Clinical assessment

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Early detection of cancer in AYAs > Clinical assessment
Recommendation Grade
Investigations by GPs should not delay referral. In patients with less typical symptoms and/or signs initial investigations may be necessary, but should be undertaken straightaway to avoid delay. If specific investigations are not readily available locally, an urgent specialist referral should be made.
D
Recommendation Grade
The presence of any of the following symptoms and signs requires consideration of investigation with full blood count (FBC):
  • Pallor
  • Fatigue
  • Irritability
  • Unexplained fever
  • Persistent or recurrent upper respiratory tract infections
  • Generalised lymphadenopathy
  • Persistent or unexplained bone pain (and X-ray)
  • Persistent back pain
  • Unexplained bruising.


C


Practice point(s)

AYAs presenting with symptoms and/or signs suggestive of cancer should be assessed through a detailed history and examination, irrespective of the presence of risk factors.

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Overview

General practitioners (GPs) may instigate initial investigations in adolescents and young adults (AYAs) presenting with symptoms and/or signs suggestive of cancer to aid diagnosis (Figure 1).

However, these investigations should be done in consultation with a specialist and should not delay referral. Telephone consultations with specialists can be a useful avenue for GPs to advocate for patients and expedite referral.

If specific investigations are not readily available locally, an urgent referral should be made.

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

Further investigations should be avoided, particularly if they would result in delayed referral to a specialist. AYAs may not be loyal to individual practices and ongoing tests may deter them from returning to the same GP.

Figure AYA early detection guide clinical assessment
Figure 1. Clinical assessment steps for AYAs presenting with possible cancer

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After a detailed history and physical examination has been completed by the GP (irrespective of the presence of risk factors), initial investigations that can be done, without delaying referral, include:

Haematology, biochemistry and tumour markers

Tests may include (but should not be limited to):[1]

  • Full blood count (FBC)
  • Differential white cell count (WCC)
  • Blood film
  • Coagulation studies
  • Electrolytes/Urea/Creatinine (EUC)
  • Liver function tests (LFTs)
  • Lactate dehydrogenase (LDH)
  • Urate - plasma or serum
  • Immunoglobulins G, A, M; protein electrophoresis
  • Calcium - plasma or serum; phosphate - plasma or serum
  • C-reactive protein (CRP)
  • Parathyroid hormone (PTH)
  • Alpha fetoprotein - serum
  • Human chorionic gonadotrophin
  • Thyroid-stimulating hormone (TSH), T3, Free T4


Use of alpha fetoprotein and beta human chorionic gonadotrophin would be dictated by clinical suspicion; if these diagnoses were being considered, urgent referral to a specialist would be justified.[2]

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Imaging

Tests may include (but should not be limited to):[3]

  • X-ray - chest, abdomen, bone
  • Ultrasound scan (USS)
  • Computed tomography (CT) scan - chest, abdomen, pelvis
  • Magnetic resonance imaging (MRI)


Positron emission tomography (PET scans) and selective radionuclide scans (e.g. thyroid and bone scans) should be ordered by a specialist.[4]

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Biopsy

Tests may include (but should not be limited to):[1]

  • Needle aspiration biopsy - fine needle aspiration cytology (FNAC), fine needle aspiration biopsy (FNAB)
  • Tissue biopsy
  • Bone biopsy - fracture site
  • Bone marrow aspiration
  • Trephine biopsy


The diagnosis and management of cancer is very complex and many protocols require enough tumour tissue to do morphological, molecular and cytogenetic investigations. A tumour stage may also be increased by the method of biopsy. Therefore biopsies in primary care should be avoided as they may lead to referral delays, inappropriate or inadequate tests and upstaging.

Tissue samples (including biopsies) should be collected by oncology specialists experienced in AYA cancers (especially if possible bone or soft tissue sarcoma)[5] after pre-operative staging has been completed.

AYAs with symptoms and/or signs suggestive of cancer should be referred to a paediatric oncologist or Youth Cancer Service, depending on local arrangements, for appropriate investigations and workup. It is ideal to try and streamline the number of health professionals patients are required to see if possible.


Further information on individual cancers can be found here.

Algorithms for the assessment of individual cancers are detailed in the Referral Guidelines for Suspected Cancer.[6]

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References

  1. 1.0 1.1 Royal College of Pathologists of Australia. RCPA Manual. Sydney: Royal College of Pathologists of Australia; 2011.
  2. New Zealand Guidelines Group. Suspected cancer in primary care: guidelines for investigation, referral and reducing ethnic disparities. Wellington: New Zealand Guidelines Group; 2009.
  3. Mendelson R, editor. Diagnostic Imaging Pathways. Perth: Western Australia Department of Health; 2011.
  4. 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].
  5. 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.
  6. National Collaborating Centre for Primary Care. Referral Guidelines for Suspected Cancer. Clinical guideline 27. London: National Institute for Health and Clinical Excellence; 2005.

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