Childhood bone tumours in primary care: helping GPs to identify ‘the needle in the haystack’

Non-specificity of symptoms

CYP with bone tumours present with non-specific symptoms that can be attributed to many other, more common illnesses and injuries.

A systematic review and meta-analysis were conducted to identify how bone tumours present in this cohort. This identified 29 bone tumour symptoms/signs.^7,8 The top symptoms, ranked by pooled proportions, were bone pain (76%), swelling (21%), fever (4%), history of trauma (3%), functional limitation (3%), palpable mass (3%), pain and swelling (2%), limp (2%), and pathological fracture (2%).

These symptoms are seen daily in CYP within primary care, and identifying those who need further investigation can be difficult.

Perceived rarity and lack of awareness

There is a misconception that childhood cancer is rare, despite it being the leading illness cause of child death in >1-year-olds. An individual’s cumulative risk of cancer from birth to age 15 years is 1 in 450, with 1840 new cases diagnosed in CYP aged 0‒15 years each year in the UK.^2,9

As a result, public and professional awareness of childhood cancer is low. A face-to-face public survey (n = 1000) showed that the general public are unaware of childhood cancer risk, have a lack of confidence in recognising signs and symptoms, and have inaccurate knowledge of which symptoms could be caused by cancer in children.¹⁰ Bone tumour symptom awareness was particularly low with considerably fewer than half of responders being aware of presenting symptoms of recurrent/persistent bone pain (23%), bone or joint swelling (27%), and slow recovery after injury (14%) as typical symptoms of malignancy.

This combination of perceived rarity and a lack of awareness contributes to lengthier diagnostic intervals. Qualitative research with parents who have experienced a childhood cancer diagnosis highlights that cancer was never on their radar prior to diagnosis and that healthcare professionals who saw them had not considered it as a diagnosis either.¹¹

Think childhood cancer

‘Three strikes’ with the same complaint without a diagnosis should justify considering cancer as a potential differential.⁹ A high index of suspicion should be maintained for bone tumours in children presenting with persistent or concerning symptoms. GPs should use the symptom checklist (Figure 1) in their consultations to identify symptoms and ask about duration. This will identify those who require further investigation. Persistent is defined as occurring on most days for 2 weeks. Two or more persistent symptoms require imaging. Imaging requests should be labelled as urgent and carried out within 24 hours; however, an imaging request should not delay referral.

Phone a friend

If you have a suspicion of cancer, call your local paediatrician for discussion. Often, this will ensure that the CYP is seen in the most suitable place according to need, either the same day or in rapid-access or standard clinic settings. Discussing the case, rather than sending a written referral, provides the opportunity for a more nuanced discussion about probability, allowing more prompt and shared decision making.

Address the elephant in the room

Parents and families who attend recurrently with the same symptoms often have a gut instinct that something is wrong, just as clinicians do. GPs should ask them directly, ‘What are you worried this could be?’ This allows honest and genuine discussion about their concerns, and whether they can either be reassured, reviewed, or referred for further investigations.

Avoid the injury red herring

It is common for CYP presenting with bone symptoms to have some recall bias when asked if they have injured themselves, and so it is important to take a thorough injury history including mechanism, onset of symptoms, and any relieving factors. If symptoms are a result of an injury, it should have improved considerably within 2 weeks. If no or slow improvement after 2 weeks, they need an X-ray.