colorectal cancer · prostate cancer follow-up of results by one-stop prostate clinic same-day...
TRANSCRIPT
Con
stip
atio
n
Dia
rrho
ea
Rec
tal b
leed
ing
Loss
of w
eigh
t
Abd
omin
al p
ain
Abd
omin
al
tend
erne
ss
Abn
orm
al
rect
al e
xam
Hae
mog
lobi
n 10
ndash13
gdL
Hae
mog
lobi
n lt1
0 g
dL PPV= Positive predictive value () or probability of cancer
042 094 24 12 11 11 15 097 23 PPV as a single clinical feature
081 11 24 30 15 17 26 12 26 Constipation
15 34 31 19 24 11 22 29 Diarrhoea
68 47 31 45 85 36 32 Rectal bleeding
14 34 64 74 13 47 Loss of weight
30 14 33 22 69 Abdominal pain
17 58 27 gt10 Abdominal tenderness
Find Cancer Early A Guide for General PractitionersFind Cancer Early A Guide for General Practitioners is a tool designed to assist Western Australian (WA) General Practitioners (GPs) in the early diagnosis of patients with colorectal lung prostate and breast cancers The resource reflects the most current clinical guidelines and uses the positive predictive value (PPV) tables which are based on evidence for clinical features (including signs symptoms and common investigations) that best predict cancer
View referral contact details for metropolitan and regional WA
Colorectal Cancer
Implications for practicebull Findings of a physical examination including rectal examination
can significantly alter the probability of colorectal cancer
bull Conduct a full blood count in people with possible symptoms of colorectal cancer
bull Low haemoglobin in the presence of symptoms significantly raises the probability of colorectal cancer
bull Positive FOBT can provide justification for an urgent referral for colonoscopy
bull Negative FOBT does not exclude cancer in people with symptoms
bull Recent onset of symptoms in patients gt40 years should be viewed with a higher degree of suspicion
Figure 1 shows the probability of colorectal cancer for individual and pairs of clinical features including second presentation
For example the probability of colorectal cancer for rectal bleeding alone is 24 but rectal bleeding combined with an abnormal rectal exam increases the probability to 85 Two separate episodes of rectal bleeding have a probability of 68
gt5 probability of cancer
2-5 probability of cancer
1-2 probability of cancer
lt1 probability of cancer
Second presentation
Figure 1 Probability of cancer if clinical features present1
Risk factorsbull Increasing age
bull Previous history of colorectal cancer adenomas or Lynch syndrome-related cancers2
bull Inflammatory bowel disease
bull Family history of colorectal cancer (suspected Lynch syndrome) other Lynch syndrome-related cancers or adenoma (suspected familial adenomatous polyposis (FAP) (see RACGP Red Book2 for risk criteria)
bull Alcohol consumption physical inactivity unhealthy diet obesity smoking3
Refer all suspected colorectal cancer for colonoscopy or appropriate specialist review
Probabilities highlighted in red are gt5 and urgent referral should be considered
Symptoms that best predict colorectal cancer1
bull Rectal bleeding
bull Symptoms of anaemia (tiredness or fatigue)
bull Weight loss
bull Abdominal pain or tenderness
bull Change in bowel habit(diarrhoea or constipation)
Government of Western AustraliaDepartment of Health
Partner
Lung Cancer
Lung cancer clinical features NON-smokers (including ex-smokers)
Cou
gh
Fatig
ue
Dys
pnoe
a
Che
st p
ain
Loss
of w
eigh
t
Loss
of a
ppet
ite
Thro
mbo
- cy
tosi
s
Abn
orm
al
spiro
met
ry
Hae
mop
tysi
s
PPV= Positive predictive value () or probability of cancer
040 043 066 082 11 087 16 16 24 PPV as a single clinical feature
058 063 079 076 18 16 20 12 20 Cough
057 089 084 10 12 18 40 33 Fatigue
088 12 20 20 20 23 49 Dyspnoea
095 18 18 20 14 50 Chest pain
12 23 61 15 92 Loss of weight
17 09 27 gt10 Loss of appetite
36 gt10 Thrombocytosis
gt10 Abnormal spirometry
17 Haemoptysis
Symptoms that best predict lung cancer 4
bull Haemoptysis
bull Thrombocytosis
bull Weight loss or fatigue particularly in smoker or ex-smoker
bull Loss of appetite
bull Unexplained bone or chest painshoulder pain
bull Dyspnoea
bull Cough gt3 weeks or change in nature of cough
bull Persistent hoarseness
bull Non-resolving pneumonia
bull Significant neurological signs eg ataxia weakness
gt5 probability of cancer
2-5 probability of cancer
1-2 probability of cancer
lt1 probability of cancer
Second presentation
denotes data unknown
Figure 3 Probability of cancer if smokers in clinical features present 4
Figures 2 and 3 show the probability of lung cancer for individual and pairs of clinical features including second presentation in non-smokers (including ex-smokers) and smokers respectively
For example the probability of lung cancer for haemoptysis alone in non-smokers is 24 but haemoptysis combined with weight loss increases the probability to 92
The probability of lung cancer for haemoptysis alone in smokers is 45 but haemoptysis combined with dyspnoea increases the probability to 69 Two separate episodes of haemoptysis in non-smokers and smokers have a probability of 17 and 12 respectively
Figure 2 Probability of cancer in NON-smokers if clinical features present4
