels are above the threshold for their age. I have put a table with these values in the podcast description. The summary of this table is that for men under 40 and or 80 or over we need to use our clinical judgement when assessing the PSA. For the remainder, the PSA threshold is 2.5 for men in their 40’s, 3.5 in their 50’s is, 4.5 in their 60’s and 6.5 in their 70’s. That means consider referring men whose result is above those limits.

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When it come to Bladder cancer

We must refer people using a suspected cancer pathway referral if they are:

·      aged 45 and over and have:

o  unexplained visible haematuria without urinary tract infection or

o  visible haematuria that persists or recurs after successful treatment of urinary tract infection, or

·      aged 60 and over and have unexplained non‑visible haematuria and either dysuria or a raised white cell count on a blood test. 

We should also consider non-urgent referral in people aged 60 and over with recurrent or persistent unexplained urinary tract infection. 

Renal cancer

We must refer people using a suspected cancer pathway referral if, like in bladder cancer, they are aged 45 and over and have:

·      unexplained visible haematuria without urinary tract infection or

·      visible haematuria that persists or recurs after successful treatment of urinary tract infection. 

For Testicular cancer

We need to consider a suspected cancer pathway referral in men if they have a non‑painful enlargement or change in shape or texture of the testis. 

And we should consider a direct access ultrasound scan in men with unexplained or persistent testicular symptoms. 

For Penile cancer

We need to consider a suspected cancer pathway referral in men if they have:

·      a penile mass or ulcerated lesion, when a sexually transmitted infection has been excluded as a cause, or

·      a persistent penile lesion after treatment for a sexually transmitted infection has been completed. 

We should also consider a cancer referral in men with unexplained or persistent symptoms affecting the foreskin or glans. 

This is the end of this episode of the Clinical Guidelines in Primary Care podcast. I hope that you have enjoyed this episode and I hope that you will join me in the next one. Thank you for listening