Symptoms and signs

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Diagnosis of cancer on clinical grounds alone can be difficult. GPs should be familiar with common symptoms and signs of typical AYA cancers, and be able to readily identify these features when AYAs consult with them.
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AYAs who present with symptoms and/or signs of cancer should be referred urgently to a paediatric oncologist or Youth Cancer Service, depending on local arrangements.
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AYA cancers may present initially with symptoms and/or signs associated with common conditions. AYAs presenting several times (three or more) with the same problem, who are clinically unwell, but with no clear diagnosis, should be considered for urgent referral to a specialist.
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The need to consider action increases as the number of presenting symptoms and/or signs increases. Consider that combinations of symptoms and/or signs can have a higher predictive value than a single sign or symptom in isolation. However, a single symptom and/or sign should not be overlooked when considering a cancer diagnosis.

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Overview

Improvements in cancer survival for adolescents and young adults (AYAs) still lag behind paediatric and adult patients.[1] It is very important to identify ways to improve survival and reduce morbidity in this age group. The early detection of cancer and simplifying referral pathways are two important strategies to do this.

General practitioners (GPs) should be familiar with common symptoms and signs of typical AYA cancers, and be able to readily identify these features when AYAs consult with them.

Key steps GPs should consider when assessing AYA patients include:[2]
  1. Consider common signs of AYA cancers (e.g. seven sites starting with the letter ‘B’)
  2. Consider common symptoms of AYA cancers (e.g. seven symptoms each represented by a letter in ‘CAUTION’)
  3. Refer to a paediatric oncologist or Youth Cancer Service, depending on local arrangements, if high suspicion of cancer.

GPs may instigate investigations if cancer is suspected, but these should not delay referral.

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Common symptoms and signs

Symptoms are distinct from signs in that they typically represent a change in normal function, as opposed to being a direct causal feature of malignancy.

The seven symptom groups of AYA cancers can each be represented by a letter in ‘CAUTION’ (Table 1). Signs of AYA cancer on physical examination can also be grouped into seven major sites (starting with the letter ‘B’) and seven orifices of abnormal discharge. Recognising the most common sites of AYA cancer can help GPs evaluate symptoms and formulate the differential diagnosis.[3]

Table 1. Symptoms of AYA cancer ('CAUTION')[3]

Seven symptom groups of AYA cancer

C = change in mole or new skin lesions

A = abnormal discharge from orifice

U = unilateral knee/shoulder pain/swelling

T = tumor/bulge/bump/mass anywhere

I = increasing lymph gland

O = obstinate fatigue, fever

N = neurologic deficit


Cancer should be suspected in AYAs presenting with the following specific symptoms:[4][5][6]

  • Pallor plus bleeding i.e. purpure, unexplained bruises or persistent oozing from mouth or nose
  • Bone pain (>2 weeks); may be indicated by limp or reluctance to move the affected limb
  • Lymphadenopathy (>2cm) when persistent and unexplained, especially if no response to antibiotic treatment
  • Headaches (>2 weeks), vomiting (>1 week), ataxia or cranial nerve palsy
  • Unexplained mass especially in the abdomen, testes, head/neck or limbs
  • Fever (> 2 weeks), apathy or weight loss if unexplained


Symptoms such as unexplained pain, unexplained fatigue and masses are most frequently reported by AYAs in the primary care setting.[7]

In general, symptoms and signs of individual AYA cancers are similar to those of the same cancer in younger and older patients (Table 2).[3]

Table 2. Summary of common symptoms and signs of individual AYA cancers[3]

Cancer Symptom Sign
Melanoma Increasing size, color change, bleeding, itching of skin lesion Increasing size, irregularity of shape, colour change, ulceration or bleeding of skin lesion
Testicular cancer Painless lump in testicle Firm testicular mass
Bone sarcoma Pain, limping, swelling, non-resolution of prior athletic injury or other physical trauma Joint swelling, palpable mass
CNS tumours Headache, vomiting, deterioration in intellectual capacity, alteration in mood, limb weakness, bladder and bowel disturbance, seizures or fits Gait disturbance, loss of coordination, nystagmus, proptosis, dysconjugate eye movements, cranial nerve palsy, dysarthria, deafness, limb weakness
Thyroid cancer Lump in neck, hoarseness, cough, difficulty in swallowing Hard, irregular mass in neck
Soft tissue sarcoma Enlarging painless lump Palpable mass, proptosis, cranial nerve palsy or nasal obstruction
Lymphoma Fever, night sweats, weight loss, enlarged lymph node(s) Adenopathy, mediastinal obstruction, abdominal mass, hepatomegaly, splenomegaly
Leukaemia Pallor, fatigue, fever, bone pain (ALL), abnormal bleeding (AML) Hepatomegaly, splenomegaly, petechiae, purpura, mucosal bleeding, palpable lymphadenopathy (ALL)

ALL, acute lymphoblastic leukaemia; AML, acute myelogenous leukaemia; CNS, central nervous system

Further information on individual cancers can be found here.

