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The nurse's role in referring patients with suspected cancer

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VOL: 101, ISSUE: 28, PAGE NO: 26

Jason Beckford-Ball, BA, RMN, is assistant clinical editor, Nursing Times

Although fewer people are dying of cancer in the UK - mortality fell by 12 per cent between 1971 and 2002 - 128,000 people still die of the disease each year in England alone (National Audit Office, 2004). There is also evidence that people are being diagnosed with cancer at a more advanced stage in the UK than in other European countries and that mortality rates are higher in deprived areas (National Audit Office, 2004).

Although fewer people are dying of cancer in the UK - mortality fell by 12 per cent between 1971 and 2002 - 128,000 people still die of the disease each year in England alone (National Audit Office, 2004). There is also evidence that people are being diagnosed with cancer at a more advanced stage in the UK than in other European countries and that mortality rates are higher in deprived areas (National Audit Office, 2004).

These anomalies in the UK's cancer services are exacerbated by some patients' reluctance to come forward with symptoms (National Audit Office, 2004) and also by the health service's continuing struggle with waiting-time targets for diagnostic tests and treatment.

The government has recently warned that the two-month waiting time between referral and treatment for people with suspected cancer promised in The NHS Cancer Plan is not being met across the country (Department of Health, 2000a).

In an effort to address these problems, newly published guidelines from NICE (2005) aim to reduce the referral times between people with suspected cancer being seen in primary care and receiving specialist investigation.

As primary care nurses take on more specialist roles, including diagnosis and referral (Department of Health, 2002), it is imperative that they are able to identify people at risk of cancer.

It is also essential that they can make the decision as to whether any referral that they make to specialist services should be classed as immediate, urgent or non-urgent.

The guidance
The new guideline seeks to provide in one document the best available evidence for health care professionals when referring patients who have suspected cancer. It incorporates new evidence on best treatments and the findings of audits carried out since the publication of the last guidance in 2000 (DoH, 2000b). It covers the following types of cancer:

- Lung cancer;

- Upper gastrointestinal cancer;

- Lower gastrointestinal cancer;

- Breast cancer;

- Gynaecological cancer;

- Urological cancer;

- Haematological cancer;

- Skin cancer;

- Head and neck cancer, including thyroid cancer;

- Brain and central nervous system cancer;

- Bone cancer and sarcoma;

- Cancer in children and young people.

In practice
The guidance outlines the symptoms of each cancer type and whether the health professional should consider an immediate, urgent or non-urgent referral:

- Immediate - where the patient needs an acute admission or a referral within a few hours or less;

- Urgent - where the patient should be seen within the national target (two weeks);

- Non-urgent - all other referrals.

For example, in the case of lung cancer, the guidance recommends an immediate referral be considered in a patient exhibiting (NICE, 2005):

- Signs of superior vena caval obstruction (swelling of the face and/or neck with fixed elevation of jugular venous pressure);

- Stridor.

Patients should be referred urgently if they exhibit the following symptoms (NICE, 2005):

- Persistent expectoration of blood or blood in the sputum of smokers or ex-smokers aged over 40;

- Chest X-ray suggesting cancer, includes pleural effusion and slowly resolving consolidation;

- A normal chest X-ray where there is a strong suspicion of lung cancer;

- A history of exposure to asbestos or recent chest pain, breathing difficulties or unexplained systemic symptoms where a chest X-ray indicates pleural effusion, pleural mass or any suspicious pathology.

The guidance recommends that patients should be sent for urgent X-ray if they have any of the following symptoms (NICE, 2005):

- Haemoptysis;

- Unexplained or persistent (over three weeks) chest/shoulder pain, dyspnoea, weight loss, chest signs, hoarseness, finger clubbing, cervical or supraclavicular lymphadenopathy, cough, features that suggest metastasis (that is, secondaries in other organs such as the brain or liver);

- Underlying chronic respiratory difficulties with symptom changes that cannot be explained.

The guidance also details the risk factors and any investigations that should be carried out. In the case of lung cancer the guidance lists the following groups of patients as having a high risk of lung cancer (NICE, 2005):

- All current or ex-smokers;

- People with chronic obstructive pulmonary disease (COPD);

- People who have been exposed to asbestos;

- People with a history of cancer (especially of the head or neck).

Patient-centred care
The guidance stresses that patients' individual needs and preferences should be taken into account and that the referral process should include the opportunity for patients to make informed decisions about their care.

This means that good communication skills are essential in order that evidence-based information about cancer can be provided in a form that the patient is comfortable with and is able to understand. This includes taking account of patients' cultural background and, for example, providing information in different languages. Information should also be available for people with disabilities of any kind. The guidance also recommends that unless the patient specifically asked them to be excluded, carers and relatives should be involved in any decisions as much as possible.

The guideline has important implications for nurses' professional development as it states that primary health care professionals should be able to identify the typical presenting features of cancer. To do this it recommends that nurses should participate in continuing education and peer review in order to maintain their knowledge base.

It also expects that nurses should be prepared to consider cancer when they see unusual symptoms or symptoms that do not respond to treatment in the normal manner.

As well as keeping up to date with their knowledge base, nurses are encouraged to consult with specialists if they are uncertain about interpreting any signs or symptoms.

The guidance is very clear that in cases where the patient presents with typical features of cancer, local investigations should not delay referral to specialist services. Where a patient has less typical symptoms that could nevertheless be due to cancer, the guidance accepts that local investigations may be necessary but must be carried out immediately.

The need for support and information
The guidance stresses that when a patient with suspected cancer has been referred to a specialist service, nurses should be aware that the person may need support while they wait for the appointment. The information supplied should include that listed in Table 1.

Nurses should also take into account that some patients may find being referred for suspected cancer particularly difficult because of factors including age, family or work commitments. They should also bear in mind cultural differences including the relative importance of the family in providing support and the different cultural interpretations attached to a possible cancer diagnosis.

Continuing education
Nurses should also ensure that they keep their knowledge base up to date by taking part in educational activities such as study days and courses.

It is crucial that nurses maintain their assessment and diagnostic skill in order that they are well placed to identify patients who may have cancer and able to communicate this possibility to the patient.

- This article has been double-blind peer-reviewed.

For related articles on this subject and links to relevant websites see

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