Recommendations organised by symptom and findings of primary care investigations

The recommendations in this section are displayed alphabetically by symptom then in order of urgency of the action needed, to make sure that the most urgent actions are not missed. Where there are several recommendations relating to the same cancer these have been grouped for ease of reference. Occasionally the same symptom may suggest more than 1 cancer site. In such instances, the recommendations are displayed together and the GP should use their clinical judgement to decide on the most appropriate action.

Use this guideline to guide referrals. If still uncertain about whether a referral is needed, consider contacting a specialist (see the recommendations on the diagnostic process). Consider a review for people with any symptom associated with increased cancer risk who do not meet the criteria for referral or investigative action (see the recommendations on safety netting).

Abdominal symptoms

See also the section on bleeding for recommendations on rectal bleeding.

Abdominal distension
Symptom and specific features Possible cancer Recommendation

Abdominal distension (persistent or frequent – particularly more than 12 times per month) in women, especially if 50 and over

Ovarian

Carry out tests in primary care [1.5.2]

Measure serum CA125 in primary care [1.5.6]

See the section on primary care investigations for more information on tests for ovarian cancer

These recommendations apply to women aged 18 and over

Abdominal examination findings
Symptoms and signs Possible cancer Recommendation

Ascites and/or a pelvic or abdominal mass identified by physical examination (which is not obviously uterine fibroids) in women

Ovarian

Refer women using a suspected cancer pathway referral [1.5.1]

These recommendations apply to women aged 18 and over

Abdominal, pelvic or rectal mass or enlarged abdominal organ
Symptom and specific features Possible cancer Recommendation

Abdominal or pelvic mass identified by physical examination (which is not obviously uterine fibroids) in women

Ovarian

Refer women using a suspected cancer pathway referral [1.5.1]

These recommendations apply to women aged 18 and over

Abdominal mass

Colorectal

Offer quantitative faecal immunochemical testing [1.3.1]

Rectal mass

Colorectal

Consider a suspected cancer pathway referral [1.3.5]

Splenomegaly (unexplained) in adults

Non‑Hodgkin's lymphoma

Consider a suspected cancer pathway referral. When considering referral, take into account any associated symptoms, particularly fever, night sweats, shortness of breath, pruritus or weight loss [1.10.8]

Separate recommendations have been made for adults and for children and young people to reflect that there are different referral pathways. In practice young people (aged 16 to 24) may be referred using either pathway depending on their age and local arrangements

Upper abdominal mass consistent with stomach cancer

Stomach

Consider a suspected cancer pathway referral [1.2.6]

Upper abdominal mass consistent with an enlarged gall bladder

Gall bladder

Consider an urgent direct access ultrasound scan (to be done within 2 weeks) [1.2.10]

Upper abdominal mass consistent with an enlarged liver

Liver

Consider an urgent direct access ultrasound scan (to be done within 2 weeks) [1.2.11]

Hepatosplenomegaly

Leukaemia

Consider a very urgent full blood count (within 48 hours) [1.10.1]

Abdominal or pelvic pain
Symptom and specific features Possible cancer Recommendation

Abdominal pain with weight loss (unexplained), 40 and over

Colorectal

Offer quantitative faecal immunochemical testing [1.3.1]

Abdominal pain (unexplained) with rectal bleeding in adults under 50

Colorectal

Offer quantitative faecal immunochemical testing [1.3.1]

Abdominal pain (unexplained), 50 and over

Colorectal

Offer quantitative faecal immunochemical testing [1.3.1]

Upper abdominal pain with weight loss, 55 and over

Oesophageal or stomach

Offer urgent direct access upper gastrointestinal endoscopy (to be done within 2 weeks) [1.2.1] [1.2.7]

Upper abdominal pain with low haemoglobin levels or raised platelet count or nausea or vomiting, 55 and over

Oesophageal or stomach

Consider non-urgent, direct access upper gastrointestinal endoscopy [1.2.3] [1.2.9]

Abdominal or pelvic pain (persistent or frequent – particularly more than 12 times per month) in women, especially if 50 and over

Ovarian

Carry out tests in primary care [1.5.2]

Measure serum CA125 in primary care [1.5.6]

See the section on primary care investigations for more information on tests for ovarian cancer

These recommendations apply to women aged 18 and over

Abdominal pain with weight loss, 60 and over

Pancreatic

Consider an urgent, direct access CT scan (to be done within 2 weeks), or an urgent ultrasound scan if CT is not available [1.2.5]

Irritable bowel syndrome symptoms within the last 12 months in women 50 and over

Ovarian

Carry out appropriate tests for ovarian cancer, because irritable bowel syndrome rarely presents for the first time in women of this age [1.5.5]

Measure serum CA125 in primary care [1.5.6]

See the section on primary care investigations for more information on tests for ovarian cancer

These recommendations apply to women aged 18 and over

Also see the NICE guideline on irritable bowel syndrome in adults.

Change in bowel habit
Symptom and specific features Possible cancer Recommendation

Change in bowel habit

Colorectal

Offer quantitative faecal immunochemical testing [1.3.1]

Change in bowel habit (unexplained) in women

Ovarian

Consider carrying out tests in primary care [1.5.3]

Measure serum CA125 in primary care [1.5.6]

See the section on primary care investigations for information on tests for ovarian cancer

These recommendations apply to women aged 18 and over

Diarrhoea or constipation with weight loss, 60 and over

Pancreatic

Consider an urgent, direct access CT scan (to be done within 2 weeks), or an urgent ultrasound scan if CT is not available [1.2.5]

Irritable bowel syndrome symptoms within the last 12 months, in women 50 and over

Ovarian

Carry out appropriate tests for ovarian cancer, because irritable bowel syndrome rarely presents for the first time in women of this age [1.5.5]

Measure serum CA125 in primary care [1.5.6]

See the section on primary care investigations for more information about tests for ovarian cancer

These recommendations apply to women aged 18 and over

Also see the NICE guideline on irritable bowel syndrome in adults

Dyspepsia
Symptom and specific features Possible cancer Recommendation

Dyspepsia (treatment‑resistant), 55 and over

Oesophageal or stomach

Consider non-urgent, direct access upper gastrointestinal endoscopy [1.2.3] [1.2.9]