Lung cancer clinical features for smokers
Cou
gh
Fatig
ue
Dys
pnoe
a
Che
st p
ain
Loss
of w
eigh
t
Loss
of a
ppet
ite
Thro
mbo
- cy
tosi
s
Abn
orm
al
spiro
met
ry
Hae
mop
tysi
s
PPV= Positive predictive value () or probability of cancer
09 08 12 13 21 18 42 40 45 PPV as a single clinical feature
13 10 14 09 23 28 65 36 39 Cough
12 14 13 20 23 24 gt10 61 Fatigue
15 22 31 55 24 gt10 69 Dyspnoea
14 44 76 gt10 gt10 41 Chest pain
17 50 gt10 gt10 Loss of weight
27 Loss of appetite
12 Haemoptysis
Risk factors5
bull Smoker or ex-smoker
bull Increasing age
bull Passive smoking
bull Asbestos exposure
bull Occupational exposures6
bull Previous lung diseases
bull Family history of lung cancer
Implications for practicebull Perform early CXR in those with relevant
symptoms
bull Conduct a full blood count in people with possible symptoms of lung cancer
Diagnostic pathways Refer to Cancer Australiarsquos lsquoInvestigating symptoms of lung cancer a guide for GPsrsquo7 for investigation pathways
Refer all suspected lung cancer to a respiratory physician affiliated with a lung cancer multidisciplinary team (MDT)
Government of Western AustraliaDepartment of Health
Partner
Probabilities highlighted in red are gt5 and urgent referral should be considered
View referral contact details for metropolitan and regional WA
Hae
mat
uria
Wei
ght l
oss
Noc
turia
Hes
itanc
y
Ben
ign
rect
al
exam
Mal
igna
nt re
ctal
ex
am
Freq
uenc
y
urge
ncy PPV= Positive
predictive value () or probability of cancer
10 075 22 30 28 12 22 PPV as a single clinical feature
16 19 33 39 18 Haematuria
21 12 94 18 Loss of weight
33 28 39 15 32 Nocturia
20 33 10 47 Hesitancy
31 Frequency urgency
40 Benign rectal exam
13 Rectal exam malignant
Figure 4 shows the probability of prostate cancer for individual and pairs of clinical features including second presentation
For example the probability of prostate cancer for nocturia alone is 22 but nocturia combined with weight loss increases the probability to 12 Two separate presentations of nocturia have a probability of 33
gt5 probability of cancer
2-5 probability of cancer
1-2 probability of cancer
lt1 probability of cancer
Second presentation
denotes data unknown
Figure 4 Probability of cancer if clinical features present1
Probabilities highlighted in red are gt5 and urgent referral should be considered
Prostate Cancer
Follow-up of results by One-Stop Prostate Clinic
Same-day assessment and TRUS biopsy at
Fiona Stanley Hospital
Fax referral to One-Stop Prostate Clinic at
Fiona Stanley Hospital f (08) 6152 8069
Risk factorsbull Increasing age8
bull Family history of prostate breast or ovarian cancer (see RACGP Red Book2 for risk criteria)
Implications for practicebull Severity of symptoms does not predict prostate cancer
bull Men age gt40 years with lower urinary tract symptoms should have a Digital Rectal Exam (DRE) and PSA blood test
Diagnostic option to One-Stop Prostate ClinicCriteria for referral
bull Hard irregular prostate on DRE regardless of PSA result
bull Risingraised age-specific PSA with symptoms
Note PSA should be taken at least 2 weeks after treatment for UTI Two PSA measures should accompany referral
For further information contact One-Stop Prostate Clinic
p (08) 6152 6916
Symptoms that best predict prostate cancer1
bull Hesitancy bull Nocturia bull Frequencyurgency bull Haematuria bull Weight loss
Refer all suspected prostate cancer to a Urologist affiliated with a MDT
Government of Western AustraliaDepartment of Health
Partner
View referral contact details for metropolitan and regional WA
Figure 5 shows the probability of breast cancer for clinical features paired with age groups
For example the probability of breast cancer for a breast lump at age 40-49 years is 48 This increases to 48 for a woman aged 70 years or over The breast lumppain column is the PPV when a woman has reported both a breast lump and breast pain at least once each during the year before the index date
PPV= Positive predictive value () or probability of cancer
Age
(yea
rs)
Bre
ast p
ain
Nip
ple
disc
harg
e
Nip
ple
retra
ctio
n
Bre
ast l
ump
Bre
ast l
ump
pain
40-49 017 12 48 49
50-59 080 21 26 85 57
60-69 12 23 34 25 65
gt70 28 23 12 48 gt5
gt5 probability of cancer
2-5 probability of cancer
1-2 probability of cancer
lt1 probability of cancer
denotes data unknown
Figure 5 Probability of cancer if clinical features present9
Symptoms that best predict breast cancer9
bull Lump or lumpiness in breast or axilla especially if itrsquos only in one breast
bull Breast lump and pain
bull Changes in nipple appearance eg retraction scaliness inversion redness
bull Discharge from the nipple
bull Breast pain particularly localised with or without cyclic variation
bull Change in shape or appearance of breast eg dimpling redness
Probabilities highlighted in red are gt5 and urgent referral should be considered
Breast Cancer
Risk factorsbull Family history of breast or ovarian cancer
(see RACGP Red Book2 for risk criteria)bull Increasing age (uncommon lt40 years)bull Previous diagnosis of breast cancer
or DCISbull Breast density10
bull Hormonal factors10w Longer menstrual history (age at
