STEP 2: Presentation, initial investigations and referral
This step outlines the process for the patient’s general practitioner to initiate the right investigations and refer to the appropriate specialist in a timely manner. The types of investigations the general practitioner undertakes will depend on many factors, including access to diagnostic tests, the availability of medical specialists and patient preferences.
Most HCC are asymptomatic at diagnosis, being incidental findings, or are found via a surveillance program.
The best outcomes for HCC are in cases detected by screening or surveillance via an ultrasound before the patient develops overt symptoms.
The following signs, symptoms or results should be investigated:
- right upper quadrant abdominal pain or discomfort
- a hard lump on the right side of the abdomen
- significant weight loss
- abnormal liver function tests
- worsening liver failure (jaundice, ascites, portal hypertension)
- constitutional symptoms including night sweats and anorexia.
Multiple signs and symptoms, particularly in combination with other underlying risk factors, indicates an increased risk of HCC.
Presenting symptoms should be promptly and clinically triaged with a health professional.
If HCC is suspected, general practitioner examinations and investigations should include:
- ultrasound of the liver (further imaging to be done in conjunction with specialist referral)
- assessment of tumour marker AFP
- liver function tests, full blood examination, urea and electrolytes
- investigations for underlying liver disease including viral makers, alcohol abuse, iron overload and fatty liver
- quad phase CT of the liver (if appropriate).
An abnormal result should be discussed face to face with the patient and information provided.
Tests should be conducted within two weeks of a patient presenting with symptoms.
If a patient’s general practitioner suspects a cancer diagnosis but cannot confirm it, they must refer the patient to a specialist (gastroenterologist, hepatologist, oncologist or hepato-pancreato-biliary (HPB) surgeon) to confirm the diagnosis.
If the general practitioner confirms an HCC diagnosis with initial tests including a quad-phase liver CT scan, the patient should be referred to a specialist multidisciplinary team where possible (patients treated by multidisciplinary teams have better outcomes). If this is not available, patients should be referred to a gastroenterologist, hepatologist, oncologist or HPB surgeon who is affiliated with or who has access to a multidisciplinary team and MDMs.
Patients should be enabled to make informed decisions about their choice of specialist and health service. General practitioners should make referrals in consultation with the patient after considering the clinical care needed, cost implications (see referral options and informed financial consent), waiting periods, location and facilities, including discussing the patient’s preference for health care through the public or the private system.
Referral for suspected or diagnosed HCC should include the following essential information to accurately triage and categorise the level of clinical urgency:
- important psychosocial history and relevant medical history that includes comorbidities
- family history, current symptoms, medications and allergies
- results of current clinical investigations (imaging and pathology reports)
- results of all prior relevant investigations
- notification if an interpreter service is required.
Many services will reject incomplete referrals, so it is important that referrals comply with all relevant health service criteria.
If access is via online referral, a lack of a hard copy should not delay referral.
The specialist should provide timely communication to the general practitioner about the consultation and should notify the general practitioner if the patient does not attend appointments.
Aboriginal and Torres Strait Islander patients will need a culturally appropriate referral. To view the optimal care pathway for Aboriginal and Torres Strait Islander people and the corresponding quick reference guide, visit the Cancer Australia website. Download the consumer resources – Checking for cancer and Cancer from the Cancer Australia website.
The patient should be seen by a specialist linked to multidisciplinary team within two weeks of the general practitioner referral.
The multidisciplinary team should have a rapid access program or contact person to set up the appointment. This is commonly the nurse coordinator for the service.
The patient’s general practitioner should consider an individualised supportive care assessment where appropriate to identify the needs of an individual, their carer and family. Refer to appropriate support services as required. See validated screening tools mentioned in Principle 4 ‘Supportive care’.
A number of specific needs may arise for patients at this time:
- assistance for dealing with the emotional distress and/or anger of dealing with a potential cancer diagnosis, anxiety/depression, interpersonal problems and adjustment difficulties
- in patients with HCC, commonly there is chronic liver disease present as well, which must be specifically managed by an appropriate specialist
- management of physical symptoms including pain, fatigue, weight loss and altered bowel function
- encouragement and support to increase levels of exercise (Cormie et al. 2018; Hayes et al. 2019).
For more information refer to the National Institute for Health and Care Excellence 2015 guidelines, Suspected cancer: recognition and referral.
For additional information on supportive care and needs that may arise for different population groups, see Appendices A and B, and special population groups.
The general practitioner is responsible for:
- providing patients with information that clearly describes to whom they are being referred, the reason for referral and the expected timeframes for appointments
- requesting that patients notify them if the specialist has not been in contact within the expected timeframe
- considering referral options for patients living rurally or remotely
supporting the patient while waiting for the specialist appointment (Cancer Council nurses are available to act as a point of information and reassurance during the anxious period of awaiting further diagnostic information; patients can contact 13 11 20 nationally to speak to a cancer nurse).
Refer to Principle 6 ‘Communication’ for communication skills training programs and resources.