Dyspepsia

Dyspepsia with weight loss, 55 and over

Oesophageal or stomach

Offer urgent, direct access upper gastrointestinal endoscopy (to be done within 2 weeks) [1.2.1] [1.2.7]

Dyspepsia with raised platelet count or nausea or vomiting, 55 and over

Oesophageal or stomach

Consider non-urgent, direct access upper gastrointestinal endoscopy [1.2.3] [1.2.9]

Dysphagia
Symptom and specific features Possible cancer Recommendation

Dysphagia

Oesophageal or stomach

Offer urgent, direct access upper gastrointestinal endoscopy (to be done within 2 weeks) [1.2.1, 1.2.7]

Nausea or vomiting
Symptom and specific features Possible cancer Recommendation

Nausea or vomiting with weight loss, 60 and over

Pancreatic

Consider an urgent, direct access CT scan (to be done within 2 weeks), or an urgent ultrasound scan if CT is not available [1.2.5]

Nausea or vomiting with raised platelet count or weight loss or reflux or dyspepsia or upper abdominal pain, 55 and over

Oesophageal or stomach

Consider non-urgent, direct access upper gastrointestinal endoscopy [1.2.3] [1.2.9]

Rectal examination findings
Symptom and signs Possible cancer Recommendation

Prostate feels malignant on digital rectal examination, in men

Prostate

Refer men using a suspected cancer pathway referral [1.6.1]

Anal mass or anal ulceration (unexplained)

Anal

Consider a suspected cancer pathway referral [1.3.6]

Rectal mass

Colorectal

Consider a suspected cancer pathway referral [1.3.5]

Reflux
Symptom and specific features Possible cancer Recommendation

Reflux with weight loss, 55 and over

Oesophageal or stomach

Offer urgent, direct access upper gastrointestinal endoscopy (to be done within 2 weeks) [1.2.1] [1.2.7]

Reflux with raised platelet count or nausea or vomiting, 55 and over

Oesophageal or stomach

Consider non-urgent, direct access upper gastrointestinal endoscopy [1.2.3] [1.2.9]

Bleeding

See also:

Bleeding, bruising or petechiae
Symptom and specific features Possible cancer Recommendation

Bleeding, bruising or petechiae (unexplained)

Leukaemia

Consider a very urgent full blood count (within 48 hours) [1.10.1]

Haematemesis
Symptom and specific features Possible cancer Recommendation

Haematemesis

Oesophageal or stomach

Consider non-urgent, direct access upper gastrointestinal endoscopy [1.2.2] [1.2.8]

Haemoptysis
Symptom and specific features Possible cancer Recommendation

Haemoptysis (unexplained), 40 and over

Lung

Refer people using a suspected cancer pathway referral [1.1.1]

Post‑menopausal bleeding
Symptom and specific features Possible cancer Recommendation

Post‑menopausal bleeding in women 55 and over

Endometrial

Refer women using a suspected cancer pathway referral [1.5.10]

Post‑menopausal bleeding in women under 55

Endometrial

Consider a suspected cancer pathway referral [1.5.11]

Post‑menopausal bleeding is unexplained vaginal bleeding more than 12 months after menstruation has stopped because of the menopause.

Rectal bleeding
Symptom and specific features Possible cancer Recommendation

Rectal bleeding (unexplained), 50 and over

Colorectal

Offer quantitative faecal immunochemical testing [1.3.1]

Rectal bleeding with unexplained abdominal pain or weight loss in adults under 50

Colorectal

Offer quantitative faecal immunochemical testing [1.3.1]

Vulval bleeding
Symptom and specific features Possible cancer Recommendation

Vulval bleeding (unexplained) in women

Vulval

Consider a suspected cancer pathway referral [1.5.14]

Gynaecological symptoms

See also the section on bleeding for post‑menopausal (vaginal) bleeding

Gynaecological examination findings
Symptom and signs Possible cancer Recommendation

Appearance of cervix consistent with cervical cancer

Cervical

Consider a suspected cancer pathway referral [1.5.13]

Vaginal symptoms
Symptom and specific features Possible cancer Recommendation

Vaginal discharge (unexplained) either at first presentation or with thrombocytosis or with haematuria, in women 55 and over

Endometrial

Consider a direct access ultrasound scan [1.5.12]

Vaginal mass (unexplained and palpable) in or at the entrance to the vagina

Vaginal

Consider a suspected cancer pathway referral [1.5.15]

Vulval symptoms
Symptom and specific features Possible cancer Recommendation

Vulval bleeding (unexplained)

Vulval

Consider a suspected cancer pathway referral [1.5.14]

Vulval lump or ulceration (unexplained)

Vulval

Consider a suspected cancer pathway referral [1.5.14]

Lumps or masses

Lumps and masses
Symptom and specific features Possible cancer Recommendation

Anal mass (unexplained)

Anal

Consider a suspected cancer pathway referral 1.3.6]

Axillary lump (unexplained), 30 and over

Breast

Consider a suspected cancer pathway referral [1.4.2]

Breast lump (unexplained) with or without pain, 30 and over

Breast

Refer people using a suspected cancer pathway referral [1.4.1]

Breast lump (unexplained) with or without pain, under 30

Breast

Consider non-urgent referral

See also recommendations 1.16.2 and 1.16.3 for information about seeking specialist advice [1.4.3]

Lip or oral cavity lump

Oral

Consider an urgent referral (for an appointment within 2 weeks) for assessment by a dentist [1.8.3]

Consider a suspected cancer pathway referral by the dentist in people when assessed by a dentist as having a lump on the lip or in the oral cavity consistent with oral cancer [1.8.4]

Lump (unexplained) that is increasing in size in adults

Soft tissue sarcoma

Consider an urgent, direct access ultrasound scan (to be done within 2 weeks) [1.11.4]

Separate recommendations have been made for adults and for children and young people to reflect that there are different referral pathways. In practice young people (aged 16 to 24) may be referred using either pathway depending on their age and local arrangements

Neck lump (unexplained), 45 and over

Laryngeal

Consider a suspected cancer pathway referral [1.8.1]

Neck lump (persistent and unexplained)

Oral

Consider a suspected cancer pathway referral [1.8.2]

Penile mass (and sexually transmitted infection has been excluded as a cause) in men

Penile

Consider a suspected cancer pathway referral [1.6.9]

Thyroid lump (unexplained)

Thyroid

Consider a suspected cancer pathway referral [1.8.5]

Vaginal mass (unexplained and palpable) in or at the entrance to the vagina in women

Vaginal

Consider a suspected cancer pathway referral [1.5.15]

Vulval lump (unexplained) in women

Vulval

Consider a suspected cancer pathway referral [1.5.14]

See also the section on abdominal symptoms for abdominal, anal, pelvic and rectal lumps or masses.

