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.
Many cases present with non-specific symptoms or are asymptomatic until advanced stages of the disease. The following signs and symptoms should be investigated:
- acute pancreatitis where the cause is not alcohol ingestion and gallstones are not evident
- new-onset diabetes
- jaundice that is progressive, together with unexplained weight loss and abdominal pain that may radiate to the back (the jaundice may also be accompanied with dark urine, light-coloured stools and itchy skin)
- pain, which is often severe, unrelenting and of a short duration
- unexplained weight loss
- pale and greasy stools
- nausea and vomiting
- constipation
- fatigue
- enlargement of gall bladder
- blood clot in the leg without a clear risk factor
- incidental lesions found on radiology (Freelove & Walling 2006; Kamisawa et al. 2016).
The presence of multiple signs and symptoms, particularly in combination with other underlying risk factors, indicates an increased risk of pancreatic cancer.
Increasingly, incidental diagnosis may occur with pancreatic abnormalities detected on investigation for other complaints.
The incidence of pancreatic cancer in people below 40 years is extremely low. The cause of jaundice in people aged under 40 years is more likely to be caused by other conditions such as alcoholism or hepatitis. People aged under 40 years with jaundice should be referred to non–cancer related pathways.
Presenting symptoms should be promptly and clinically triaged with a health professional.
Depending on the presenting symptoms and risk factors, the general practitioner examinations include the following.
Where there is suspicion of pancreatic cancer, consider:
- an abdominal CT scan with pancreatic protocol
- serum CA 19-9 and liver function tests
- early referral (strongly indicated), usually prior to a definitive diagnosis being made.
Where jaundice is present, the following should be performed urgently:
- liver function tests
- abdominal ultrasound
- CT where appropriate.
An abnormal result should be discussed face to face with the patient and information provided.
Patients who present with jaundice should be referred for tests within 48 hours and followed up rapidly.
Other symptoms require review within two weeks (NICE 2015).
If the cancer diagnosis is confirmed or the results are inconsistent or indeterminate, the general practitioner must refer the patient to an appropriate specialist (gastroenterologist, oncologist or hepatopancreaticobiliary [HPB] surgeon with professional expertise in pancreatic cancer management and access to a multidisciplinary team) to make the diagnosis. In patients with locally advanced, non-metastatic disease, if resectability needs to be determined, referral should be to an HPB surgeon.
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 pancreatic 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
- 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.
All patients with suspected or proven pancreatic cancer should be seen by a specialist (gastroenterologist, oncologist or HPB surgeon) with expertise in pancreatic cancer management and linked to a multidisciplinary team within one week of referral to the specialist.
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
- management of physical symptoms including chronic pain and fatigue
- 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.
