Workup of Common Cancers

Rationale

A skillful initial workup for suspected cancer is an essential part of effective primary care practice. Developing a logical and practical diagnostic approach to the more common cancers (e.g., breast, skin, colon, lung, prostate) is an excellent means of sharpening basic history-taking, physical examination, and communication skills and learning how to use diagnostic studies in a cost-effective manner. Encountering patients in whom cancer is a diagnostic possibility will stimulate learning the important clinical presentations and natural histories of these life-threatening conditions. Focusing on cancer diagnosis helps to concentrate the student's learning and avoids premature immersion in the often very technical and specialized issues of treatment.

Prerequisites

Prior knowledge, skills and attitudes acquired during the pre-clinical (basic science) years should include:

  1. Knowledge of basic concepts of clinical epidemiology pertinent to test selection and interpretation (e.g., sensitivity, specificity, predictive value)
  2. Knowledge of the symptoms and signs of common cancers
  3. Basic communication skills
  4. Basic physical examination skills (including ability to elicit abnormal skin, breast, lymph node, pleural, liver, prostate, pelvic, genital, and rectal abnormalities)

Specific Learning Objectives

  1. Knowledge: Students should be able to define and describe:
    1. principal clinical presentations, clinical courses, complications, and causes of death for the most common cancers
    2. basic methods of initial evaluation, including the sensitivity and specificity of basic diagnostic studies and indications for their use, including:
      1. indications for skin biopsy in a patient with a suspicious skin lesion
      2. indications for breast biopsy in a person with a breast nodule or abnormal screening mammogram
      3. indications for a lymph node biopsy in a person with isolated lymphadenopathy
      4. initial cost-effective workups for: isolated pleural effusion, pulmonary nodule, liver nodule, prostate nodule, elevated PSA, testicular nodule, stool test positive for occult blood, abnormal PAP smear, testicular nodule, and other findings suggestive of gastrointestinal and urogenital cancers
      5. indications for sigmoidoscopy, barium enema, and colonoscopy in individuals at risk for colon cancer
  2. Skills: Students should demonstrate specific skills including:
    1. history-taking skills: Students should be able to obtain, document and present an age-appropriate medical history, that differentiates among etiologies of disease, including:
      1. skin cancer
      2. breast nodules and secondary signs of breast cancer
      3. lymphadenopathy
      4. pulmonary nodule
      5. prostate cancer
      6. colon cancer
    2. physical exam skills: Students should be able to perform a physical exam to establish the diagnosis and severity of disease, including assessing for:
      1. common skin cancers
      2. breast nodules and secondary signs of breast cancer
      3. lymphadenopathy
      4. pleural effusion
      5. liver nodularity and enlargement
      6. prostatic nodule
      7. testicular nodule
      8. pelvic mass
      9. cervical erosion
      10. cost-effectively designs and carries out the initial diagnostic and staging workup, which includes ordering and interpreting, when appropriate:
        • skin biopsy
        • breast imaging and biopsy
        • lymph node biopsy
        • chest CT and pleural fluid analysis
        • upper and lower GI imaging and endoscopy
        • abdominal CT and ultrasound
        • prostate and testicular ultrasounds and biopsy
        • alkaline phosphatase/acid phosphatase/PSA
        • liver biopsy
        • bone scan
        • Pap smear
    3. differential diagnosis: Students should be able to generate a prioritized differential diagnosis recognizing specific history and physical exam findings to:
      1. provide prompt and critical review of the findings of the initial evaluation
      2. establish a tentative diagnosis and estimate severity and prognosis by use of staging criteria
    4. laboratory interpretation: Students should be able to recommend when to order diagnostic and laboratory tests and be able to interpret them, both prior to and after initiating treatment, based on the differential diagnosis including consideration for test cost and performance characteristics, as well as patient preferences
      1. laboratory and diagnostic tests should include, when appropriate:
        • selecting tests carefully to minimize the risks of false-positive and false negative results
    5. communication skills: Students should be able to:
      1. communicate the working plans, diagnosis, treatment plan and prognosis of the disease to patients and their families in a clear and supportive manner for bearing bad news
      2. provide a concise oral and written presentation of clinical findings, assessment, and initial diagnostic plan to faculty preceptor
    6. basic procedural skills: Skills that students should be able to perform:
      1. chest tap for pleural fluid analysis*
      2. cervical PAP smear
      3. stool occult blood testing
    7. management skills: Students should develop an appropriate evaluation and treatment plan for patients with cancer including:
      1. provision of support and information to patient, and coordination of care for work-up
      2. timely arrangement of pertinent consultations
      3. accessing and utilizing appropriate information systems and resources to help delineate issues related to common cancers
  3. Attitudes and Professional Behavior: Students should appreciate the importance of:
    1. keeping the patient well-informed and well-supported
    2. maintaining close collaboration and coordination with specialty consultants
    3. maintaining responsibility for coordinated care and support of the patient
    4. being able to discuss DNR status with a patient and family

      * optional