When to Refer for Pediatric Oncology

Approximately 1 in every 285 children in the United States will be diagnosed with cancer before turning 20. Given the rarity of childhood cancer, it’s not surprising that diagnostic delay in pediatric oncology is common. Avoiding delay can help minimize acute complications, decrease treatment required, and improve outcomes.

When health care providers should think about childhood cancer*

  • Fevers lasting more than three to five days, especially if associated with:
    • Weight loss
    • Bone pain
    • Abnormal blood count (“others,” two cell lines down, anemia with high MCV)
  • Bone pain, especially if pain is:
    • Involving the back (perform a testicular and neurologic exam)
    • Persistent and limiting activity
    • Diffuse
  • Lymphadenopathy, especially if:
    • Non-tender, firm, matted, or >2 cm in diameter
    • Progressively enlarging
    • Associated with fever, fatigue, or weight loss
    • Involves unusual locations (axillary, supraclavicular, mediastinal, generalized)
  • Headaches of recent onset with one of these features:
    • Increasing in severity or frequency
    • Worse in the morning or causing early wakening
    • Associated with vomiting or abnormal neurologic exam
    • Associated with behavioral change, weight loss, or decline in school performance
  • Soft tissue masses, especially if:
    • Rapid or progressive growth
    • Size >3 cm in diameter
    • Fixed or deep to the fascia
  • Absent red reflex

*Based in part on guidelines from the National Institute for Health and Care Excellence from the UK. BMJ 2015; 350:h3036.