menarche lt12 years age at menopause gt55 years)
w Use of hormonal treatments (combined hormone replacement therapy oral contraceptive pill)
w Conception history (age at first birth gt29 years nulliparity)
bull Alcohol consumption overweight amp obesity (particularly in postmenopausal women) physical inactivity10
Implications for practicebull The triple-test is the recommended approach
in the investigation of breast changesbull The triple-test includes
1 Clinical examination 2 Imaging (mammography andor ultrasound) 3 Non-excision biopsy (FNA andor core biopsy)
bull If any of the triple test results are abnormal or if all three do not fit with a benign diagnosis refer urgently to a Breast Assessment Clinic
bull Nipple retraction in women over 50 years should be investigated
bull Any new breast symptom or sign should be investigated as clinically indicated
Refer all suspected breast cancer to a Breast Assessment Clinic affiliated with a MDT
Diagnostic pathwaysRefer to Cancer Australiarsquos lsquoThe investigation of a new breast symptom a guide for GPsrsquo11 for investigation pathways
Government of Western AustraliaDepartment of Health
Partner
View referral contact details for metropolitan and regional WA
1 Hamilton W The CAPER studies five case-control studies aimed at identifying and quantifying risk of cancer in symptomatic primary care patients British Journal of Cancer 2009101(Suppl 2) S80-S86
2 The Royal Australian College of General Practitioners Guidelines for preventive activities in general practice 9th edition East Melbourne VIC RACGP 2016 Available from httpwwwracgporgauyour-practiceguidelinesredbook
3 International Agency for Research on Cancer World Cancer Report 2008 Lyon France IARC 2008 Available from httpwwwiarcfrenpublicationspdfs-onlinewcr2008
4 Hamilton W Peters TJ Round A Sharp D What are the clinical features of lung cancer before the diagnosis is made A population based case-control study Thorax 200560(12)1059-65
5 Australian Institute of Health and Welfare Lung cancer in Australia an overview Cancer series no 643 Cat no CAN 58 Canberra ACT AIHW 2011 Available from httpwwwaihwgovaupublication-detailid=10737420419
6 Safe Work Australia Deemed Diseases in Australia Canberra ACT SWA 2015 Available from to httpswwwsafeworkaustraliagovausystemfilesdocuments1702deemed-diseasespdf
7 Cancer Australia Investigating symptoms of lung cancer a guide for GPs Cancer Australia 2012 Available from httpscanceraustraliagovaupublications-and-resourcescancer-australia-publicationsinvestigating-symptoms-lung-cancer-guide-gps
8 Australian Institute of Health and Welfare Australian Cancer Incidence and Mortality (ACIM) books prostate cancer Canberra ACT AIHW 2016 Available from httpwwwaihwgovauacim-books
9 Walker S Hyde C Hamilton W Risk of breast cancer in symptomatic women in primary care a case-control study using electronic records British Journal of General Practice 201464(629) e788-93
10 National Breast and Ovarian Cancer Centre Breast cancer risk factors a review of the evidence July 2009 Surry Hills NSW NBOCC 2009 Available from httpscanceraustraliagovaupublications-and-resourcescancer-australia-publicationsbreast-cancer-risk-factors-review-evidence
11 Cancer Australia The investigation of a new breast symptom a guide for General Practitioners Cancer Australia 2006 Available from httpscanceraustraliagovaupublications-and-resourcescancer-australia-publicationsinvestigation-new-breast-symptom-guide-general-practitioners
This resource was initially developed as part of the Improving Rural Cancer Outcomes Project by The University of Western
Australia Cancer Council WA and Department of Health WArsquos Rural Cancer Initiative project team which investigated ways
to improve cancer outcomes for people in rural WA The resource was last updated by Cancer Council WA in July 2018
References
Government of Western AustraliaDepartment of Health
Partner
Lung Cancer
Lung cancer clinical features NON-smokers (including ex-smokers)
Cou
gh
Fatig
ue
Dys
pnoe
a
Che
st p
ain
Loss
of w
eigh
t
Loss
of a
ppet
ite
Thro
mbo
- cy
tosi
s
Abn
orm
al
spiro
met
ry
Hae
mop
tysi
s
PPV= Positive predictive value () or probability of cancer
040 043 066 082 11 087 16 16 24 PPV as a single clinical feature
058 063 079 076 18 16 20 12 20 Cough
057 089 084 10 12 18 40 33 Fatigue
088 12 20 20 20 23 49 Dyspnoea
095 18 18 20 14 50 Chest pain
12 23 61 15 92 Loss of weight
17 09 27 gt10 Loss of appetite
36 gt10 Thrombocytosis
gt10 Abnormal spirometry
17 Haemoptysis
Symptoms that best predict lung cancer 4
bull Haemoptysis
bull Thrombocytosis
bull Weight loss or fatigue particularly in smoker or ex-smoker
bull Loss of appetite
bull Unexplained bone or chest painshoulder pain
bull Dyspnoea
bull Cough gt3 weeks or change in nature of cough
bull Persistent hoarseness
bull Non-resolving pneumonia
bull Significant neurological signs eg ataxia weakness
gt5 probability of cancer
2-5 probability of cancer
1-2 probability of cancer
lt1 probability of cancer
Second presentation
denotes data unknown
Figure 3 Probability of cancer if smokers in clinical features present 4
