Referral Guideline for Possible Cancer in Children

Context

Cancer in children is uncommon, affecting around 1 in 600 children. However it is the commonest cause of death for children over 1 year. Delay in diagnosis is not unusual and can affect prognosis and treatment, as well as damaging patient-doctor trust.

The NICE guideline on recognition and referral of suspected cancer (NG12) does offer guidance to GPs on a number of childhood cancers, but is not thought to offer the best possible guidance to the average GP, nor does it address the particular needs of GPs and patients in Devon. Specifically, it is usually not appropriate for GPs to use Direct Access tests in the investigation of possible cancers, with investigation of a bony lump being a notable exception.

Scope

This guideline is intended support GPs to make the best possible choice of referral route for children in whom they are concerned there is a possibility of cancer. This includes children and young people between the ages of 0 and 15 years. Young people aged 16 or 17 can be referred to children’s or adult services according to their wishes and/or those of their family. There is a regional TYA (Teenager and Young Adult) cancer service which is available to all 16-25 year olds, regardless of whether they are referred via site-specific adult cancer pathways or paediatric pathways.

Referral Routes

Referral Routes differ between the four Devon acute trust footprints. The routes suggested in the guideline below are intended as a guide only to help GPs think about the degree of urgency required. If you are faced with a child in whom your list of differentials includes cancer and you have any doubt as to how to proceed, all units will have a same day paediatric on call service through which an SHO or Registrar will be able to advise you on both route and urgency.

In the site/symptom specific guidance below, figures in parentheses indicate the numbered option on the route guidance towards the end of this document.

Site/Symptom Specific Guidance

CNS

Headache

Separate guidance exists for the referral of children and young people with headache – please consult this guideline: Headache in Children and Young people.

If a child has suspected signs of raised intracranial pressure they will require emergency referral to the acute paediatric team (1). Other red flag symptoms should be seen within 2 weeks – this can be via a 2WW suspected cancer pathway (phone and speak to on-call paediatric team if you are not sure that this is appropriate, or if you are not sure if it is available in your trust) or urgent general paediatric outpatient appointment (2 or 3).

Referrers should give consideration to probability of presence of tumour, as suspected cancer pathway is specifically to promote early diagnosis of brain tumours.

Back Pain

All patients 10 years or under should be referred for paediatric out-patient assessment urgently (3). Over 10 years back pain is increasingly common, but the presence of a tumour should be considered in the presence of any neurological signs. Any child with long tract signs should be referred for urgent paediatric outpatient assessment (3).

Cranial nerve signs

Any child with new cranial nerve findings should be referred for urgent paediatric assessment– either as same day referral or outpatient depending on circumstances – if in doubt call to discuss (1 or 3).

Papilloedema

Any child with papilloedema should be referred for urgent assessment. Isolated papilloedema should be referred urgently to ophthalmology. If other signs or symptoms present the patient should be referred to paediatrics as an emergency (1).

Ataxia

Any child that presents with acute onset of ataxia should be referred urgently to paediatrics as an emergency (1).

Retinoblastoma

Leucoria/loss of red reflex

Refer for urgent outpatient ophthalmology assessment (6 – ophthalmology)

Leukaemia/lymphoma

Suspected leukaemia on FBC

Any child with suspected leukaemia should be referred urgently to paediatrics as an emergency (1).

Enlarged Lymph Nodes – separate guidance

Pallor – separate guidance

Bruising/bleeding

Any child with spontaneous bruising or bleeding should be referred urgently to paediatrics as emergency (1). Occasionally, massive epistaxis requires urgent assessment at ED.

All bruising in a pre-ambulant infant must be referred urgently to paediatrics as emergency and MASH referral made (1).

If the bleeding is isolated, for example, recurrent epistaxis, it is reasonable to check Full Blood Count and coagulation profile in primary care. If the patient has thrombocytopenia or other abnormalities in FBC they should be urgently referred to paediatrics (1).

Abnormalities of coagulation in a well child should be referred as an outpatient to paediatric haematology (4).

Fever >5days/persistent infection

Persistent fever without focus should raise suspicion of covert malignancy, as well as other serious problems such as sub-clinical infection or Kawasaki disease. These children should be referred for urgent assessment by paediatrics as emergency. If they are well it is reasonable to await next-day assessment. Please discuss with paediatric on-call team (1).

