When to Refer Suspected Cancer

A doctor should refer a patient with suspected cancer when a symptom is persistent, progressive or peculiar, especially when it matches one of seven warning signs of cancer. Dr. Shubham Jain, Senior Director Surgical Oncology, Fortis Cancer Institute, Defence Colony, New Delhi, India, advises referring early to a high-volume cancer centre, after one imaging test of the area of concern, and leaving the decision on a biopsy to the treating oncologist.

The problem he set out to solve is a pattern he sees in patients who travel to him from many countries: they arrive with cancer that is already advanced, which often rules out curative treatment. This guide covers when to suspect cancer, the minimum workup before referral, and why he believes the first specialist should be a surgical oncologist. Two deeper articles follow from it:

• Cancer screening guidelines, from mammography to colonoscopy: the screening tests, age thresholds and red flags for breast, head and neck, lung, ovarian, endometrial, cervical and gastrointestinal cancers.
• What happens after a suspected cancer referral: biopsy, diagnosis and treatment: how the biopsy is planned, what to do when results are slow, cancer of unknown primary, and the surgical and medical options a high-volume centre offers.

Why late referral costs patients the chance of cure

Early diagnosis is the single most effective lever in cancer care. Dr. Jain puts it plainly: there is no better way to beat cancer than an early diagnosis, because the stage at which a cancer is found is directly related to how long the patient survives. A cancer found early can usually be treated with intent to cure. The same cancer found late often cannot.

The first clinician a patient sees is therefore well placed to change the outcome, because that doctor often meets the disease when the symptoms are still vague and easy to attribute to something benign. Late presentation, in Dr. Jain's experience, is a common problem among the international patients he treats, and it is the reason this masterclass focused on recognition and referral rather than on treatment.

The five ways primary care doctors change cancer outcomes

Dr. Jain sees five distinct contributions from primary healthcare providers, each of which shifts the stage at which cancer is caught or the completeness of treatment:

1. Knowing the symptoms. Recognising the warning signs is the foundation of early diagnosis.
2. Following up unusual or persistent symptoms and abnormal laboratory findings. A single consultation rarely reveals cancer; a symptom that has not settled at the next visit is what should raise suspicion.
3. Stressing screening for the cancers common in their own community. Among the patients he sees from Africa, men are mostly diagnosed with prostate cancer and women with breast cancer, and both can be identified early with a major effect on survival.
4. Keeping patients compliant during treatment and with regular follow-up.
5. Spreading awareness and debunking myths, a responsibility he considers shared by every clinician who manages patients with cancer.

The persistent, progressive or peculiar rule for suspecting cancer

The working rule Dr. Jain teaches is simple enough to apply in a busy clinic: think of cancer whenever a symptom is persistent, progressive or peculiar. A cough that has not resolved, a lump that is slowly getting bigger, or a pattern of bleeding that does not fit the patient's history each meets that test. Timely follow-up by the first-contact doctor is what turns this rule into earlier diagnoses, because persistence and progression only become visible over time.

He also warns that cancer is a master of disguise. Symptoms are often difficult to interpret and one disease can easily mask another. Hoarseness is his example: it can come from a cancer of the larynx, but because the recurrent laryngeal nerve (the nerve that moves the vocal cord) runs through the chest, an advanced lung or oesophageal cancer can cause it too. That ambiguity is one reason he argues for an early opinion from a surgical oncologist.

Seven warning signs that should prompt a cancer referral

Dr. Jain's seven warning signs are the symptoms that should make any clinician consider cancer and refer the patient onwards:

• A swelling or lump that is gradually increasing, in the breast or elsewhere, which may be painless.
• A persistent, unexplained wart or sore, in the mouth or elsewhere, with changes in the appearance of the skin, that is not healing or is getting worse.
• Persistent hoarseness or a nagging cough, especially with blood-streaked sputum or a history of tobacco use.
• Persistent bloating or abdominal symptoms, particularly with jaundice.
• Unscheduled or unexplained bleeding, or a persistent discharge, from anywhere in the body.
• A recent change in eating patterns, bowel or bladder habits, or breathing.
• Recent, persistent pain, recurrent infections or functional decline that cannot otherwise be explained.