Figures 2 and 3 show the probability of lung cancer for individual and pairs of clinical features including second presentation in non-smokers (including ex-smokers) and smokers respectively
For example the probability of lung cancer for haemoptysis alone in non-smokers is 24 but haemoptysis combined with weight loss increases the probability to 92
The probability of lung cancer for haemoptysis alone in smokers is 45 but haemoptysis combined with dyspnoea increases the probability to 69 Two separate episodes of haemoptysis in non-smokers and smokers have a probability of 17 and 12 respectively
Figure 2 Probability of cancer in NON-smokers if clinical features present4
Lung cancer clinical features for smokers
Cou
gh
Fatig
ue
Dys
pnoe
a
Che
st p
ain
Loss
of w
eigh
t
Loss
of a
ppet
ite
Thro
mbo
- cy
tosi
s
Abn
orm
al
spiro
met
ry
Hae
mop
tysi
s
PPV= Positive predictive value () or probability of cancer
09 08 12 13 21 18 42 40 45 PPV as a single clinical feature
13 10 14 09 23 28 65 36 39 Cough
12 14 13 20 23 24 gt10 61 Fatigue
15 22 31 55 24 gt10 69 Dyspnoea
14 44 76 gt10 gt10 41 Chest pain
17 50 gt10 gt10 Loss of weight
27 Loss of appetite
12 Haemoptysis
Risk factors5
bull Smoker or ex-smoker
bull Increasing age
bull Passive smoking
bull Asbestos exposure
bull Occupational exposures6
bull Previous lung diseases
bull Family history of lung cancer
Implications for practicebull Perform early CXR in those with relevant
symptoms
bull Conduct a full blood count in people with possible symptoms of lung cancer
Diagnostic pathways Refer to Cancer Australiarsquos lsquoInvestigating symptoms of lung cancer a guide for GPsrsquo7 for investigation pathways
Refer all suspected lung cancer to a respiratory physician affiliated with a lung cancer multidisciplinary team (MDT)
Government of Western AustraliaDepartment of Health
Partner
Probabilities highlighted in red are gt5 and urgent referral should be considered
View referral contact details for metropolitan and regional WA
Hae
mat
uria
Wei
ght l
oss
Noc
turia
Hes
itanc
y
Ben
ign
rect
al
exam
Mal
igna
nt re
ctal
ex
am
Freq
uenc
y
urge
ncy PPV= Positive
predictive value () or probability of cancer
10 075 22 30 28 12 22 PPV as a single clinical feature
16 19 33 39 18 Haematuria
21 12 94 18 Loss of weight
33 28 39 15 32 Nocturia
20 33 10 47 Hesitancy
31 Frequency urgency
40 Benign rectal exam
13 Rectal exam malignant
Figure 4 shows the probability of prostate cancer for individual and pairs of clinical features including second presentation
For example the probability of prostate cancer for nocturia alone is 22 but nocturia combined with weight loss increases the probability to 12 Two separate presentations of nocturia have a probability of 33
gt5 probability of cancer
2-5 probability of cancer
1-2 probability of cancer
lt1 probability of cancer
Second presentation
denotes data unknown
Figure 4 Probability of cancer if clinical features present1
Probabilities highlighted in red are gt5 and urgent referral should be considered
Prostate Cancer
Follow-up of results by One-Stop Prostate Clinic
Same-day assessment and TRUS biopsy at
Fiona Stanley Hospital
Fax referral to One-Stop Prostate Clinic at
Fiona Stanley Hospital f (08) 6152 8069
Risk factorsbull Increasing age8
bull Family history of prostate breast or ovarian cancer (see RACGP Red Book2 for risk criteria)
Implications for practicebull Severity of symptoms does not predict prostate cancer
bull Men age gt40 years with lower urinary tract symptoms should have a Digital Rectal Exam (DRE) and PSA blood test
Diagnostic option to One-Stop Prostate ClinicCriteria for referral
bull Hard irregular prostate on DRE regardless of PSA result
bull Risingraised age-specific PSA with symptoms
Note PSA should be taken at least 2 weeks after treatment for UTI Two PSA measures should accompany referral
For further information contact One-Stop Prostate Clinic
p (08) 6152 6916
Symptoms that best predict prostate cancer1
bull Hesitancy bull Nocturia bull Frequencyurgency bull Haematuria bull Weight loss
Refer all suspected prostate cancer to a Urologist affiliated with a MDT
Government of Western AustraliaDepartment of Health
Partner
View referral contact details for metropolitan and regional WA
Figure 5 shows the probability of breast cancer for clinical features paired with age groups
For example the probability of breast cancer for a breast lump at age 40-49 years is 48 This increases to 48 for a woman aged 70 years or over The breast lumppain column is the PPV when a woman has reported both a breast lump and breast pain at least once each during the year before the index date
PPV= Positive predictive value () or probability of cancer
Age
(yea
rs)
Bre
ast p
ain
Nip
ple
disc
harg
e
Nip
ple
retra
ctio
n
Bre
ast l
ump
Bre
ast l
ump
pain
40-49 017 12 48 49
50-59 080 21 26 85 57
60-69 12 23 34 25 65
gt70 28 23 12 48 gt5
gt5 probability of cancer
2-5 probability of cancer
1-2 probability of cancer
lt1 probability of cancer
denotes data unknown
Figure 5 Probability of cancer if clinical features present9
Symptoms that best predict breast cancer9
bull Lump or lumpiness in breast or axilla especially if itrsquos only in one breast
