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 skin cancer, head and neck cancers, haematological cancers, nervous system cancers, sarcoma and childhood cancers as well as other non-site specific symptoms of concern..

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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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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 third episode of the cancer guidelines series and is the last one reviewing the section “recommendations by site of cancer” of the NICE guideline NG12 “Suspected cancer recognition and referral”. In this podcast, I will cover skin cancer, head and neck cancers, haematological cancers, nervous system cancers sarcoma and childhood cancers as well as other non-site specific symptoms of concern. I hope that you enjoy the episode.

We will start with Skin cancers and the first ones to consider will be

Malignant melanoma and squamous cell carcinoma of the skin. For this,

We need to consider a cancer referral for melanoma in people with a pigmented or non‑pigmented skin lesion that suggests clinically the possibility of nodular melanoma or squamous cell carcinoma. This includes the use of dermoscopy

We must also refer people using a suspected cancer pathway referral to exclude melanoma if they have a suspicious pigmented skin lesion with a weighted 7‑point checklist score of 3 

We will quickly go through the Weighted 7‑point checklist which lists

Major features of the lesions (scoring 2 points each): 

·      change in size

·      irregular shape

·      irregular colour.

And Minor features of the lesions (scoring 1 point each): 

·      largest diameter 7 mm or more

·      inflammation

·      oozing

·      change in sensation.

In respect of Basal cell carcinomas

We should only consider a suspected cancer pathway referral for a basal cell carcinoma if there is particular concern that a delay may have a significant impact, because of factors such as lesion site or size. 

Otherwise it should be a routine referral.

We are now going t move to Head and neck cancers and the first one to look at is

Laryngeal cancer

For this we need to consider a suspected cancer pathway referral in people aged 45 and over with:

·      persistent unexplained hoarseness or

·      an unexplained lump in the neck. 

For Oral cancers

We need to consider a suspected cancer pathway referral in people with either:

·      an unexplained ulceration in the oral cavity lasting for more than 3 weeks or

·      a persistent and unexplained lump in the neck. 

We also need to consider an urgent referral to a dentist (for an appointment within 2 weeks) for assessment for possible oral cancer in people who have either:

·      a lump on the lip or in the oral cavity or

·      a red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia. 

Then the dentist will decide whether these patients get referred through a full

For Thyroid cancers

We need to consider a cancer referral in people with an unexplained thyroid lump. 

The next section is Brain and central nervous system cancers

And the recommendations are different depending if the suspicion refers to adults or children and young people.

In Adults

We need to consider an urgent, direct access, MRI scan of the brain (or CT scan if MRI is contraindicated; to be done within 2 weeks) in adults with progressive, sub‑acute loss of central neurological function. That is, to be done within 2 weeks if there is progressive, sub‑acute loss of central neurological function. 

However, in Children and young people

We need to consider a very urgent referral (which means an appointment within 48 hours) in children and young people with newly abnormal cerebellar or other central neurological function. This is straightforward and simple, to be seen within 48 hours if there is newly abnormal cerebellar or other central neurological function. 

We will nnow look at the Haematological cancers

And for Leukaemia in adults

We need to consider a very urgent full blood count (which is to be done within 48 hours) with any of the following:

·      pallor

·      persistent fatigue

·      unexplained fever

·      unexplained persistent or recurrent infection

·      generalised lymphadenopathy

·      unexplained bruising

·      unexplained bleeding

·      unexplained petechiae

·      hepatosplenomegaly. 

To say this again, do a FBC within 48 hours if there is:

·      pallor

·      persistent fatigue

·      unexplained fever

·      unexplained persistent or recurrent infection

·      generalised lymphadenopathy

·      unexplained bruising

·      unexplained bleeding

·      unexplained petechiae

·      hepatosplenomegaly. 

In terms of Leukaemia in children and young people

Firstly, We need to Refer children and young people for immediate specialist assessment for leukaemia if they have unexplained petechiae or hepatosplenomegaly. 

Also, similarly to adults, we must offer a very urgent full blood count (within 48 hours) in children and young people with any of the following:

·      pallor

·      persistent fatigue

·      unexplained fever

·      unexplained persistent infection

·      generalised lymphadenopathy

·      persistent or unexplained bone pain

·      unexplained bruising

·      unexplained bleeding. 

For Myeloma

We need to offer a full blood count and blood tests for calcium and plasma viscosity or erythrocyte sedimentation rate in people aged 60 and over with persistent bone pain, particularly back pain, or unexplained fracture. 

