Early diagnosis, key learning points

Childhood cancer diagnoses can be easy to miss

Currently, in the UK, up 80% of childhood cancer cases have evidence of spread at diagnosis. We are diagnosing cancer later than our European counterparts.

The pressures of primary and secondary care mean there are several ways children with cancer could potentially be missed.

Often children may see a different practitioner at each General Practice attendance and there is often limited feedback from other professionals such as health visitors and GP out of hours so we may not be aware of how many times a child is presenting.
Childhood cancer can present with similar symptoms to other common childhood illnesses.
A misconception that cancer in children is incredibly rare. It is not common, but an average GP will see several children with cancer during their career, so it is important to have in the back of your mind.
Children can’t often tell you what is wrong.
Lack of awareness of the signs and symptoms amongst parents and professionals.
Parental anxiety about self-limiting illnesses which makes it harder to identify children with serious illnesses.

Remember, sick kids do not always look sick. Listen to the concerns of the caregiver.

Interventions that may help earlier identification of cancer

If you have some concerns about a child, pre-book a follow-up appointment. If they cannot see you again, record in the notes the symptoms that need to be followed up by the next person consulting and tell them when.
Know the signs and symptoms – order some awareness cards for the clinicians in your surgery.
Always examine a child if they have symptoms, even if they look well. This is vital. If it is not possible to examine them initially, bring them back.
If you still cannot examine them (e.g. you cannot view an optic disk, then send them to someone with suitable equipment such as the opticians).
Ask a carer how many times their child has been seen by healthcare professionals for that particular problem.
Safety net, safety net, safety net. Many childhood cancers are difficult to pick up at the first presentation, but with adequate safety netting, many can be identified on follow up.

Red flags. When should our alarm bells ring?

Beware of persistent symptoms
Pain that does not respond to simple analgesia
Unusual symptoms or worsening despite simple interventions
A change in attendance rates (for example a family that usually attend infrequently suddenly attending frequently.)
Attendance 3 or more times increases risk of symptoms being due to cancer up to 10-fold.*
Consider referral if parents or carers have persistent concerns, even if symptoms are more likely to have a benign cause.

* Dommet R, Redaniel T, Stevens M, Martin R, Hamilton W (2013). Risk of childhood cancer with symptoms in primary care: A population-based case-control study. British Journal of General Practice 63(606), e22-e29. doi: 10.3399/bjgp13X660742