bull Breast lump and pain
bull Changes in nipple appearance eg retraction scaliness inversion redness
bull Discharge from the nipple
bull Breast pain particularly localised with or without cyclic variation
bull Change in shape or appearance of breast eg dimpling redness
Probabilities highlighted in red are gt5 and urgent referral should be considered
Breast Cancer
Risk factorsbull Family history of breast or ovarian cancer
(see RACGP Red Book2 for risk criteria)bull Increasing age (uncommon lt40 years)bull Previous diagnosis of breast cancer
or DCISbull Breast density10
bull Hormonal factors10w Longer menstrual history (age at
menarche lt12 years age at menopause gt55 years)
w Use of hormonal treatments (combined hormone replacement therapy oral contraceptive pill)
w Conception history (age at first birth gt29 years nulliparity)
bull Alcohol consumption overweight amp obesity (particularly in postmenopausal women) physical inactivity10
Implications for practicebull The triple-test is the recommended approach
in the investigation of breast changesbull The triple-test includes
1 Clinical examination 2 Imaging (mammography andor ultrasound) 3 Non-excision biopsy (FNA andor core biopsy)
bull If any of the triple test results are abnormal or if all three do not fit with a benign diagnosis refer urgently to a Breast Assessment Clinic
bull Nipple retraction in women over 50 years should be investigated
bull Any new breast symptom or sign should be investigated as clinically indicated
Refer all suspected breast cancer to a Breast Assessment Clinic affiliated with a MDT
Diagnostic pathwaysRefer to Cancer Australiarsquos lsquoThe investigation of a new breast symptom a guide for GPsrsquo11 for investigation pathways
Government of Western AustraliaDepartment of Health
Partner
View referral contact details for metropolitan and regional WA
1 Hamilton W The CAPER studies five case-control studies aimed at identifying and quantifying risk of cancer in symptomatic primary care patients British Journal of Cancer 2009101(Suppl 2) S80-S86
2 The Royal Australian College of General Practitioners Guidelines for preventive activities in general practice 9th edition East Melbourne VIC RACGP 2016 Available from httpwwwracgporgauyour-practiceguidelinesredbook
3 International Agency for Research on Cancer World Cancer Report 2008 Lyon France IARC 2008 Available from httpwwwiarcfrenpublicationspdfs-onlinewcr2008
4 Hamilton W Peters TJ Round A Sharp D What are the clinical features of lung cancer before the diagnosis is made A population based case-control study Thorax 200560(12)1059-65
5 Australian Institute of Health and Welfare Lung cancer in Australia an overview Cancer series no 643 Cat no CAN 58 Canberra ACT AIHW 2011 Available from httpwwwaihwgovaupublication-detailid=10737420419
6 Safe Work Australia Deemed Diseases in Australia Canberra ACT SWA 2015 Available from to httpswwwsafeworkaustraliagovausystemfilesdocuments1702deemed-diseasespdf
7 Cancer Australia Investigating symptoms of lung cancer a guide for GPs Cancer Australia 2012 Available from httpscanceraustraliagovaupublications-and-resourcescancer-australia-publicationsinvestigating-symptoms-lung-cancer-guide-gps
8 Australian Institute of Health and Welfare Australian Cancer Incidence and Mortality (ACIM) books prostate cancer Canberra ACT AIHW 2016 Available from httpwwwaihwgovauacim-books
9 Walker S Hyde C Hamilton W Risk of breast cancer in symptomatic women in primary care a case-control study using electronic records British Journal of General Practice 201464(629) e788-93
10 National Breast and Ovarian Cancer Centre Breast cancer risk factors a review of the evidence July 2009 Surry Hills NSW NBOCC 2009 Available from httpscanceraustraliagovaupublications-and-resourcescancer-australia-publicationsbreast-cancer-risk-factors-review-evidence
11 Cancer Australia The investigation of a new breast symptom a guide for General Practitioners Cancer Australia 2006 Available from httpscanceraustraliagovaupublications-and-resourcescancer-australia-publicationsinvestigation-new-breast-symptom-guide-general-practitioners
This resource was initially developed as part of the Improving Rural Cancer Outcomes Project by The University of Western
Australia Cancer Council WA and Department of Health WArsquos Rural Cancer Initiative project team which investigated ways
to improve cancer outcomes for people in rural WA The resource was last updated by Cancer Council WA in July 2018
References
Government of Western AustraliaDepartment of Health
Partner
Hae
mat
uria
Wei
ght l
oss
Noc
turia
Hes
itanc
y
Ben
ign
rect
al
exam
Mal
igna
nt re
ctal
ex
am
Freq
uenc
y
urge
ncy PPV= Positive
predictive value () or probability of cancer
10 075 22 30 28 12 22 PPV as a single clinical feature
16 19 33 39 18 Haematuria
21 12 94 18 Loss of weight
33 28 39 15 32 Nocturia
20 33 10 47 Hesitancy
31 Frequency urgency
40 Benign rectal exam
13 Rectal exam malignant
Figure 4 shows the probability of prostate cancer for individual and pairs of clinical features including second presentation