Lymphadenopathy
Symptom and specific features Possible cancer Recommendation

Lymphadenopathy (unexplained) in adults

Non‑Hodgkin's lymphoma or Hodgkin's lymphoma

Consider a suspected cancer pathway referral

When considering referral for Hodgkin's lymphoma, take into account any associated symptoms, particularly fever, night sweats, shortness of breath, pruritus, weight loss or alcohol‑induced lymph node pain [1.10.10]

When considering referral for non‑Hodgkin's lymphoma, take into account any associated symptoms, particularly fever, night sweats, shortness of breath, pruritus or weight loss [1.10.8]

Separate recommendations have been made for adults and for children and young people to reflect that there are different referral pathways. In practice young people (aged 16 to 24) may be referred using either pathway depending on their age and local arrangements

Lymphadenopathy (supraclavicular or persistent cervical), 40 and over

Lung

Consider an urgent chest X‑ray (to be done within 2 weeks) [1.1.3]

Lymphadenopathy (generalised) in adults

Leukaemia

Consider a very urgent full blood count (within 48 hours) [1.10.1]

Oral lesions
Symptom and specific features Possible cancer Recommendation

Ulceration in the oral cavity (unexplained and lasting for more than 3 weeks)

Oral

Consider a suspected cancer pathway referral [1.8.2]

Lip or oral cavity lump

Oral

Consider an urgent referral (for an appointment within 2 weeks) for assessment by a dentist [1.8.3]

Consider a suspected cancer pathway referral by the dentist in people when assessed by a dentist as having a lump on the lip or in the oral cavity consistent with oral cancer [1.8.4]

Neurological symptoms in adults

Neurological symptoms in adults
Symptom and specific features Possible cancer Recommendation

Loss of central neurological function (progressive, sub‑acute) in adults

Brain or central nervous system

Consider an urgent, direct access MRI scan of the brain (or CT scan if MRI is contraindicated; to be done within 2 weeks) [1.9.1]

Pain

See also the section on abdominal symptoms for abdominal or pelvic pain.

Pain
Symptom and specific features Possible cancer Recommendation

Alcohol‑induced lymph node pain with unexplained lymphadenopathy in adults

Hodgkin's lymphoma

Consider a suspected cancer pathway referral. When considering referral, take into account any associated symptoms [1.10.10]

Separate recommendations have been made for adults and for children and young people to reflect that there are different referral pathways. In practice young people (aged 16 to 24) may be referred using either pathway depending on their age and local arrangements

Back pain with weight loss, 60 and over

Pancreatic

Consider an urgent, direct access CT scan (to be done within 2 weeks), or an urgent ultrasound scan if CT is not available [1.2.5]

Back pain (persistent), 60 and over

Myeloma

Offer a full blood count and blood tests for calcium and plasma viscosity or erythrocyte sedimentation rate [1.10.4]

See the section on primary care investigations for more information on tests for myeloma

Bone pain (persistent), 60 and over

Myeloma

Offer a full blood count and blood tests for calcium and plasma viscosity or erythrocyte sedimentation rate to assess for myeloma [1.10.4]

See the section on primary care investigations for more information on tests for myeloma

Chest pain (unexplained), 40 and over, ever smoked

Lung or mesothelioma

Offer an urgent chest X‑ray (to be done within 2 weeks) [1.1.2] [1.1.5]

Chest pain (unexplained), 40 and over, exposed to asbestos

Mesothelioma

Offer an urgent chest X‑ray (to be done within 2 weeks) [1.1.5]

Chest pain (unexplained) with cough or fatigue or shortness of breath or weight loss or appetite loss (unexplained), 40 and over

Lung or mesothelioma

Offer an urgent chest X‑ray (to be done within 2 weeks) [1.1.2] [1.1.5]

Respiratory symptoms

Chest infection
Symptom and specific features Possible cancer Recommendation

Chest infection (persistent or recurrent), 40 and over

Lung

Consider an urgent chest X‑ray (to be done within 2 weeks) [1.1.3]

Chest pain
Symptom and specific features Possible cancer Recommendation

Chest pain (unexplained), 40 and over, ever smoked

Lung or mesothelioma

Offer an urgent chest X‑ray (to be done within 2 weeks) [1.1.2] [1.1.5]

Chest pain (unexplained), 40 and over, exposed to asbestos

Mesothelioma

Offer an urgent chest X‑ray (to be done within 2 weeks) [1.1.5]

Chest pain (unexplained) with cough or fatigue or shortness of breath or weight loss or appetite loss (unexplained), 40 and over

Lung or mesothelioma

Offer an urgent chest X‑ray (to be done within 2 weeks) [1.1.2] [1.1.5]

Cough
Symptom and specific features Possible cancer Recommendation

Cough (unexplained), 40 and over, ever smoked

Lung or mesothelioma

Offer an urgent chest X‑ray (to be done within 2 weeks) [1.1.2] [1.1.5]

Cough (unexplained), 40 and over, exposed to asbestos

Mesothelioma

Offer an urgent chest X‑ray (to be done within 2 weeks) [1.1.5]

Cough (unexplained) with fatigue or shortness of breath or chest pain or weight loss or appetite loss (unexplained), 40 and over

Lung or mesothelioma

Offer an urgent chest X‑ray (to be done within 2 weeks) [1.1.2] [1.1.5]

