Signs and symptoms of childhood cancer for health professionals​
Childhood cancer is a diagnosis that no one wants to miss. While the average GP may see a child with cancer only once every 5-10 years, the overall cancer risk for children is significant, with one in 450 children receiving a diagnosis before the age of 15. 1
The risk of cancer from birth to age 25 is now one in 180, so it is not as rare as many may think. Childhood cancer is the leading cause of death in UK children aged one to 15 years (responsible for over one in five deaths in this age group), so remains a critical differential for children and young people presenting with unexplained symptoms.2
Why early diagnosis of childhood cancer is important
Research indicates that tumours diagnosed in childhood within the UK tend to be larger and more advanced compared to those in other European countries. Although treatment strategies are largely comparable across regions, outcomes for childhood cancer in the UK tend to be poorer than in some European nations. 3,4
Due to the lack of identified modifiable risk factors or viable screening options, early diagnosis remains the most effective strategy for improving outcomes in children with cancer.
This means it is vital for clinicians in primary care, emergency settings and paediatrics to maintain a high level of suspicion, especially when something is ‘not right’ to encourage earlier diagnosis.
Early detection expands treatment possibilities, allows for less aggressive therapies and improves the overall quality of life for survivors. Children diagnosed at an early stage are also less likely to experience severe long-term health issues and are more likely to enjoy healthier lives after treatment.5
Early diagnosis of childhood cancer is a clinical challenge
This represents a significant diagnostic challenge for clinicians who have to triage symptoms, many of which are non-specific and occur regularly in consultations.
Often, it is not a single symptom that points to a diagnosis of cancer, it is a group of symptoms parental concern or changed consulting behaviours that raise the index of suspicion further. 6
- Recurrent presentations to any health professionals. Three or more attendances can increase the chances of it being cancer by up to 10-fold.6
- Pallor
- Persistent exhaustion or shortness of breath.
- Persistent or recurrent pain anywhere, especially at night: Beware of slow to resolve injuries and remember, growing pains are a diagnosis of exclusion only.
- A persistent or growing mass, lump or swelling anywhere.Â
- Ataxia, unexplained neurological signs or a new limp.
- Unexplained bleeding or bruising anywhere. Beware of haematuria, old blood has an appearance like cola
- Diplopia, a new squint, an unequal appearance of the eyes, leukocoria. Pupil appears grey/ white/ yellow or silver on photos or on checking red reflex. Colour can vary dependent on ethnicity and baseline pigmentation. Occasionally, a unilateral change in iris colour can also occur.
- Persistent or recurrent pyrexia with no obvious source of infection.
- Failure to thrive with no obvious cause.
- Parental concern, especially if out of keeping with normal consulting behaviours.
Although childhood cancer can be difficult to identify, knowing the red flags to be aware of can help children and young people get diagnosed at an earlier stage. Regional red flags for childhood cancer
Please take a look at this simple aide memoir. These cards can be downloaded or ordered free of charge by GP surgeries, emergency care settings and paediatrics.
Find out about our decision making support tool
Tips for Clinicians
- Ask how many times the child has been seen by healthcare professionals for the same issue. Recurrent attendances raise the index of suspicion.
- Always examine symptomatic children, even if they look well. If this is not possible, then arrange a follow up.
- Beware of persistent, unusual or worsening symptoms, such as well localised pain that wakes a child from sleep.
- Parental concern or anxiety out of keeping with normal consulting behaviours.
- Many cancers are difficult to identify at first presentation, but with adequate safety netting, many can be identified on return.
- Familiarise yourself with the signs and symptoms. Consider ordering our awareness cards for your care setting.
Safety netting advice
- Specify a timeframe as to when to return and make it clear why they need to return.
- Ensure they understand what to do if their symptoms worsen during that time.
- Address parental concerns to build trust.
- If you have concerns, even if they’re not enough to act on initially, consider scheduling a follow-up appointment.
- Consider the use of a symptom diary.
Emergency presentations
Symptoms that constitute a medical emergency and need immediate emergency admission:
- Spinal cord compression or symptoms of cauda equina. Although rare in children and young people, it can and does happen.
- A child with shortness of breath and marked lymphadenopathy. They may have a mediastinal mass causing the shortness of breath and can deteriorate quickly with airway obstruction.
- Occasionally children with acute lymphocytic leukaemia may present with DIC, leukostasis or tumour lysis syndromes. They will usually clinically be very unwell.
Signs to look out for:
- Symptoms that are persistent, unusual or worsening or waking from sleep.
- 3 or more attendances (10-fold increase in risk of a cancer diagnosis).
- Raised parental concern.
- Something just is not right.
Link to health care resources
- Teaching presentation for GPs and other primary care professionals. This is perfect for use in clinical learning sessions and for PDP.
- Publications and resources for GPs and emergency doctors
- Learning resources for Health Visitors and other health professionals nurses
- For more information on presentation of brain tumours, see: Brain Tumour Trust Better Safe than Tumour for professionals.
- For more information on presentation of retinoblastoma, see Childhood Eye Cancer Trust.
- NICE Guidance, NG12 Suspected Cancer: recognition and referral.
- Referral guidance for suspected cancer in children and young people created by the Children’s Cancer and Leukaemia Group and endorsed by NICE.
Prewritten primary care presentations
Take a look at our our prewritten teaching presentations, perfect for primary care education sessions and GP VTS teaching
References
- Cancer Research UK. Childhood cancer statistics 2021. [Available from: Cancer Research UK. Children’s Cancer Statistics].
- Child mortality in England And Wales : 2016. Office of National Statistics.
- Gatta G, Corazziari I, Magnani C, et al. Childhood cancer survival in Europe. Ann Oncol. 2003;14(Suppl 5):v119–27. doi: 10.1093/annonc/mdg755. PMID: 14684502.
- Lethaby CD, Picton S, Kinsey SE, et al. A systematic review of time to diagnosis in children and young adults with cancer. Arch Dis Child. 2013;98(5):349–55. doi: 10.1136/archdischild-2012-303034. PMID: 23476000.
- Shanmugavadivel D, et al. The Childhood Cancer Diagnosis (CCD) Study: a UK observational study to describe referral pathways and quantify diagnostic intervals in children and young people with cancer. BMJ Open. 2022.
- Dommett RM, Redaniel T, Stevens MC, Martin RM, Hamilton W. Risk of childhood cancer with symptoms in primary care: a population-based case-control study. Br J Gen Pract. 2013 Jan;63(606):e22-9. doi: 10.3399/bjgp13X660742. PMID: 23336454; PMCID: PMC3529289.
