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 lung and pleural cancers as well as upper and lower gastrointestinal tract cancers.

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NICE guideline NG12 can be found here:

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

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Transcript

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. Now think. After seeing a patient, have you ever found yourself wondering whether you may have missed an important diagnosis? And what if it is cancer? Are you sometimes unsure about cancer red flags and how you should manage those patients? I know that I have and, if you have too, then you are in the right place because with this episode we are starting a new cancer series that will help you in this respect. In this episode I will go through a section of the NICE guideline NG12 which is “Suspected cancer recognition and referral” which was published in June 2015 and was last updated in December 2021. This episode will cover lung cancer and mesothelioma as well as all gastrointestinal tract cancers. I hope that you enjoy the episode.

We are going to start with the respiratory cancers, that is, Lung cancer and mesothelioma.

The recommendations in respect of Lung cancer and mesothelioma are described separately in the NICE guideline. However, as it can be expected, there is a significant overlap between the red flags for the two conditions and therefore, for simplicity and the avoidance of repetition, I have amalgamated both recommendations into one. These recommendations say the following:

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

·      have chest X‑ray findings that suggest lung cancer or mesothelioma or

·      are aged 40 and over with unexplained haemoptysis. I understand this to be that we would need to refer someone over 40 with unexplained haemoptysis even before doing a chest x-ray or, if it has already been done, even if it is normal

We must offer an urgent chest X‑ray (to be done within 2 weeks) to assess for lung cancer or mesothelioma in people aged 40 and over if:

·      they have 2 or more of the following unexplained symptoms, or

·      they have 1 or more of the following unexplained symptoms and have ever smoked, or

·      they have 1 or more of the following unexplained symptoms and have been exposed to asbestos:

·      cough

·      shortness of breath

·      chest pain

·      fatigue

·      weight loss

·      appetite loss. 

·      That it, while the first three (cough, SOB and chest pain) may appear evident, the last three (fatigue, weight loss and appetite loss) may not always prompt us to think about lung cancer.

·      These are the cases where we must refer for a CXR. However:

We need to “consider” ( as opposed to “must”) an urgent chest X‑ray (to be done within 2 weeks) to assess for lung cancer in people aged 40 and over with any of the following:

·      persistent or recurrent chest infection 

·      finger clubbing 

·      supraclavicular lymphadenopathy or persistent cervical lymphadenopathy 

·      chest signs consistent with lung cancer or pleural disease

·      thrombocytosis. 

Now we are going to move to the gastrointestinal tract cancers, both upper and lower parts of the gastrointestinal tract.

In terms of Oesophageal and stomach cancers

Obviously we must consider a suspected cancer pathway referral (for an appointment within 2 weeks) for people with an upper abdominal mass consistent with stomach cancer. 

We must offer urgent, direct access upper gastrointestinal endoscopy (to be done within 2 weeks) to assess for oesophageal and stomach cancer in people:

·      with dysphagia or

·      aged 55 and over with weight loss and any of the following: 

o  upper abdominal pain 

o  reflux

o  dyspepsia. 

We need to consider non-urgent direct access upper gastrointestinal endoscopy to assess for oesophageal or stomach cancer in people with haematemesis. Obviously I understand that the urgency of the referral will be guided by our clinical judgement depending on the severity of the haematemesis.

We also need to consider non‑urgent direct access upper gastrointestinal endoscopy to assess for oesophageal cancer in people aged 55 or over with:

·      treatment‑resistant dyspepsia or

·      upper abdominal pain with low haemoglobin levels or

·      raised platelet count with any of the following:

o  nausea

o  vomiting

o  weight loss

o  reflux

o  dyspepsia

o  upper abdominal pain, or

·      nausea or vomiting with any of the following:

o  weight loss

o  reflux

o  dyspepsia

o  upper abdominal pain. 

When it comes to Pancreatic cancers

We must refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for pancreatic cancer if they are aged 40 and over and have jaundice. 

We need to consider an urgent direct access CT scan (to be done within 2 weeks), or an urgent ultrasound scan if CT is not available, to assess for pancreatic cancer in people aged 60 and over with weight loss and any of the following: 

·      diarrhoea

·      back pain

·      abdominal pain

·      nausea

·      vomiting

·      constipation

·      new‑onset diabetes. 

·      I would personally say that if you do not have direct access to CT scan, you should not be entirely reassured by just an ultrasound and perhaps a referral for further investigations should be in order if the symptoms are significant.

In terms of Gall bladder and liver cancers

We need to consider an urgent direct access ultrasound scan (to be done within 2 weeks) to assess for gall bladder or liver cancer in people with an upper abdominal mass consistent with an enlarged gall bladder or liver.

When it comes to Colorectal cancer

We must refer adults using a suspected cancer pathway referral (for an appointment within 2 weeks) for colorectal cancer if:

·      they are aged 40 and over with unexplained weight loss and abdominal pain or

·      they are aged 50 and over with unexplained rectal bleeding or

·      they are aged 60 and over with:

o  iron‑deficiency anaemia or

o  changes in their bowel habit, or

·      tests show occult blood in their faeces (and it seems that the guideline indicates this irrespective of age).

·      These are when we “must” refer. However:

We need to consider a suspected cancer pathway referral (for an appointment within 2 weeks) for colorectal cancer in adults with a rectal or abdominal mass. And

We also need to consider a suspected cancer pathway referral (for an appointment within 2 weeks) for colorectal cancer in adults aged under 50 with rectal bleeding and any of the following unexplained symptoms or findings:

·      abdominal pain

·      change in bowel habit

·      weight loss

·      iron‑deficiency anaemia. 

·      This means that for any other patient not meeting the age requirements:

We can offer testing with quantitative faecal immunochemical tests to assess for colorectal cancer in adults without rectal bleeding who:

·      are aged 50 and over with unexplained:

o  abdominal pain or

o  weight loss, or

·      are aged under 60 with:

o  changes in their bowel habit or

o  iron-deficiency anaemia, or

·      are aged 60 and over and have anaemia even in the absence of iron deficiency. 

Finally, in terms of Anal cancer

We need to consider a suspected cancer pathway referral (for an appointment within 2 weeks) for anal cancer in people with an unexplained anal mass or unexplained anal ulceration. 

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