Hoarseness
Symptom and specific features Possible cancer Recommendation

Hoarseness (persistent and unexplained), 45 and over

Laryngeal

Consider a suspected cancer pathway referral [1.8.1]

Respiratory examination findings
Symptom and signs Possible cancer Recommendation

Chest signs consistent with lung cancer, 40 and over

Lung

Consider an urgent chest X‑ray (to be done within 2 weeks) [1.1.3]

Chest signs compatible with pleural disease, 40 and over

Mesothelioma

Consider an urgent chest X‑ray (to be done within 2 weeks) [1.1.6]

Finger clubbing, 40 and over

Lung or mesothelioma

Consider an urgent chest X‑ray (to be done within 2 weeks) [1.1.3] [1.1.6]

Shortness of breath
Symptom and specific features Possible cancer Recommendation

Shortness of breath (unexplained), 40 and over, ever smoked

Lung or mesothelioma

Offer an urgent chest X‑ray (to be done within 2 weeks) [1.1.2] [1.1.5]

Shortness of breath (unexplained), 40 and over, and exposed to asbestos

Mesothelioma

Offer an urgent chest X‑ray (to be done within 2 weeks) [1.1.5]

Shortness of breath with cough or fatigue or chest pain or weight loss or appetite loss (unexplained), 40 and over

Lung or mesothelioma

Offer an urgent chest X‑ray (to be done within 2 weeks) [1.1.2] [1.1.5]

Shortness of breath with unexplained lymphadenopathy in adults

Non‑Hodgkin's lymphoma or Hodgkin's lymphoma

Consider a suspected cancer pathway referral. When considering referral, take into account any associated symptoms [1.10.8]

Separate recommendations have been made for adults and for children and young people to reflect that there are different referral pathways. In practice young people (aged 16 to 24) may be referred using either pathway depending on their age and local arrangements

Shortness of breath with unexplained splenomegaly in adults

Non‑Hodgkin's lymphoma

Consider a suspected cancer pathway referral. When considering referral, take into account any associated symptoms [1.10.8]

Separate recommendations have been made for adults and for children and young people to reflect that there are different referral pathways. In practice young people (aged 16 to 24) may be referred using either pathway depending on their age and local arrangements

Skeletal symptoms

Back pain
Symptom and specific features Possible cancer Recommendation

Back pain with weight loss, 60 and over

Pancreatic

Consider an urgent, direct access CT scan (to be done within 2 weeks), or an urgent ultrasound scan if CT is not available [1.2.5]

Back pain (persistent), 60 and over

Myeloma

Offer a full blood count and blood tests for calcium and plasma viscosity or erythrocyte sedimentation rate [1.10.4]

See the section on primary care investigations for more information on tests for myeloma

Bone pain
Symptom and specific features Possible cancer Recommendation

Bone pain (persistent), 60 and over

Myeloma

Offer a full blood count and blood tests for calcium and plasma viscosity or erythrocyte sedimentation rate to assess for myeloma [1.10.4]

See the section on primary care investigations for more information on tests for myeloma

Fracture
Symptom and specific features Possible cancer Recommendation

Fracture (unexplained), 60 and over

Myeloma

Offer a full blood count and blood tests for calcium and plasma viscosity or erythrocyte sedimentation rate [1.10.4]

See the section on primary care investigations for more information on tests for myeloma

Skin or surface symptoms

See also the section on lumps or masses for oral lesions.

Skin or surface symptoms
Symptoms and signs Possible cancer Recommendation

Anal ulceration (unexplained)

Anal

Consider a suspected cancer pathway referral [1.3.6]

Bruising (unexplained) in adults

Leukaemia

Consider a very urgent full blood count (within 48 hours) [1.10.1]

Nipple changes of concern (in one nipple only) including discharge and retraction, 50 and over

Breast

Refer people using a suspected cancer pathway referral [1.4.1]

Oral cavity red or red and white patch consistent with erythroplakia or erythroleukoplakia

Oral

Consider urgent referral (for an appointment within 2 weeks) for assessment by a dentist [1.8.3]

Consider a suspected cancer pathway referral by the dentist for people when assessed by a dentist as having a red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia [1.8.4]

Pallor

Leukaemia

Consider a very urgent full blood count (within 48 hours) [1.10.1]

Penile lesion (ulcerated and sexually transmitted infection has been excluded, or persistent after treatment for a sexually transmitted infection has been completed) in men

Penile

Consider a suspected cancer pathway referral [1.6.9]

Penile mass (and sexually transmitted infection has been excluded as a cause) in men

Penile

Consider a suspected cancer pathway referral [1.6.9]

Penile symptoms affecting the foreskin or glans (unexplained or persistent) in men

Penile

Consider a suspected cancer pathway referral [1.6.10]

Petechiae (unexplained) in adults

Leukaemia

Consider a very urgent full blood count (within 48 hours) [1.10.1]

Pruritus with unexplained splenomegaly in adults

Non‑Hodgkin's lymphoma

Consider a suspected cancer pathway referral. When considering referral, take into account any associated symptoms [1.10.8]

Separate recommendations have been made for adults and for children and young people to reflect that there are different referral pathways. In practice young people (aged 16 to 24) may be referred using either pathway depending on their age and local arrangements

Pruritus with unexplained lymphadenopathy in adults

Hodgkin's lymphoma or non‑Hodgkin's lymphoma

Consider a suspected cancer pathway referral. When considering referral, take into account any associated symptoms [1.10.10]

Separate recommendations have been made for adults and for children and young people to reflect that there are different referral pathways. In practice young people (aged 16 to 24) may be referred using either pathway depending on their age and local arrangements

Skin changes that suggest breast cancer

Breast

Consider a suspected cancer pathway referral [1.4.2]

Skin lesion (pigmented and suspicious) with a weighted 7‑point checklist score of 3 or more

Melanoma

Refer people using a suspected cancer pathway referral [1.7.1]

Skin lesion (pigmented or non‑pigmented) that suggests nodular melanoma

Melanoma

Consider a suspected cancer pathway referral [1.7.3]

Skin lesion that raises the suspicion of a squamous cell carcinoma

Squamous cell carcinoma

Consider a suspected cancer pathway referral [1.7.4]