For example the probability of prostate cancer for nocturia alone is 22 but nocturia combined with weight loss increases the probability to 12 Two separate presentations of nocturia have a probability of 33
gt5 probability of cancer
2-5 probability of cancer
1-2 probability of cancer
lt1 probability of cancer
Second presentation
denotes data unknown
Figure 4 Probability of cancer if clinical features present1
Probabilities highlighted in red are gt5 and urgent referral should be considered
Prostate Cancer
Follow-up of results by One-Stop Prostate Clinic
Same-day assessment and TRUS biopsy at
Fiona Stanley Hospital
Fax referral to One-Stop Prostate Clinic at
Fiona Stanley Hospital f (08) 6152 8069
Risk factorsbull Increasing age8
bull Family history of prostate breast or ovarian cancer (see RACGP Red Book2 for risk criteria)
Implications for practicebull Severity of symptoms does not predict prostate cancer
bull Men age gt40 years with lower urinary tract symptoms should have a Digital Rectal Exam (DRE) and PSA blood test
Diagnostic option to One-Stop Prostate ClinicCriteria for referral
bull Hard irregular prostate on DRE regardless of PSA result
bull Risingraised age-specific PSA with symptoms
Note PSA should be taken at least 2 weeks after treatment for UTI Two PSA measures should accompany referral
For further information contact One-Stop Prostate Clinic
p (08) 6152 6916
Symptoms that best predict prostate cancer1
bull Hesitancy bull Nocturia bull Frequencyurgency bull Haematuria bull Weight loss
Refer all suspected prostate cancer to a Urologist affiliated with a MDT
Government of Western AustraliaDepartment of Health
Partner
View referral contact details for metropolitan and regional WA
Figure 5 shows the probability of breast cancer for clinical features paired with age groups
For example the probability of breast cancer for a breast lump at age 40-49 years is 48 This increases to 48 for a woman aged 70 years or over The breast lumppain column is the PPV when a woman has reported both a breast lump and breast pain at least once each during the year before the index date
PPV= Positive predictive value () or probability of cancer
Age
(yea
rs)
Bre
ast p
ain
Nip
ple
disc
harg
e
Nip
ple
retra
ctio
n
Bre
ast l
ump
Bre
ast l
ump
pain
40-49 017 12 48 49
50-59 080 21 26 85 57
60-69 12 23 34 25 65
gt70 28 23 12 48 gt5
gt5 probability of cancer
2-5 probability of cancer
1-2 probability of cancer
lt1 probability of cancer
denotes data unknown
Figure 5 Probability of cancer if clinical features present9
Symptoms that best predict breast cancer9
bull Lump or lumpiness in breast or axilla especially if itrsquos only in one breast
bull Breast lump and pain
bull Changes in nipple appearance eg retraction scaliness inversion redness
bull Discharge from the nipple
bull Breast pain particularly localised with or without cyclic variation
bull Change in shape or appearance of breast eg dimpling redness
Probabilities highlighted in red are gt5 and urgent referral should be considered
Breast Cancer
Risk factorsbull Family history of breast or ovarian cancer
(see RACGP Red Book2 for risk criteria)bull Increasing age (uncommon lt40 years)bull Previous diagnosis of breast cancer
or DCISbull Breast density10
bull Hormonal factors10w Longer menstrual history (age at
menarche lt12 years age at menopause gt55 years)
w Use of hormonal treatments (combined hormone replacement therapy oral contraceptive pill)
w Conception history (age at first birth gt29 years nulliparity)
bull Alcohol consumption overweight amp obesity (particularly in postmenopausal women) physical inactivity10
Implications for practicebull The triple-test is the recommended approach
in the investigation of breast changesbull The triple-test includes
1 Clinical examination 2 Imaging (mammography andor ultrasound) 3 Non-excision biopsy (FNA andor core biopsy)
bull If any of the triple test results are abnormal or if all three do not fit with a benign diagnosis refer urgently to a Breast Assessment Clinic
bull Nipple retraction in women over 50 years should be investigated
bull Any new breast symptom or sign should be investigated as clinically indicated
Refer all suspected breast cancer to a Breast Assessment Clinic affiliated with a MDT
Diagnostic pathwaysRefer to Cancer Australiarsquos lsquoThe investigation of a new breast symptom a guide for GPsrsquo11 for investigation pathways
Government of Western AustraliaDepartment of Health
Partner
View referral contact details for metropolitan and regional WA
1 Hamilton W The CAPER studies five case-control studies aimed at identifying and quantifying risk of cancer in symptomatic primary care patients British Journal of Cancer 2009101(Suppl 2) S80-S86
2 The Royal Australian College of General Practitioners Guidelines for preventive activities in general practice 9th edition East Melbourne VIC RACGP 2016 Available from httpwwwracgporgauyour-practiceguidelinesredbook
3 International Agency for Research on Cancer World Cancer Report 2008 Lyon France IARC 2008 Available from httpwwwiarcfrenpublicationspdfs-onlinewcr2008