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Persistent symptoms and signs

As the symptoms and signs for many cancers are non-specific, repeated consultations and presentations for the same symptom or symptom complex is more important than a single presentation.[8]

Persistent (occurring beyond a period normally indicative of a self-limiting condition) unexplained (no diagnosis has been made to identify the cause)[8] symptoms and/or signs require further investigation and possibly referral. AYAs presenting several times (three or more times) with the same problem, where there is no clear diagnosis, should be referred urgently.

GPs should be willing to reassess the initial diagnosis or seek a second opinion if a patient fails to recover as expected.[9]

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Distinguishing AYAs with cancer

AYAs typically present to GPs with relatively minor complaints such as respiratory, skin, and musculoskeletal conditions.[10]

Vague or common symptoms for AYA cancers can be mistakenly attributed to fatigue, stress, growing pains or other causes. For example, bone pain related to bone tumours (osteosarcoma and Ewing sarcoma) may be attributed to injury, trauma or growing pains[11] while respiratory symptoms and signs of leukaemia and lymphoma may be similar to those for asthma or croup.[12]

Presentations with high suspicion of cancer should be referred urgently, such as those with persistent and unexplained symptoms and/or signs.

This lack of distinction can lead to diagnostic delay.[13][14] As combinations of symptoms and/or signs have a higher predictive value than a single sign or symptom in isolation, GPs need to consider increased action the greater the number of presenting symptoms and/or signs.

Risk factors for individual cancers should also be considered in the assessment of symptomatic patients.[8]

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References

  1. Australian Institute of Health and Welfare (AIHW). Cancer in adolescents and young adults in Australia. Cancer series number 62. Canberra: AIHW; 2011.
  2. Adolescent and Young Adult Working Party of the Statewide Cancer Clinical Network. South Australian Adolescent and Young Adult Cancer Care Pathway: Optimising outcomes for all adolescent and young adult South Australians with a cancer diagnosis. Adelaide: South Australia Department of Health; 2010.
  3. 3.0 3.1 3.2 3.3 Bleyer A. CAUTION! Consider cancer: common symptoms and signs for early detection of cancer in young adults. Semin Oncol 2009 Jun;36(3):207-12 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/19460578.
  4. Hartley P, Daubenton JD. Curing cancer in children--early recognition and appropriate treatment are the key. S Afr Med J 2001 Jan;91(1):40-2 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/11236294.
  5. Young G, Toretsky JA, Campbell AB, Eskenazi AE. Recognition of common childhood malignancies. Am Fam Physician 2000 Apr 1;61(7):2144-54 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/10779255.
  6. Raab CP, Gartner JC Jr. Diagnosis of childhood cancer. Prim Care 2009 Dec;36(4):671-84 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/19913181.
  7. Fern LA, Campbell C, Eden TO, Grant R, Lewis I, Macleod U, et al. How frequently do young people with potential cancer symptoms present in primary care? Br J Gen Pract 2011 May;61(586):e223-30 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/21619746.
  8. 8.0 8.1 8.2 New Zealand Guidelines Group. Suspected cancer in primary care: guidelines for investigation, referral and reducing ethnic disparities. Wellington: New Zealand Guidelines Group; 2009.
  9. National Collaborating Centre for Primary Care. Referral Guidelines for Suspected Cancer. Clinical guideline 27. London: National Institute for Health and Clinical Excellence; 2005.
  10. Chown P, Kang M, Sanci L, Newnham V, Bennett DL. Adolescent Health: Enhancing the skills of General Practitioners in caring for young people from culturally diverse backgrounds, GP Resource Kit 2nd edition. Sydney: NSW Centre for the Advancement of Adolescent Health and Transcultural Mental Health Centre; 2008.
  11. Stachowicz-Stencel T, Bień E. Bone pains in malignant disorders in children. Family Medicine and Primary Care Review 2007;9(3):859-61.
  12. Saraswatula A, McShane D, Tideswell D, Burke GA, Williams DM, Nicholson JC, et al. Mediastinal masses masquerading as common respiratory conditions of childhood: a case series. Eur J Pediatr 2009 Nov;168(11):1395-9 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/19205733.
  13. Schnurr C, Pippan M, Stuetzer H, Delank KS, Michael JW, Eysel P. Treatment delay of bone tumours, compilation of a sociodemographic risk profile: a retrospective study. BMC Cancer 2008 Jan 23;8:22 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/18215297.
  14. Goyal S, Roscoe J, Ryder WD, Gattamaneni HR, Eden TO. Symptom interval in young people with bone cancer. Eur J Cancer 2004 Oct;40(15):2280-6 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/15454254.

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