You are an FY2 in a GP surgery  

Personal Details:

Name: Tom Parker

Age: 19

Medical Record:

Past medical history: Fit and well.

Notes:

A 19-year-old man presents for his results. He first came in two weeks ago with a one-month history of persistent, worsening pain and swelling in his lower leg. An X-ray was performed.

X-ray Report: Lytic lesion with periosteal reaction and ‘sunburst’ appearance in the distal femur, highly suggestive of osteosarcoma.

Task:

1. Disclose the results and explain the X-ray findings in simple terms.

2. Address his immediate concerns and outline the management plan.

Opening Sentence: “Hi, Doctor, you’ve got my X-ray result?

Open History (to give freely): “This pain has been getting worse and worse. It’s a deep ache that never goes away, and it’s even waking me up at night. Ibuprofen does nothing. I can’t even walk on it properly now.”

Cues to give: “I’m supposed to be starting university in September.”

ICE (Ideas, Concerns, Expectations):

Ideas: “I have no idea what it could be. I haven’t injured it.”

Concerns: “What’s happening? Why is it so painful?” (After hearing the news) “Cancer? At my age? Is it curable?”

Expectation: “I need to know what’s wrong.” (After hearing the news) “When will I be seen by a specialist?”

How to Act: You are a typical 19-year-old. You start off relaxed but become shocked, scared, and overwhelmed when you hear the news.

More History (only if asked): You are otherwise fit and well, with no other medical problems.

Social History: You have just finished your A-levels and are planning to go to university.

Questions to ask:

“Are you sure it’s cancer?”

“What happens now? Am I going to die?”

Opening & Setting the Scene:

Thanks for coming in. I have your X-ray result here. I have to be honest, the result is not what we were hoping for. The X-ray shows a problem with the bone itself. I’m very sorry to tell you this, but the appearance is very suspicious of a type of bone cancer. (Pause, allow for reaction).

I will discuss with you further what we will need to do next, but may I know more about your symptoms (Confirming Red Flags): Can you tell me again about the pain? How bad is it? Have you noticed anything else, like any weight loss? Any fever? Any lumps or swelling? How is your appetite?

ICE (Ideas, Concerns, Expectations): I know this is a massive shock. What’s going through your mind right now? What were you expecting me to say today?

Explain the results:

Hi Tom, thanks for coming in. I have your X-ray report here, and I’m afraid the news is not what we were hoping for. The X-ray shows an abnormal area in the bone of your lower thigh. The way it looks on the X-ray, with a ‘sunburst’ pattern, is very typical of a type of bone cancer called osteosarcoma. I know this is a massive shock to hear.

(Pause. Give him time to process. Pass tissues if needed.)

Addressing and answering the patient’s ICE:

You’re asking if it’s curable. Yes, osteosarcoma is curable, especially when we catch it early. The treatment has improved dramatically over the years, and many young people who are diagnosed with this go on to be completely cured and live full lives. It’s a long road, but there is a well-established treatment path.

Next Steps:

You asked when you’ll be seen. This is now our absolute priority. I will refer you urgently to be seen in the next two weeks by the orthopaedic team.

The specialist team will arrange for more detailed scans, like an MRI, to confirm the diagnosis. Once the diagnosis is confirmed, the standard treatment is a course of chemotherapy to shrink the tumour, followed by surgery to remove it, and then more chemotherapy afterwards.

I know this is terrifying and raises a huge number of questions, especially about your plans for university.

Reassure and explain available support

The specialist team will have a clinical nurse specialist who will be your dedicated point of contact to help you and your family navigate all of this. The most important thing right now is that we have found this, and we are getting you to the right experts immediately.

Again, I want to reassure you that although it is one of the bone cancers, it usually responds really well to treatment, and mostly people make a good recovery from it.

Addressing ideas, concerns, and expectations: Be honest but hopeful. Provide a clear diagnosis of suspected osteosarcoma. Give a realistic but positive message about curability. 

The critical action is an immediate, urgent referral to a specialist sarcoma centre. Explain the next steps (MRI) and the role of the multi-disciplinary team (MDT) and the clinical nurse specialist.

What is scenario testing? This is a very difficult breaking bad news scenario due to the patient’s young age. It tests the candidate’s ability to deliver a devastating diagnosis with empathy and maturity. It also tests their knowledge of the specific urgent referral pathway for suspected bone sarcoma to a specialist.