4 Hamilton W Peters TJ Round A Sharp D What are the clinical features of lung cancer before the diagnosis is made A population based case-control study Thorax 200560(12)1059-65
5 Australian Institute of Health and Welfare Lung cancer in Australia an overview Cancer series no 643 Cat no CAN 58 Canberra ACT AIHW 2011 Available from httpwwwaihwgovaupublication-detailid=10737420419
6 Safe Work Australia Deemed Diseases in Australia Canberra ACT SWA 2015 Available from to httpswwwsafeworkaustraliagovausystemfilesdocuments1702deemed-diseasespdf
7 Cancer Australia Investigating symptoms of lung cancer a guide for GPs Cancer Australia 2012 Available from httpscanceraustraliagovaupublications-and-resourcescancer-australia-publicationsinvestigating-symptoms-lung-cancer-guide-gps
8 Australian Institute of Health and Welfare Australian Cancer Incidence and Mortality (ACIM) books prostate cancer Canberra ACT AIHW 2016 Available from httpwwwaihwgovauacim-books
9 Walker S Hyde C Hamilton W Risk of breast cancer in symptomatic women in primary care a case-control study using electronic records British Journal of General Practice 201464(629) e788-93
10 National Breast and Ovarian Cancer Centre Breast cancer risk factors a review of the evidence July 2009 Surry Hills NSW NBOCC 2009 Available from httpscanceraustraliagovaupublications-and-resourcescancer-australia-publicationsbreast-cancer-risk-factors-review-evidence
11 Cancer Australia The investigation of a new breast symptom a guide for General Practitioners Cancer Australia 2006 Available from httpscanceraustraliagovaupublications-and-resourcescancer-australia-publicationsinvestigation-new-breast-symptom-guide-general-practitioners
This resource was initially developed as part of the Improving Rural Cancer Outcomes Project by The University of Western
Australia Cancer Council WA and Department of Health WArsquos Rural Cancer Initiative project team which investigated ways
to improve cancer outcomes for people in rural WA The resource was last updated by Cancer Council WA in July 2018
References
Government of Western AustraliaDepartment of Health
Partner
Figure 5 shows the probability of breast cancer for clinical features paired with age groups
For example the probability of breast cancer for a breast lump at age 40-49 years is 48 This increases to 48 for a woman aged 70 years or over The breast lumppain column is the PPV when a woman has reported both a breast lump and breast pain at least once each during the year before the index date
PPV= Positive predictive value () or probability of cancer
Age
(yea
rs)
Bre
ast p
ain
Nip
ple
disc
harg
e
Nip
ple
retra
ctio
n
Bre
ast l
ump
Bre
ast l
ump
pain
40-49 017 12 48 49
50-59 080 21 26 85 57
60-69 12 23 34 25 65
gt70 28 23 12 48 gt5
gt5 probability of cancer
2-5 probability of cancer
1-2 probability of cancer
lt1 probability of cancer
denotes data unknown
Figure 5 Probability of cancer if clinical features present9
Symptoms that best predict breast cancer9
bull Lump or lumpiness in breast or axilla especially if itrsquos only in one breast
bull Breast lump and pain
bull Changes in nipple appearance eg retraction scaliness inversion redness
bull Discharge from the nipple
bull Breast pain particularly localised with or without cyclic variation
bull Change in shape or appearance of breast eg dimpling redness
Probabilities highlighted in red are gt5 and urgent referral should be considered
Breast Cancer
Risk factorsbull Family history of breast or ovarian cancer
(see RACGP Red Book2 for risk criteria)bull Increasing age (uncommon lt40 years)bull Previous diagnosis of breast cancer
or DCISbull Breast density10
bull Hormonal factors10w Longer menstrual history (age at
menarche lt12 years age at menopause gt55 years)
w Use of hormonal treatments (combined hormone replacement therapy oral contraceptive pill)
w Conception history (age at first birth gt29 years nulliparity)
bull Alcohol consumption overweight amp obesity (particularly in postmenopausal women) physical inactivity10
Implications for practicebull The triple-test is the recommended approach
in the investigation of breast changesbull The triple-test includes
1 Clinical examination 2 Imaging (mammography andor ultrasound) 3 Non-excision biopsy (FNA andor core biopsy)
bull If any of the triple test results are abnormal or if all three do not fit with a benign diagnosis refer urgently to a Breast Assessment Clinic
bull Nipple retraction in women over 50 years should be investigated
bull Any new breast symptom or sign should be investigated as clinically indicated
Refer all suspected breast cancer to a Breast Assessment Clinic affiliated with a MDT
Diagnostic pathwaysRefer to Cancer Australiarsquos lsquoThe investigation of a new breast symptom a guide for GPsrsquo11 for investigation pathways
Government of Western AustraliaDepartment of Health
Partner
View referral contact details for metropolitan and regional WA
1 Hamilton W The CAPER studies five case-control studies aimed at identifying and quantifying risk of cancer in symptomatic primary care patients British Journal of Cancer 2009101(Suppl 2) S80-S86
