Symptoms and signs
|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.||D|
|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.||D|
|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.||D|
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.
Improvements in cancer survival for adolescents and young adults (AYAs) still lag behind paediatric and adult patients. 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:
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.
Table 1. Symptoms of AYA cancer ('CAUTION')
|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
- 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.
In general, symptoms and signs of individual AYA cancers are similar to those of the same cancer in younger and older patients (Table 2).
Table 2. Summary of common symptoms and signs of individual AYA cancers
|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.
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.
Persistent (occurring beyond a period normally indicative of a self-limiting condition) unexplained (no diagnosis has been made to identify the cause) 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.
Distinguishing AYAs with cancer
AYAs typically present to GPs with relatively minor complaints such as respiratory, skin, and musculoskeletal conditions.
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 while respiratory symptoms and signs of leukaemia and lymphoma may be similar to those for asthma or croup.
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. 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.
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