RCGP: When could it be cancer?


The UK cancer survival rates are poorer than in many developed countries. For instance 8.8% of lung cancer patients are alive 5 years after diagnosis compared to 18.4% in Canada. Delayed diagnosis is thought to be one of the factors involved. There are patterns of illness that have increased risk of underlying cancers.

Persistent or recurrent infection

Acute exacerbations of chronic obstructive pulmonary disease, that are repeatedly given antibiotics and steroids can be due to lung cancer. The common causative factor is cigarette smoking.  Recurrent urine infections being due to bladder cancer is another cause. If the patient had the antibiotics and fully recovered and then relapsed then it is probably another infection, but if they didn’t get better, then the possibility of a new cancer arises.

Constant pain

Musculoskeletal pain tends to vary with time, position and movement. Constant pain can be more sinister. Shoulder pain for instance can be due to a lung cancer in a smoker. Pain, most commonly in the shoulder, lower back and groin can be a presentation of cancer that has already spread.

Unusual age at diagnosis

People are often thought to be too young to be developing certain cancers. There is currently a big increase in the number of under 50s developing bowel cancer. The reason for this is not clear.

In older patients they may get sore heads, gut symptoms and back pain. Sometimes these are diagnosed as migraine, irritable bowel syndrome and muscular back pain.  When these “new” clinical diagnoses are made in older patients it is often best to investigate them with cancer in mind.

Infrequent attenders

People who attend infrequently are more likely to have a serious problem underlying their symptoms.

Negative first line investigations

A chest X ray is often thought to be a good test for example lung cancer. But in lung cancer one in four will not be revealed by a chest X ray and a CT scan will be required. If clinical suspicion persists the GP may need to do further tests.

Safety netting

Making sure all clinical staff such as nurses and phlebotomists as well as doctors safety net appropriately is necessary. Sometimes patients don’t attend for follow up blood tests or they assume their test results are normal when they are not. Follow up arrangements in the practice need to be robust.

Although NICE wants widespread investigation and referral when symptoms could indicate cancer at 1% to 3% of risk, we need to be pragmatic about how this can be done in today’s health service.

Adapted from Improving early diagnosis of cancer in UK general practice by Dr Ian Morgan and Professor Scott Wilkes published in BJGP June 2017.

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