2 The Royal Australian College of General Practitioners Guidelines for preventive activities in general practice 9th edition East Melbourne VIC RACGP 2016 Available from httpwwwracgporgauyour-practiceguidelinesredbook
3 International Agency for Research on Cancer World Cancer Report 2008 Lyon France IARC 2008 Available from httpwwwiarcfrenpublicationspdfs-onlinewcr2008
4 Hamilton W Peters TJ Round A Sharp D What are the clinical features of lung cancer before the diagnosis is made A population based case-control study Thorax 200560(12)1059-65
5 Australian Institute of Health and Welfare Lung cancer in Australia an overview Cancer series no 643 Cat no CAN 58 Canberra ACT AIHW 2011 Available from httpwwwaihwgovaupublication-detailid=10737420419
6 Safe Work Australia Deemed Diseases in Australia Canberra ACT SWA 2015 Available from to httpswwwsafeworkaustraliagovausystemfilesdocuments1702deemed-diseasespdf
7 Cancer Australia Investigating symptoms of lung cancer a guide for GPs Cancer Australia 2012 Available from httpscanceraustraliagovaupublications-and-resourcescancer-australia-publicationsinvestigating-symptoms-lung-cancer-guide-gps
8 Australian Institute of Health and Welfare Australian Cancer Incidence and Mortality (ACIM) books prostate cancer Canberra ACT AIHW 2016 Available from httpwwwaihwgovauacim-books
9 Walker S Hyde C Hamilton W Risk of breast cancer in symptomatic women in primary care a case-control study using electronic records British Journal of General Practice 201464(629) e788-93
10 National Breast and Ovarian Cancer Centre Breast cancer risk factors a review of the evidence July 2009 Surry Hills NSW NBOCC 2009 Available from httpscanceraustraliagovaupublications-and-resourcescancer-australia-publicationsbreast-cancer-risk-factors-review-evidence
11 Cancer Australia The investigation of a new breast symptom a guide for General Practitioners Cancer Australia 2006 Available from httpscanceraustraliagovaupublications-and-resourcescancer-australia-publicationsinvestigation-new-breast-symptom-guide-general-practitioners
This resource was initially developed as part of the Improving Rural Cancer Outcomes Project by The University of Western
Australia Cancer Council WA and Department of Health WArsquos Rural Cancer Initiative project team which investigated ways
to improve cancer outcomes for people in rural WA The resource was last updated by Cancer Council WA in July 2018
References
Government of Western AustraliaDepartment of Health
Partner
1 Hamilton W The CAPER studies five case-control studies aimed at identifying and quantifying risk of cancer in symptomatic primary care patients British Journal of Cancer 2009101(Suppl 2) S80-S86
2 The Royal Australian College of General Practitioners Guidelines for preventive activities in general practice 9th edition East Melbourne VIC RACGP 2016 Available from httpwwwracgporgauyour-practiceguidelinesredbook
3 International Agency for Research on Cancer World Cancer Report 2008 Lyon France IARC 2008 Available from httpwwwiarcfrenpublicationspdfs-onlinewcr2008
4 Hamilton W Peters TJ Round A Sharp D What are the clinical features of lung cancer before the diagnosis is made A population based case-control study Thorax 200560(12)1059-65
5 Australian Institute of Health and Welfare Lung cancer in Australia an overview Cancer series no 643 Cat no CAN 58 Canberra ACT AIHW 2011 Available from httpwwwaihwgovaupublication-detailid=10737420419
6 Safe Work Australia Deemed Diseases in Australia Canberra ACT SWA 2015 Available from to httpswwwsafeworkaustraliagovausystemfilesdocuments1702deemed-diseasespdf
7 Cancer Australia Investigating symptoms of lung cancer a guide for GPs Cancer Australia 2012 Available from httpscanceraustraliagovaupublications-and-resourcescancer-australia-publicationsinvestigating-symptoms-lung-cancer-guide-gps
8 Australian Institute of Health and Welfare Australian Cancer Incidence and Mortality (ACIM) books prostate cancer Canberra ACT AIHW 2016 Available from httpwwwaihwgovauacim-books
9 Walker S Hyde C Hamilton W Risk of breast cancer in symptomatic women in primary care a case-control study using electronic records British Journal of General Practice 201464(629) e788-93
10 National Breast and Ovarian Cancer Centre Breast cancer risk factors a review of the evidence July 2009 Surry Hills NSW NBOCC 2009 Available from httpscanceraustraliagovaupublications-and-resourcescancer-australia-publicationsbreast-cancer-risk-factors-review-evidence
11 Cancer Australia The investigation of a new breast symptom a guide for General Practitioners Cancer Australia 2006 Available from httpscanceraustraliagovaupublications-and-resourcescancer-australia-publicationsinvestigation-new-breast-symptom-guide-general-practitioners
This resource was initially developed as part of the Improving Rural Cancer Outcomes Project by The University of Western
Australia Cancer Council WA and Department of Health WArsquos Rural Cancer Initiative project team which investigated ways
to improve cancer outcomes for people in rural WA The resource was last updated by Cancer Council WA in July 2018
References
Government of Western AustraliaDepartment of Health
Partner