Cases corner – 62 year old with dysuria and urinary frequency

7th October 2020

Mrs G, is a 62 year old female, who presents to you with a two month history of urinary frequency and polydipsia. She has also noticed that her clothes feel looser. She is otherwise well in herself with no other symptoms. You perform a random plasma glucose which is 13 mmol/L. You also weigh her and she’s 7 kg lighter than last year (last recorded weight).

What would you do next?

  1. Confirm the diagnosis of diabetes and start treatment
  2. Refer the patient to endocrinologist
  3. Refer the patient along a 2-week-wait pathway
  4. Refer the patient for a CT scan of the pancreas

New-onset diabetes mellitus in the context of weight loss is a new feature in the NICE NG12 guidelines. The concerning feature here is that the patient is loosing weight which is not a typical presentation for someone with type 2 diabetes (the most common in this age group). This patient is at risk of pancreatic cancer and should be referred for a CT scan of the pancreas. Where this service is not available a direct access ultrasound scan could be considered, or an upper gastrointestinal 2-week-wait referral.

Diagnosing pancreatic cancer early is extremely difficult. The earliest signs of pancreatic cancer are vague, non-specific and overlap with many other cancer types. The survival statistics have not changed significantly over the past 50 years, with less 7% of patients surviving 5 years. This is why patients with these features should be referred for a CT scan of their pancreas to enable earlier diagnosis.

The guideline recommends that any patient over the age of 60 presenting with weight loss and any one of the following features should be investigated for pancreatic cancer:

  • Diarrhoea
  • Back pain
  • Abdominal pain
  • Nausea
  • Vomiting
  • Constipation
  • New-onset diabetes

Mrs G is also at risk of colorectal and ovarian cancer She would benefit from:

  • Ca125 blood test – recommended in women who report unexplained weight loss, fatigue or changes in bowel habit for suspected ovarian cancer
  • Faecal Immunochemical testing (FIT)- recommended (if available) for suspected colorectal cancer in people without rectal bleeding who have unexplained symptoms.

Weight loss features in many cancer pathways including pancreatic, colorectal, chest, gastro-oesophageal, haematological and ovarian. However the risk of each type of cancer will depend on the clinical presentation, which is why this Mrs G triggered a CT Pancreas as she was at the highest risk of pancreatic cancer compared to the simpler tests for the other tumour types.