Top Tips - GPs Holding a 2WW Referral Conversation
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Efforts are made to ensure the accuracy and agreement of these guidelines. However, we cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties
UHB Patient Information Leaflet
NBT Patient Information Leaflet
NSCCG Sign off form 2017
CUP NSCCG Sign Off Sept 2016
This pathway is for patients where evidence of metastatic disease (such as liver metastasis) is found radiologically or on a biopsy, but the primary cancer is unknown. These patients currently often endure repeated 2WW referrals whilst the primary site is investigated, causing distress, poor outcomes and considerable GP workload. This new pathway involves early Advice and Guidance from the Oncology team and where appropriate the patient is then accepted onto the pathway. Once on the pathway they are managed with the same level of urgency as a “fast track” referral (meeting 62 day targets), and the Oncology team take responsibility for arranging whole body CT or further tests as appropriate and coordinating the patient’s onward care.
NICE Pathway
http://pathways.nice.org.uk/pathways/metastatic-malignant-disease-of-unknown-primary-origin
NICE Guidelines https://www.nice.org.uk/guidance/cg104
Important Definitions:
Malignancy of undefined primary origin (MUO): this is metastatic malignancy identified after a limited number of tests, without an obvious primary site.
Provisional carcinoma of unknown primary (CUP): metastatic epithelial or neuro-endocrine malignancy on the basis of biopsy, with no primary site identified despite initial investigations and before specialist review.
Confirmed CUP: as above, but after specialist review and appropriate specialised investigations.
In Primary Care these cases arise where an X-Ray or scan reveal possible metastatic disease, or where a skin or lymph node biopsy reveals a malignancy of unknown origin, and this pathway is designed to help us get the patient quickly and appropriately assessed.
Refer the patient with MUO to the CUP team immediately, using the rapid referral pathway for cancer.
From Monday 30th June 2014, UHBristol has a specific Cancer of Unknown Primary clinic.
To refer to UHBristol
There is an electronic referral form for referral to UHBristol. To make sure that the right patients access the service and reduce the likelihood of unnecessary delays, check that you have done the following before making a referral:
- Consider if referral to another cancer multidisciplinary team is appropriate particularly if the patient has previously had cancer
- Refer only if there is radiological evidence of cancer and the primary site is not clear.
- In cases where radiological evidence of cancer is not from a full CT chest/abdomen/pelvis, a request to complete this CT staging is considered a minimum requirement
- If there are concerns that a CT is not appropriate (such as patient preference or poor performance status) please state reasons on the form in “Other Information”.
- Inform the patient that they are being referred because they have cancer or it is highly likely that they have cancer and that it is important that they attend their appointment
- If in doubt, call the team to discuss the case before referring
Once the form is completed, refer via e-Referral Service in the usual way booking the dummy appointment and attaching the referral form at the time the referral is created.
Communication to practices for UHB CUP clinic
GP referral support tool - CUP - UHBristol
Local administrative information
Referral to UHBristol
CUP Clinic – 0117 342 2195
2WW Referral forms are available as EMIS templates
To refer to NBT
To refer a patient with Cancer of Unknown Primary please use the BNSSG CUP 2WW referral form and email to NBT. See local information for details.
Local administrative information
Referral to NBT
Fast Track Office – 0117 414 0538 or Email: cancerservices@nhs.net
2WW Referral forms are available as EMIS templates
GPs can phone for advice at designated times (please see local info):
BEFORE PHONING FOR ADVICE, PLEASE PERFORM FULL HISTORY AND EXAMINATION AND BASIC ASSESSMENT / TESTS (AS INDICATED IN THIS PROTOCOL).
Basic assessment / tests:
Complete medical history including history of previous malignancy.
Physical examination including breasts; thyroid; nodes; skin; testes; rectum; prostate; pelvic examination.
Blood tests:
- FBC, U and Es, Creatinine, LFTs, Calcium, LDH, CRP, Glucose, TSH
- AFP if hepato-cellular cancer suspected.
- PSA if prostate cancer suspected.
- AFP, β-hCG and LDH if germ cell tumours suspected e.g. testicular masses or mediastinal/retroperitoneal masses in young men.
- CA125 in women with peritoneal disease, ovarian masses, ascites, pleural effusions or inguinal nodes.
- CEA, CA15-3 and CA19-9 are not specific or sensitive enough in this setting and should not be requested.
Urinalysis
Further investigations:
- Myeloma screen if lytic bone lesions.
- CXR
- CT scan chest, abdomen and pelvis.
Please note:
- Upper or lower GI endoscopy is ONLY indicated if patients have upper or lower GI symptoms, or CT scan indicates a primary at these sites.
- Mammography is only indicated if a breast primary is suspected.
- MRI of the breast may be indicated after discussion at a breast MDT.
- FDG PET-CT is only indicated in patients with cervical lymphadenopathy and a normal ENT panendoscopy, or in other patients after MDT discussion.
Biopsy:
- Biopsy (trucut if possible) should be performed if appropriate.
- If patients are felt to be unfit, advice should be sought from oncology re: the appropriateness of performing a biopsy.
- Patients with solitary liver, brain, lung, skin or bone tumours need MDT review before biopsy is attempted because biopsy may affect the outcome of radical treatment.
Immunohistochemistry for adenocarcinoma of unknown origin will include CK7, CK20, TTF-1, PLAP, ER in women, PSA in men.
Additional immunohistochemistry will be performed as indicated if not an adenocarcinoma.
CUPprotocol_Oct20141 Gp info
Cancer of Unknown Primary MDT Request Form
Local administrative information
GPs can phone for advice at designated times (please see below):
CAN PHONE THE AOS CLINICAL NURSE SPECIALIST FOR ADVICE / INFORMATION ON 01934 881080 ON TUESDAYS (9:00 am to 10:30 am) AND THURSDAYS (1:30 pm to 3:30 pm).
The Lead Clinician for Management of Patients with CUP/MUO is Dr Thomas Wells, Consultant Medical Oncologist. Dr Alison Rich is the designated CUP Palliative Care Consultant.
The AOS / CUP Clinical Nurse Specialists are Corrine Thomas and Vanessa Fountain.
2WW Referral forms are available as EMIS templates
GPs can phone for advice at designated times (please see local information):
BEFORE PHONING FOR ADVICE, PLEASE PERFORM FULL HISTORY AND EXAMINATION AND BASIC ASSESSMENT / TESTS (AS INDICATED IN THIS PROTOCOL).
Local administrative information
CAN PHONE THE AOS CLINICAL NURSE SPECIALIST FOR ADVICE / INFORMATION ON 01934 881080 ON TUESDAYS (9:00 am to 10:30 am) AND THURSDAYS (1:30 pm to 3:30 pm).
The Lead Clinician for Management of Patients with CUP/MUO is Dr Thomas Wells, Consultant Medical Oncologist. Dr Alison Rich is the designated CUP Palliative Care Consultant.
The AOS / CUP Clinical Nurse Specialists are Corrine Thomas and Vanessa Fountain.