Skin lesion that raises the suspicion of a basal cell carcinoma

Basal cell carcinoma

Consider routine referral [1.7.5]

Only consider a suspected cancer pathway referral if there is particular concern that a delay may have a significant impact, because of factors such as lesion site or size [1.7.6]

Typical features of basal cell carcinoma include: an ulcer with a raised rolled edge; prominent fine blood vessels around a lesion; or a nodule on the skin (particularly pearly or waxy nodules)

Vulval lump or ulceration (unexplained) in women

Vulval

Consider a suspected cancer pathway referral [1.5.14]

Urological symptoms

Dysuria
Symptom and specific features Possible cancer Recommendation

Dysuria with unexplained non‑visible haematuria, 60 and over

Bladder

Refer people using a suspected cancer pathway referral [1.6.4]

Erectile dysfunction
Symptom and specific features Possible cancer Recommendation

Erectile dysfunction in men

Prostate

Consider a prostate‑specific antigen (PSA) test and digital rectal examination [1.6.2]

See the section on primary care investigations for more information on PSA tests and digital rectal examination

Haematuria
Symptom and specific features Possible cancer Recommendation

Haematuria (visible and unexplained) either without urinary tract infection or that persists or recurs after successful treatment of urinary tract infection, 45 and over

Bladder or renal

Refer people using a suspected cancer pathway referral [1.6.4] [1.6.6]

Haematuria (non‑visible and unexplained) with dysuria or raised white cell count on a blood test, 60 and over

Bladder

Refer people using a suspected cancer pathway referral [1.6.4]

Haematuria (visible) with low haemoglobin levels or thrombocytosis or high blood glucose levels or unexplained vaginal discharge in women 55 and over

Endometrial

Consider a direct access ultrasound scan [1.5.12]

Haematuria (visible) in men

Prostate

Consider a prostate‑specific antigen (PSA) test and digital rectal examination [1.6.2]

See the section on primary care investigations for more information on PSA tests and digital rectal examination

Testicular symptoms
Symptom and specific features Possible cancer Recommendation

Testis enlargement or change in shape or texture (non‑painful) in men

Testicular

Consider a suspected cancer pathway referral [1.6.7]

Testicular symptoms (unexplained or persistent) in men

Testicular

Consider a direct access ultrasound scan [1.6.8]

Other urinary tract symptoms
Symptom and specific features Possible cancer Recommendation

Urinary tract infection (unexplained and recurrent or persistent), 60 and over

Bladder

Consider non-urgent referral for bladder cancer in people aged 60 and over with recurrent or persistent unexplained urinary tract infection [1.6.5]

Lower urinary tract symptoms, such as nocturia, urinary frequency, hesitancy, urgency or retention in men

Prostate

Consider a prostate‑specific antigen (PSA) test and digital rectal examination [1.6.2]

See the section on primary care investigations for more information on PSA tests and digital rectal examination

Urinary urgency or frequency (increased and persistent or frequent – particularly more than 12 times per month) in women, especially if 50 and over

Ovarian

Carry out tests in primary care [1.5.2]

Measure serum CA125 in primary care [1.5.6]

See the section on primary care investigations for information on tests for ovarian cancer

These recommendations apply to women aged 18 and over

Non‑specific features of cancer

Appetite loss or early satiety
Symptom and specific features Possible cancer Recommendation

Appetite loss (unexplained)

Several, including lung, oesophageal, stomach, colorectal, pancreatic, bladder or renal

Carry out an assessment for additional symptoms, signs or findings that may help to clarify which cancer is most likely

Offer urgent investigation or a suspected cancer pathway referral [1.13.3]

Appetite loss (unexplained), 40 and over, ever smoked

Lung or mesothelioma

Offer an urgent chest X‑ray (to be done within 2 weeks) [1.1.2] [1.1.5]

Appetite loss (unexplained), 40 and over, exposed to asbestos

Mesothelioma

Offer an urgent chest X‑ray (to be done within 2 weeks) [1.1.5]

Appetite loss (unexplained) with cough or fatigue or shortness of breath or chest pain or weight loss (unexplained), 40 and over

Lung or mesothelioma

Offer an urgent chest X‑ray (to be done within 2 weeks) [1.1.2] [1.1.5]

Appetite loss or early satiety (persistent or frequent – particularly more than 12 times per month) in women, especially if 50 and over

Ovarian

Carry out tests in primary care [1.5.2]

Measure serum CA125 in primary care [1.5.6]

See the section on primary care investigations for information on tests for ovarian cancer

These recommendations apply to women aged 18 and over

Deep vein thrombosis
Symptom and specific features Possible cancer Recommendation

Deep vein thrombosis

Several, including urogenital, breast, colorectal and lung

Carry out an assessment for additional symptoms, signs or findings that may help to clarify which cancer is most likely

Consider urgent investigation or a suspected cancer pathway referral [1.13.4]

Diabetes
Symptom and specific features Possible cancer Recommendation

Diabetes (new onset) with weight loss, 60 and over

Pancreatic

Consider an urgent, direct access CT scan (to be done within 2 weeks), or urgent ultrasound scan if CT is not available [1.2.5]

Fatigue
Symptom and specific features Possible cancer Recommendation

Fatigue (unexplained), 40 and over, ever smoked

Lung or mesothelioma

Offer an urgent chest X‑ray (to be done within 2 weeks) [1.1.2] [1.1.5]

Fatigue (unexplained), 40 and over, exposed to asbestos

Mesothelioma

Offer an urgent chest X‑ray (to be done within 2 weeks) [1.1.5]

Fatigue with cough or shortness of breath or chest pain or weight loss or appetite loss (unexplained), 40 and over

Lung or mesothelioma

Offer an urgent chest X‑ray (to be done within 2 weeks) [1.1.2] [1.1.5]

Fatigue (persistent) in adults

Leukaemia

Consider a very urgent full blood count (within 48 hours) [1.10.1]

Fatigue (unexplained) in women

Ovarian

Carry out tests in primary care [1.5.2]

Measure serum CA125 in primary care [1.5.6]