Bone pain

New onset of increasing bone pain should be referred as urgent paediatric outpatient appointment (3).

If the child is febrile urgent paediatric assessment as emergency should be sought. Pre-ambulant infants should also be referred urgently as emergency (1).

Hepatosplenomegaly

If new onset or unwell child, refer urgently to paediatrics as emergency (1).

Soft Tissue Mass

Soft tissue swelling

Refer to Paediatrics using 2WW suspected cancer pathway (phone and speak to on-call paediatric team if you are not sure that this is appropriate, or if you are not sure if it is available in your trust) if suspicion of sarcoma, or uncertainty. It is often possible for patients to be seen in a one-stop appointment with imaging the same day. Do not request imaging from primary care if malignancy is in differential diagnosis (2).

Bony Mass

Unexplained new bone swelling

Arrange urgent outpatient x-ray – if x-ray suggestive of malignancy, refer as suspected cancer to paediatric oncology (phone and speak to on-call paediatric team if you are not sure that this is appropriate, or if you are not sure if it is available in your trust) (5 - greater than 2). If associated with significant pain refer urgently as emergency to paediatrics (1).

Testis

New lump testis or scrotum

Refer to paediatric oncology as 2WW suspected cancer if testicular/scrotal tumour suspected (2) Phone and speak to on-call paediatric team if you are not sure that this is appropriate, or if you are not sure that it is available in your trust.

Skin

Suspicious mole/lesion

Malignant melanoma in children and young people is extremely rare. If you have a high index of suspicion, then refer urgently to paediatric dermatology as 2-week wait (6 – dermatology). If no local paediatric dermatology service, consider seeking a local adult dermatology opinion. If you have a lower index of suspicion, and are largely seeking reassurance, then consider an urgent rather than a 2WW referral, using a paediatric dermatology clinic if available, or adult dermatology if not.

Abdominal tumour

Abdominal mass

Refer urgently to paediatrics as emergency – if patient is well, they may be discussed with on-call team and arrangements made for next day review (1).

Haematuria without infection

Refer urgently to general paediatric outpatients, if persistent, in a well child (3).

Periorbital ecchymosis

Refer urgently to paediatrics as emergency (1).

Breast

Breast lump

Breast lumps are common in infants and usually do not require any management. Adolescent gynaecomastia in boys does not require referral and is covered in the gynaecomastia guidance here. Breast lumps in older (post-pubertal) girls should be referred to breast clinic via same pathway as adults (6 – breast clinic).

Thyroid

Thyroid lump

Thyroid lumps should initially be referred to ENT urgently (6 – ENT).

*Royal Devon & Exeter to triage all thyroid referrals to the Paediatric Oncology Team who will coordinate and work closely with the ENT Team to best manage these patients.

Weight loss

Any child with significant weight loss must be referred urgently as outpatient to general paediatrics (3). Children and adolescents with a history suggestive of an eating disorder should be referred appropriately via separate pathway: Paediatric suspected eating disorders

Investigations

Consider URGENT plain X-ray for investigation of a new painless bony lump in a child.

Referral

Referral Instructions

The options for referral vary according to where you live or work in Devon. These include:

  • Contact the on-call paediatric team using the hospital telephone system. Some hospitals have a Paediatric Admissions or Assessment Unit which can be telephoned directly; in others it will be more appropriate to use the bleep system.
    • RD&E – call 01392404060 and ask to be put through to Paediatric Assessment Unit.
    • NDHT – call 01271322577 and ask for paediatric consultant on call between 09:00 and 21:00, or paediatric registrar outside of these hours.
  • Suspected Cancer referral by letter (there is no specific 2WW form for children) using the usual referral route for your area. Select clinic type as per eRS.
  • Urgent Paediatric outpatient referral if the acuity of the condition allows for this. If there is any doubt see option 1 above.
  • Routine Paediatric referral if the acuity of the condition allows for this. If there is any doubt see option 1 above.
  • Direct Access tests: only suitable for investigation of a bony lump. Please mark your X-ray request as URGENT.
  • Refer to another speciality (see specific guidance) – use usual route for that service.

Supporting Information

Pathway Group

This guideline has been signed off by the Eastern Locality on behalf of NEW Devon CCG.

Publication date: February 2022

Last updated: 08-02-2022

 

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