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Case history

image A 63-year-old woman presented to her GP with a 2 month history of increasing abdominal pain associated with loss of appetite and weight loss of over 6 kg. She was a current tobacco smoker with a 20 pack-year history.

She was referred for a straight-to-test endoscopy, the results of which were normal. In view of her significant smoking history and because she had a hard, enlarged right supraclavicular lymph node on clinical examination, she was referred to a 2 week wait pathway for suspected lung cancer. Within 2 weeks she was seen by a respiratory physician who organized a CT of her thorax, abdomen and pelvis.

The scan showed the presence of a large mediastinal mass and multiple liver and bone secondary metastases. As a mass was also shown in the body of her pancreas, her case was referred to the local upper gastrointestinal (UGI) multidisciplinary team (MDT) for further discussion. As the UGI MDT thought a primary pancreatic cancer was possible, it recommended an endoscopic ultrasound and biopsy.

What are the priorities of care in this woman’s management?

What is the role of tissue confirmation from radiological images in a patient with suspected advanced cancer?

What services could support both primary and secondary care in the optimum care of this patient?

What features confirm a diagnosis of a true carcinoma of unknown primary (CUP)?

What is the systemic anticancer therapy (SACT) for a confirmed CUP?

What pathways are available for ‘vague symptoms’, to help ensure early cancer diagnosis?

What are the priorities of care in this woman’s management?

As this woman had been symptomatic for more than 3 months, a management priority was to ensure early symptom control. Traditionally clinicians have pursued making an accurate diagnosis as a management priority, but in this case the diagnostic pathway paradigm needed to be challenged to ensure that optimum symptom control was addressed in parallel to diagnostic precision. To ensure a faster diagnosis, she had been referred by her GP to a suspected cancer pathway. Too often, however, healthcare professionals do not clearly communicate to their patients that an underlying malignant process is suspected, adding fear of uncertainty to the patient’s physical distress. Once a CT scan shows incurable advanced disease in multiple sites, patients wish to receive clear information so they can participate in shared decision making about their future.

This woman’s performance status was 2 when she was reviewed by the respiratory physician, yet no discussion was undertaken about the seriousness of her condition. Instead, a further delay of another week was added to her diagnostic pathway to ensure the UGI MDT could give an opinion on her CT, as a pancreatic mass had been reported.

In summary this lady had a huge tumour burden with no clear primary site of origin; therefore, treatment options would at best aim to control her disease. To be fit for SACT ...

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