See the section on primary care investigations for information on tests for ovarian cancer

These recommendations apply to women aged 18 and over

Fever
Symptom and specific features Possible cancer Recommendation

Fever (unexplained)

Leukaemia

Consider a very urgent full blood count (within 48 hours) [1.10.1]

Fever with unexplained splenomegaly in adults

Non‑Hodgkin's lymphoma

Consider a suspected cancer pathway referral. When considering referral, take into account any associated symptoms [1.10.8]

Separate recommendations have been made for adults and for children and young people to reflect that there are different referral pathways. In practice young people (aged 16 to 24) may be referred using either pathway depending on their age and local arrangements

Fever with unexplained lymphadenopathy in adults

Hodgkin's lymphoma or non‑Hodgkin's lymphoma

Consider a suspected cancer pathway referral. When considering referral, take into account any associated symptoms [1.10.10]

Separate recommendations have been made for adults and for children and young people to reflect that there are different referral pathways. In practice young people (aged 16 to 24) may be referred using either pathway depending on their age and local arrangements

See also the section on respiratory symptoms for chest infection.

Infection
Symptom and specific features Possible cancer Recommendation

Infection (unexplained and persistent or recurrent) in adults

Leukaemia

Consider a very urgent full blood count (within 48 hours) [1.10.1]

Night sweats
Symptom and specific features Possible cancer Recommendation

Night sweats with unexplained splenomegaly in adults

Non‑Hodgkin's lymphoma

Consider a suspected cancer pathway referral. When considering referral, take into account any associated symptoms [1.10.8]

Separate recommendations have been made for adults and for children and young people to reflect that there are different referral pathways. In practice young people (aged 16 to 24) may be referred using either pathway depending on their age and local arrangements

Night sweats with unexplained lymphadenopathy in adults

Hodgkin's lymphoma or non‑Hodgkin's lymphoma

Consider a suspected cancer pathway referral. When considering referral, take into account any associated symptoms [1.10.10]

Separate recommendations have been made for adults and for children and young people to reflect that there are different referral pathways. In practice young people (aged 16 to 24) may be referred using either pathway depending on their age and local arrangements

Pallor
Symptom and specific features Possible cancer Recommendation

Pallor

Leukaemia

Consider a very urgent full blood count (within 48 hours) [1.10.1]

Pruritus
Symptom and specific features Possible cancer Recommendation

Pruritus with unexplained splenomegaly in adults

Non‑Hodgkin's lymphoma

Consider a suspected cancer pathway referral. When considering referral, take into account any associated symptoms [1.10.8]

Separate recommendations have been made for adults and for children and young people to reflect that there are different referral pathways. In practice young people (aged 16 to 24) may be referred using either pathway depending on their age and local arrangements

Pruritus with unexplained lymphadenopathy in adults

Hodgkin's lymphoma or non‑Hodgkin's lymphoma

Consider a suspected cancer pathway referral. When considering referral, take into account any associated symptoms [1.10.10]

Separate recommendations have been made for adults and for children and young people to reflect that there are different referral pathways. In practice young people (aged 16 to 24) may be referred using either pathway depending on their age and local arrangements

Weight loss
Symptom and specific features Possible cancer Recommendation

Weight loss (unexplained)

Several, including colorectal, gastro‑oesophageal, lung, prostate, pancreatic or urological cancer

Carry out an assessment for additional symptoms, signs or findings that may help to clarify which cancer is most likely

Offer urgent investigation or a suspected cancer pathway referral [1.13.2]

Weight loss (unexplained) with abdominal pain, 40 and over

Colorectal

Offer quantitative faecal immunochemical testing [1.3.1]

Weight loss (unexplained) with rectal bleeding in adults under 50

Colorectal

Offer quantitative faecal immunochemical testing [1.3.1]

Weight loss (unexplained), 50 and over

Colorectal

Offer quantitative faecal immunochemical testing [1.3.1]

Weight loss (unexplained), 40 and over, ever smoked

Lung or mesothelioma

Offer an urgent chest X‑ray (to be done within 2 weeks) [1.1.2] [1.1.5]

Weight loss (unexplained), 40 and over, exposed to asbestos

Mesothelioma

Offer an urgent chest X‑ray (to be done within 2 weeks) [1.1.5]

Weight loss with cough or fatigue or shortness of breath or chest pain or appetite loss (unexplained), 40 and over, never smoked

Lung or mesothelioma

Offer an urgent chest X‑ray (to be done within 2 weeks) [1.1.2] [1.1.5]

Weight loss with unexplained splenomegaly in adults

Non‑Hodgkin's lymphoma

Consider a suspected cancer pathway referral. When considering referral, take into account any associated symptoms [1.10.8]

Separate recommendations have been made for adults and for children and young people to reflect that there are different referral pathways. In practice young people (aged 16 to 24) may be referred using either pathway depending on their age and local arrangements

Weight loss with unexplained lymphadenopathy in adults

Hodgkin's lymphoma or non‑Hodgkin's lymphoma

Consider a suspected cancer pathway referral. When considering referral, take into account any associated symptoms [1.10.8] [1.10.10]

Separate recommendations have been made for adults and for children and young people to reflect that there are different referral pathways. In practice young people (aged 16 to 24) may be referred using either pathway depending on their age and local arrangements

Weight loss with upper abdominal pain or reflux or dyspepsia, 55 and over

Oesophageal or stomach

Offer urgent, direct access upper gastrointestinal endoscopy (to be done within 2 weeks) [1.2.1] [1.2.7]

Weight loss (unexplained) in women

Ovarian

Consider carrying out tests in primary care [1.5.3]

Measure serum CA125 in primary care [1.5.6]

See the section on primary care investigations for information on tests for ovarian cancer

These recommendations apply to women aged 18 and over

Weight loss with diarrhoea or back pain or abdominal pain or nausea or vomiting or constipation or new‑onset diabetes, 60 and over

Pancreatic

Consider an urgent, direct access CT scan (to be done within 2 weeks), or an urgent ultrasound scan if CT is not available [1.2.5]

