Assessment for suspected cancer in children and young people

Children:

Studies show that children with cancer may attend multiple consultations before diagnosis. However, it is important to recognise that frequent attendance is common in this age group and usually reflects benign or self-limiting conditions rather than serious pathology.

An unwell child may be unwilling to comply with examination or may disguise their impairment. Developmental regression is a significant finding and lack of evidence of normality may need to be escalated for investigation.

It is essential for clinicians to balance vigilance with the broader context of frequent attendance. A child should be examined if there is concern about cancer even if they look well, and clinicians should ask how many times they have been seen by a healthcare professional or have sought advice for the problem.

The following features raise suspicion for a childhood cancer:

• Attendance across any pathway (e.g. A&E, NHS 111, GP) three or more times
• Change in attendance rates e.g. a family that usually attend infrequently suddenly attending frequently
• Unusual or persistent symptoms (see good practice), that do not respond to simple interventions e.g. antibiotics, laxatives, or a short course of steroids
• Parents or carers have persistent concerns, even if symptoms are more likely to have a benign cause

 

Young people:

Young people most commonly attend their GP for infection, psychological support or contraceptive advice. A presentation with symptoms which are unexpected within this age group should lead to focused clinical examination, even if they appear otherwise well.

Symptoms due to cancer in young people can be misattributed, for example:

• pain following sport, gym or muscle strain
• fatigue due to social life, academic pressures, studying for exams, jobs while at university, anxiety, or mental health problems

Certain conditions, such as Neuro-Developmental Difference (NDD), can affect a young person's ability to manage medical consultations, including describing symptoms, being compliant with a physical examination or the stress of the environment.

As with children, repeat presentation, including to other professionals (e.g. A&E, AHPs) should be considered a warning sign of a possible cancer.

It may be appropriate to organise urgent tests in primary care if a young person is well and there are single clinical features of concern. Examples include:

• A full blood count (FBC) if there is pallor, bruising, petechiae, infection, lymphadenopathy or generalised bone pain.
• USS for a soft tissue mass
• X-ray for unexplained localised bone pain

A referral to secondary care must not be delayed by waiting for test results if investigations are being arranged for a young person in which there is significant concern about cancer. Repeated attempts at tests (e.g. bloods) should also not delay a referral for assessment.