STEP 2: Presentation, initial investigations and referral
This step outlines the process for the 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.
The following signs and symptoms should be investigated promptly, particularly where there is new onset or changes in long-term symptoms:
- dysphagia (difficulty swallowing, especially bread or meat)
- persistent epigastric pain/dyspepsia
- pain on swallowing
- food bolus obstruction
- unexplained weight loss or anorexia
- haematemesis (vomiting blood) or melena
- early satiety
- unexplained persistent nausea/bloating or anaemia.
The following symptoms are particularly concerning (red flag) and require urgent consultation:
- new-onset or rapidly progressive dysphagia
- progressive/new epigastric pain persisting for more than two weeks.
The presence of multiple signs and symptoms, particularly in combination with other underlying risk factors, indicates an increased risk of oesophagogastric cancer.
Patients with concerning (red flag) oesophagogastric cancer symptoms should see their general practitioner within two weeks.
The patient’s general practitioner should take a thorough medical history to check for any risk factors and symptoms (e.g. bleeding or dysphagia) that suggest upper gastrointestinal (GI) cancer. If the patient is in a high-risk category, they should be triaged for rapid access to an endoscopy. The general practitioner should refer the patient to an endoscopist for a diagnostic endoscopy.
Qualifications of the endoscopist
The endoscopist should be accredited for upper GI endoscopies by the Conjoint Committee for Endoscopy Training and be working in an accredited facility.
Patients with suspected oesophagogastric cancer should be referred to a specialist and undergo an endoscopy within two weeks of the general practitioner referral.
If the general practitioner confirms a cancer diagnosis or suspects a cancer diagnosis but cannot confirm it, they must refer the patient to a specialist (upper GI surgeon) with expertise in oesophagogastric cancer and who is an active participant in an upper GI MDM to progress management.
An upper GI cancer nurse coordinator should work with the surgeon to facilitate the referral and management process in specialist units.
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 oesophagogastric cancer should include the following essential information to accurately triage and categorise the level of clinical urgency:
- important psychosocial history and relevant medical history
- family history, current symptoms, medications and allergies
- results of current clinical investigations (imaging and pathology reports)
- results of all prior relevant investigations
- information about the severity of dysphagia and inability to maintain nutrition and hydration
- 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.
- Where there is a confirmed diagnosis or high level of suspicion, patients should see an upper GI surgeon within two weeks of referral.
- Imaging and work-up by the specialist can precede initial assessment but should not delay referral. The general practitioner or cancer care coordinator is critical in this process to ensure referral is not delayed.
- Urgent referral to allied health practitioners (particularly a dietitian) may also be required before an MDM.
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
- nutritional support and supplementation – some patients may need an enteral tube for feeding if oral intake is inadequate or significant malnutrition is present; refer to a dietitian for nutritional assessment and support as early as possible
- individualised assistance with physical decline
- encouragement and support to increase levels of exercise (Cormie et al. 2018; Hayes et al. 2019) – consider referral to an accredited practicing exercise physiologist or physiotherapist.
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.