Weight loss with raised platelet count or nausea or vomiting, 55 and over

Oesophageal or stomach

Consider non-urgent, direct access upper gastrointestinal endoscopy [1.2.3] [1.2.9]

Primary care investigations

Blood test findings
Investigation findings and specific features Possible cancer Recommendation

Anaemia (iron‑deficiency)

Colorectal

Offer quantitative faecal immunochemical testing [1.3.1]

Anaemia (non-iron-deficiency), 60 and over

Colorectal

Offer quantitative faecal immunochemical testing [1.3.1]

Blood glucose levels high with visible haematuria in women 55 and over

Endometrial

Consider a direct access ultrasound scan [1.5.12]

Diabetes (new‑onset) with weight loss, 60 and over

Pancreatic

Consider an urgent, direct access CT scan (to be done within 2 weeks), or an urgent ultrasound scan if CT is not available [1.2.5]

Haemoglobin levels low with visible haematuria in women 55 and over

Endometrial

Consider a direct access ultrasound scan [1.5.12]

Haemoglobin levels low with upper abdominal pain, 55 and over

Oesophageal or stomach

Consider non-urgent, direct access upper gastrointestinal endoscopy [1.2.3] [1.2.9]

Hypercalcaemia or leukopenia and presentation consistent with possible myeloma, 60 and over

Myeloma

Offer very urgent protein electrophoresis and a Bence–Jones protein urine test (within 48 hours) [1.10.5]

Plasma viscosity or erythrocyte sedimentation rate and presentation consistent with possible myeloma

Myeloma

Consider very urgent protein electrophoresis and a Bence–Jones protein urine test (within 48 hours) [1.10.6]

Platelet count raised with nausea or vomiting or weight loss or reflux or dyspepsia or upper abdominal pain, 55 and over

Oesophageal or stomach

Consider non-urgent, direct access upper gastrointestinal endoscopy [1.2.3] [1.2.9]

Prostate‑specific antigen levels above the age‑specific threshold in table 1 plus lower urinary tract symptoms such as nocturia, urinary frequency, hesitancy, urgency or retention or erectile dysfunction or visible haematuria

Prostate

Consider a suspected cancer pathway referral [1.6.3]

Protein electrophoresis suggests myeloma

Myeloma

Refer people using a suspected cancer pathway referral [1.10.7]

Serum CA125 results

Ovarian

If serum CA125 is 35 IU/ml or greater, arrange an ultrasound scan of the abdomen and pelvis [1.5.7]

Normal serum CA125 (less than 35 IU/ml), or CA125 of 35 IU/ml or greater but a normal ultrasound:

assess her carefully for other clinical causes of her symptoms and investigate if appropriate

if no other clinical cause is apparent, advise her to return to her GP if her symptoms become more frequent and/or persistent. [1.5.9]

These recommendations apply to women aged 18 and over

Thrombocytosis, 40 and over

Lung

Consider an urgent chest X‑ray (to be done within 2 weeks) [1.1.3]

Thrombocytosis with visible haematuria or vaginal discharge (unexplained) in women 55 and over

Endometrial

Consider a direct access ultrasound scan [1.5.12]

White cell count raised on a blood test with unexplained non‑visible haematuria, 60 and over

Bladder

Refer people using a suspected cancer pathway referral [1.6.4]

Dermoscopy findings
Investigation findings and specific features Possible cancer Recommendation

Dermoscopy suggests melanoma of the skin

Melanoma

Refer people using a suspected cancer pathway referral [1.7.2]

Digital rectal examination findings
Examination findings and specific features Possible cancer Recommendation

Prostate feels malignant on digital rectal examination

Prostate

Refer men using a suspected cancer pathway referral [1.6.1]

Faecal tests
Investigation findings and specific features Possible cancer Recommendation

Occult blood in faeces

Colorectal

Refer adults using a suspected cancer pathway referral [1.3.2]

Imaging tests
Investigation findings and specific features Possible cancer Recommendation

Chest X‑ray suggests lung cancer

Lung

Refer people using a suspected cancer pathway referral [1.1.1]

Chest X‑ray suggests mesothelioma

Mesothelioma

Refer people using a suspected cancer pathway referral [1.1.4]

Ultrasound suggests ovarian cancer

Ovarian

Refer women using a suspected cancer pathway referral [1.5.8]

These recommendations apply to women aged 18 and over

Ultrasound normal with CA125 of 35 IU/ml or greater

Ovarian

Assess carefully for other clinical causes of her symptoms and investigate if appropriate

If no other clinical cause is apparent, advise her to return to her GP if her symptoms become more frequent and/or persistent [1.5.9]

These recommendations apply to women aged 18 and over

Ultrasound suggests soft tissue sarcoma or is uncertain and clinical concern persists in adults

Soft tissue sarcoma

Consider a suspected cancer pathway referral [1.11.5]

Separate recommendations have been made for adults and for children and young people to reflect that there are different referral pathways. In practice young people (aged 16 to 24) may be referred using either pathway depending on their age and local arrangements

X‑ray suggests the possibility of bone sarcoma in adults

Bone sarcoma

Consider a suspected cancer pathway referral [1.11.1]

Separate recommendations have been made for adults and for children and young people to reflect that there are different referral pathways. In practice young people (aged 16 to 24) may be referred using either pathway depending on their age and local arrangements

Jaundice
Investigation findings and specific features Possible cancer Recommendation

Jaundice, 40 and over

Pancreatic

Refer people using a suspected cancer pathway referral [1.2.4]

Urine test findings
Investigation findings and specific features Possible cancer Recommendation

Bence–Jones protein urine results suggest myeloma

Myeloma

Refer people using a suspected cancer pathway referral [1.10.7]

Symptoms in children and young people

Abdominal symptoms
Symptom and specific features Possible cancer Recommendation

Hepatosplenomegaly (unexplained) in children and young people

Leukaemia

Refer for immediate specialist assessment [1.10.2]

Abdominal mass (palpable) or enlarged abdominal organ (unexplained) in children

Neuroblastoma or Wilms' tumour

Consider very urgent referral (for an appointment within 48 hours) for specialist assessment [1.12.1] [1.12.3]

