Upper GI and hepatobiliary cancers

Upper GI & HPB Cancer: Hepatobiliary & Pancreatic Urgent Suspicion of Cancer Referral Criteria

Hepato-pancreato-biliary (HPB) cancer:

Pancreatic cancer is less likely below the age of 40 with incidence rates rising steeply from age 60. Risk factors include:

• Smoking
• Excessive alcohol use
• Chronic pancreatitis
• Family history
• Liver cancer is less common than pancreatic cancer¹. Risk factors include⁷⁴:
• Smoking
• Obesity
• Excessive alcohol use
• Chronic liver disease
• Viral hepatitis
• Haemachromatosis
• Family history of liver cancer

Good Practice Points

• Consider seeking advice in people presenting with new onset GI symptoms with known chronic liver disease Symptoms and signs of oesophago-gastric and hepatobiliary and pancreatic cancers overlap to a large extent. This table summarises examples of symptoms and signs that can be associated with the different cancers – they are NOT by themselves necessarily reasons to refer.

Upper GI & HPB Cancer: Upper GI Urgent Suspicion of Cancer Referral Criteria

Referral guidance:

Referral to secondary care for USC assessment will vary by Health Board – please follow the local pathway.

Referrals will be triaged by secondary care clinicians. It is therefore important that when a person is referred, they are advised they are being referred for assessment, not for a specific investigation (e.g. an endoscopy).

When making a referral for a person with dysphagia it is essential that the correct information is included in the referral form to allow the secondary care team to triage the referral. Please see CfSD’s Dysphagia pathway for guidance.

Overlap with other pathways:

Patients with intra-abdominal cancer can present with symptoms that overlap. Please see Lower GI cancer guideline, Ovarian cancer guideline and Kidney cancer guideline.

A normal Oesophago-Gastro-Duodenoscopy (OGD) or CT alone may be insufficient to exclude an upper GI cancer. Consideration should be given to using both modalities where clinically indicated, depending on symptoms, age, sex and risk factors.

There may also be a role for referral to a local pathway for non-specific symptoms in which cancer is suspected such as GP direct access to CT or to a RCDS. See also the Non-specific symptoms of cancer guideline.

Iron deficiency anaemia (IDA) falls below the 3% threshold for upper GI cancer and is therefore not included in the above USC referral criteria. See Lower gastrointestinal cancer guideline for initial investigation.

Thrombocytosis:

Evidence has identified thrombocytosis as a risk marker for malignancy. In cases of unexplained thrombocytosis, it is advisable to assess for any signs or symptoms of cancer and if appropriate refer to a tumour specific USC pathway. Please see the section on thrombocytosis in Referral process/Further considerations for assessment and referral.

Primary Care Management Dyspepsia without accompanying symptoms or risk factors should be managed in Primary Care

Consider routine referral for people presenting with new upper gastrointestinal pain or discomfort combined with any of the following risk factors:

• family history of oesophago-gastric cancer in a first-degree relative
• Barrett’s oesophagus
• pernicious anaemia
• previous gastric surgery
• achalasia (dysfunction of the oesophageal muscle)
• known dysplasia, atrophic gastritis or intestinal metaplasia