Viewpoint - Diagnosing cancer in young people

The signs of cancer can be difficult to identify in teenagers because these patients often have atypical and unusual presentations of symptoms. By Dr Ken Lawton.

Communication skills are vital as young patients may be reluctant to talk
Communication skills are vital as young patients may be reluctant to talk

A GP might see one case of cancer in a young person once every 30 years. The GP will also have more than 5,000 consultations a year, and with just 10 minutes for each patient, it can be difficult to identify the young patient who has a cancer.

One reason that the signs of cancer can be difficult to spot in this age group is that atypical and unusual presentations of symptoms are not uncommon. This means cancer is not always suggested by the symptoms, so will not be high on the list of possible differential diagnoses.

It can also be difficult to determine if initial symptoms point to a diagnosis of cancer, because the symptoms might be vague and common, such as feeling tired all the time.

In addition, young patients do not visit the GP as frequently as adults would for themselves or to take a younger child, so the opportunity to get it right may be limited.

Five most common cancer symptoms

The five most common symptoms of cancer in young people aged 13-24 are persistent and unexplained:

  • Pain
  • Lump, bump or swelling
  • Significant weight loss
  • Extreme tiredness
  • Changes in a mole
The Teenage Cancer Trust (www.teenagecancertrust.org) is encouraging young people to keep going back to the GP until they feel their concerns have been addressed

Improving the situation

Despite this, there are steps GPs can take to improve the situation. They need to be vigilant with young patients and investigate symptoms of common illness if they are persistent or show no improvement.

GPs should also think about further investigation and early referral - the two-week wait referral rule still applies for suspected cancer in this age group.

With each repeat visit, the GP must review previous consultations and ask about previous symptoms where appropriate, even if the patient is attending for another reason.

A thorough clinical examination is also important (for example, lymph nodes, given that lymphoma is the most common cancer in young people).

Wherever possible, practices should aim for continuity of care and make appointments with the same GP because they will be able to recognise trends.

Accurate clinical records of each consultation are an important tool to make continuity more achievable.

It can be difficult to communicate with young patients, who might be nervous or embarrassed. An appropriate consulting style is vital, so they feel comfortable discussing what is happening.

Training in communication with young people may be appropriate and the challenges of communicating with this group should be included in curricula at all levels.

Encouraging follow-up

Young people are not children, but they do not always act like adults. If a young patient is reluctant to talk or to be examined at the initial consultation, an appointment should be made for them to return, rather than relying on them to make it themselves. All follow-up consultations need to be specified by the GP.

Equally, if test results are abnormal, the GP needs to ensure the young patient returns to the surgery to talk about them.

GPs need to act on their clinical suspicions and above all, refer for further investigations early in the process if there is any doubt about the diagnosis.

  • Dr Lawton is a GP in Aberdeen and associate adviser at NHS Education for Scotland
Teenage Cancer Trust working with the RCGP
  • Teenage Cancer Trust has been working with the RCGP to more fully understand the problems GPs face when young people present with symptoms that may indicate cancer.
  • Teenage Cancer Trust understands the signs of cancer can be hard to spot in young people and hopes to continue to work with the RCGP to keep GPs aware of the five most common signs of cancer.
  • Teenage Cancer Trust encourages GPs to use safety netting techniques in consultations with young people who repeat visit with persistent symptoms, and to refer them swiftly for further tests and scans if the matter has not been resolved.
  • Professor Greg Rubin, RCGP/CRUK clinical lead for cancer, has contributed to a report on improving the diagnostic experience of young people with cancer, which will be published during Teenage Cancer Action Week, 14-20 October.

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