And then We need to offer very urgent protein electrophoresis and a Bence–Jones protein urine test (that is within 48 hours) in people aged 60 and over with hypercalcaemia or leukopenia or if the ESR or plasma viscosity are abnormal and the presentation is consistent with possible myeloma. Obviously we will refer people using a suspected cancer pathway referral if the results of protein electrophoresis or a Bence–Jones protein urine test suggest myeloma. 

Finally, the recommendations are the same for Hodgkin’s and Non-Hodgkin's lymphoma but Separate recommendations have been made for adults and for children and young people to reflect that there are different referral pathways.

For adults Adults

We need to consider a suspected cancer pathway referral in adults presenting with unexplained lymphadenopathy or splenomegaly. When considering the referral, we will take into account any associated symptoms, particularly fever, night sweats, shortness of breath, pruritus or weight loss or, in the case of Hodgkin’s lymphoma, if there is alcohol‑induced lymph node pain. [. 

For Children and young people

We need to consider a very urgent referral (, that is, for an appointment within 48 hours) for specialist assessment in children and young people presenting with unexplained lymphadenopathy or splenomegaly. Equally, when considering the referral, we will take into account any associated symptoms, particularly fever, night sweats, shortness of breath, pruritus or weight loss. 

In respect of Sarcomas

Separate recommendations have been made for adults and for children and young people to reflect that there are different referral pathways.

In terms of Bone sarcoma in adults 

We need to consider a suspected cancer pathway referral for adults if an X‑ray suggests the possibility of bone sarcoma. 

For Bone sarcoma in children and young people

We need to consider a very urgent direct access X‑ray (to be done within 48 hours) in children and young people with unexplained bone swelling or pain. 

And then we need to consider a very urgent referral (for an appointment within 48 hours) for specialist assessment if an X‑ray suggests the possibility of bone sarcoma. 

In respect of Soft tissue sarcoma in adults

We need to consider an urgent direct access ultrasound scan (to be done within 2 weeks) in adults with an unexplained lump that is increasing in size. 

And then we need to consider a suspected cancer pathway referral (also for an appointment within 2 weeks) for adults if they have ultrasound scan findings that are suggestive of soft tissue sarcoma or if ultrasound findings are uncertain and clinical concern persists. 

Now, for Soft tissue sarcoma in children and young people the recommendations are exactly the same a for adults with the exception of where we said to be done or seen within 2 weeks it is now 48 hours. So, for children

We need to consider a very urgent direct access ultrasound scan (to be done within 48 hours) to assess for soft tissue sarcoma in children and young people with an unexplained lump that is increasing in size. 

And then we need to consider a very urgent referral (for an appointment within 48 hours) for children and young people if they have ultrasound scan findings that are suggestive of soft tissue sarcoma or if ultrasound findings are uncertain and clinical concern persists. 

We are now going to look at three types of Childhood cancers

And the first one is Neuroblastoma. For this

We need to consider very urgent referral (for an appointment within 48 hours) for specialist assessment for neuroblastoma in children with a palpable abdominal mass or unexplained enlarged abdominal organ. 

For Retinoblastoma

We need to consider urgent referral (for an appointment within 2 weeks) for ophthalmological assessment for retinoblastoma in children with an absent red reflex.

For Wilms' tumour

We need to consider very urgent referral (for an appointment within 48 hours) for specialist assessment in children with any of the following:

·      a palpable abdominal mass

·      an unexplained enlarged abdominal organ

·      unexplained visible haematuria. 

Finally, for Non-site-specific cancer symptoms

We need to say that Some symptoms or symptom combinations may be features of several different cancers. For some of these symptoms, the risk for each individual cancer may be low but the total risk of cancer of any type may be higher. This section includes recommendations for these symptoms.

Firstly we will look at Symptoms of concern in children and young people

We need to consider referral for children if their parent or carer has persistent concern or anxiety about the child's symptoms, even if the symptoms are most likely to have a benign cause. 

Lastly, in respect of Symptoms of concern in adults we will say the following:

For people with either unexplained weight loss, unexplained appetite loss and deep vein thrombosis , all of which can be a symptom of several cancers:

·      we must carry out an assessment for additional symptoms, signs or findings that may help to clarify which cancer is most likely and

·      then offer urgent investigation or a suspected cancer pathway referral depending on our clinical judgement

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