When to refer a patient with suspected cancer: five thresholds

Dr. Jain closed his lecture with five rules that summarise the thresholds at which a referring doctor should act. Each pairs a symptom with an age, a duration or a risk factor:

The red flags behind each rule, and the screening tests that find these cancers before symptoms appear, are set out in the companion article on screening guidelines and red flags.

How to refer suspected cancer when diagnostics are limited

Many referring doctors work where diagnostic capacity cannot cover the whole population. Asked how a clinician in that position should decide which patients genuinely need investigation, Dr. Jain's answer was to rely on the clinical signs and symptoms. It is very difficult to predict a patient's outcome or treatment at the first consultation, so the warning signs, not the test results, should decide who is sent onwards. Because cancer demands substantial resources for investigation and treatment, a suspected cancer should be evaluated at a good high-volume centre, which gives the patient the best chance of cure.

He sets the minimum workup before referral deliberately low:

• Breast complaints: a mammogram or an ultrasound at the least and, if possible, a biopsy or fine needle aspiration cytology (FNAC, in which cells are drawn through a thin needle for examination).
• A suspected abdominal cancer: an ultrasound of the abdomen, which guides the choice of further imaging. Having travelled widely in African countries, he knows basic radiology is generally available, and a CT scan can then refine the picture.
• For most other patients: one imaging test that addresses the area of concern, plus a biopsy if it is feasible.

He does not ask referring doctors to insist on a biopsy before referral. A biopsy is a nuanced test, and a poorly planned one can harm the patient, so he would leave the decision on how and where to take it to the treating oncologist. The reasoning, and the options when biopsy reports are slow to return, are covered in the article on biopsy, diagnosis and treatment. That article also describes a patient whose presumed lymphoma turned out, on biopsy, to be a different cancer altogether, which is the clearest illustration of why clinical findings alone are not enough.

Why Dr. Jain refers to a surgical oncologist first

Dr. Jain argues that a surgical oncologist is the right first specialist for a patient suspected of having cancer, for four reasons:

1. Surgery is an integral part of the curative treatment strategy, so the specialist who can offer it should see the patient early.
2. Cancer spans organ systems and treatment modalities. A surgical oncologist, in his phrase a jack of all trades, is equipped to navigate multidisciplinary care across them.
3. Surgical oncologists keep up with oncological principles and with rehabilitative and reconstructive options, which helps them deliver better outcomes.
4. Volume brings foresight. A surgeon who sees and treats many patients can anticipate what each patient will need.

This is his view as a surgical oncologist; in practice, the multidisciplinary team at the receiving centre decides the sequence of surgery, chemotherapy and radiotherapy for each patient.

After referral: the referring doctor's continuing role

Referral is not the end of the first-contact doctor's involvement. Dr. Jain counts on referring colleagues to keep patients on schedule during treatment, to keep up regular follow-up, and to counter the myths that delay care. The two myths he singled out are that a biopsy will make the cancer spread, and that a patient who develops cancer must have brought it on through diet, tobacco or alcohol. He rejects both. Tobacco, alcohol, diet and other modifiable factors do account for an estimated 30 to 50% of cancers, but many cancers arise from ageing, genetics or environmental exposure without anything the patient did, and blame helps no one. Destigmatising patients matters because stigma is what keeps them from coming for treatment in time.

The questions doctors raised during the session, on malignant wounds, voice aids after laryngectomy, response to chemotherapy and patient assistance programmes, are answered in the masterclass Live Discussion.

Related masterclasses on early cancer detection

Other Jivo Masterclass series in oncology approach early cancer detection from different directions, and complement this referral-focused guide:

• Dr. Nithin S.G. organises the warning signs of cancer by cancer type, from solid tumours to blood cancers.
• Dr. Niti Raizada pairs each diagnostic red flag with the test that confirms it, including blood disorders.
• Dr. Rajesh Kumar Jain walks through organ-by-organ red flags in gastrointestinal, oral and other cancers that general practitioners should never dismiss.