Splenomegaly (unexplained) in children and young people

Non‑Hodgkin's lymphoma

Consider a very urgent referral (for an appointment within 48 hours) for specialist assessment. When considering referral, take into account any associated symptoms, particularly fever, night sweats, shortness of breath, pruritus or weight loss [1.10.9]

Separate recommendations have been made for adults and for children and young people to reflect that there are different referral pathways. In practice young people (aged 16 to 24) may be referred using either pathway depending on their age and local arrangements

Bleeding, bruising or rashes
Symptom and specific features Possible cancer Recommendation

Petechiae (unexplained) in children and young people

Leukaemia

Refer for immediate specialist assessment [1.10.2]

Bleeding or bruising (unexplained) in children and young people

Leukaemia

Offer a very urgent full blood count (within 48 hours) [1.10.3]

Lumps or masses
Symptom and specific features Possible cancer Recommendation

Lymphadenopathy (unexplained) in children and young people

Non‑Hodgkin's lymphoma or Hodgkin's lymphoma

Consider a very urgent referral (for an appointment within 48 hours) for specialist assessment. When considering referral, take into account any associated symptoms, particularly fever, night sweats, shortness of breath, pruritus or weight loss [1.10.9] [1.10.11]

Separate recommendations have been made for adults and for children and young people to reflect that there are different referral pathways. In practice young people (aged 16 to 24) may be referred using either pathway depending on their age and local arrangements

Lymphadenopathy (generalised) in children and young people

Leukaemia

Offer a very urgent full blood count (within 48 hours) [1.10.3]

Lump (unexplained) that is increasing in size in children and young people

Soft tissue sarcoma

Consider a very urgent, direct access ultrasound scan (to be done within 48 hours) [1.11.6]

See the section on primary care investigations for more information on ultrasound scans

Separate recommendations have been made for adults and for children and young people to reflect that there are different referral pathways. In practice young people (aged 16 to 24) may be referred using either pathway depending on their age and local arrangements

See also the section on abdominal symptoms for abdominal mass or unexplained enlarged abdominal organ, splenomegaly and hepatosplenomegaly.

Neurological symptoms
Symptom and specific features Possible cancer Recommendation

Newly abnormal cerebellar or other central neurological function in children and young people

Brain or central nervous system cancer

Consider a very urgent referral (for an appointment within 48 hours) [1.9.2]

Respiratory symptoms
Symptom and specific features Possible cancer Recommendation

Shortness of breath with lymphadenopathy in children and young people

Non‑Hodgkin's lymphoma or Hodgkin's lymphoma

Consider a very urgent referral (for an appointment within 48 hours) for specialist assessment. When considering referral, take into account any associated symptoms [1.10.9] [1.10.11]

Separate recommendations have been made for adults and for children and young people to reflect that there are different referral pathways. In practice young people (aged 16 to 24) may be referred using either pathway depending on their age and local arrangements

Shortness of breath with splenomegaly (unexplained) in children and young people

Non‑Hodgkin's lymphoma

Consider a very urgent referral (for an appointment within 48 hours) for specialist assessment. When considering referral, take into account any associated symptoms [1.10.9]

Separate recommendations have been made for adults and for children and young people to reflect that there are different referral pathways. In practice young people (aged 16 to 24) may be referred using either pathway depending on their age and local arrangements

Skeletal symptoms
Symptom and specific features Possible cancer Recommendation

Bone pain (persistent or unexplained) in children and young people

Leukaemia

Offer a very urgent full blood count (within 48 hours) [1.10.3]

Bone pain (unexplained) in children and young people

Bone sarcoma

Consider a very urgent, direct access X‑ray (to be done within 48 hours) [1.11.3]

See the section on primary care investigations for more information on X‑rays

Bone swelling (unexplained) in children and young people

Bone sarcoma

Consider a very urgent, direct access X‑ray (to be done within 48 hours) [1.11.3]

See the section on primary care investigations for more information on X‑rays

Skin or surface symptoms
Symptom and specific features Possible cancer Recommendation

Petechiae (unexplained) in children and young people

Leukaemia

Refer for immediate specialist assessment [1.10.2]

Bruising (unexplained) in children and young people

Leukaemia

Offer a very urgent full blood count (within 48 hours) [1.10.3]

Pallor in children and young people

Leukaemia

Offer a very urgent full blood count (within 48 hours) [1.10.3]

Urological symptoms
Symptom and specific features Possible cancer Recommendation

Haematuria (visible and unexplained) in children

Wilms' tumour

Consider very urgent referral (for an appointment within 48 hours) for specialist assessment [1.12.3]

Non‑specific features of cancer
Symptom and specific features Possible cancer Recommendation

Fatigue (persistent) in children and young people

Leukaemia

Offer a very urgent full blood count (within 48 hours) [1.10.3]

Fever with lymphadenopathy (unexplained) in children and young people

Non‑Hodgkin's lymphoma or Hodgkin's lymphoma

Consider a very urgent referral (for an appointment within 48 hours) for specialist assessment. When considering referral, take into account any associated symptoms [1.10.9] [1.10.11]

Separate recommendations have been made for adults and for children and young people to reflect that there are different referral pathways. In practice young people (aged 16 to 24) may be referred using either pathway depending on their age and local arrangements

Fever with splenomegaly (unexplained) in children and young people

Non‑Hodgkin's lymphoma

Consider a very urgent referral (for an appointment within 48 hours) for specialist assessment. When considering referral, take into account any associated symptoms [1.10.9]

Separate recommendations have been made for adults and for children and young people to reflect that there are different referral pathways. In practice young people (aged 16 to 24) may be referred using either pathway depending on their age and local arrangements

Fever (unexplained) in children and young people

Leukaemia

Offer a very urgent full blood count (within 48 hours) [1.10.3]

Infection (unexplained and persistent) in children and young people

Leukaemia

Offer a very urgent full blood count (within 48 hours) [1.10.3]

Lymphadenopathy (unexplained) in children and young people

Non‑Hodgkin's lymphoma or Hodgkin's lymphoma

Consider a very urgent referral (for an appointment within 48 hours) for specialist assessment. When considering referral, take into account any associated symptoms, particularly fever, night sweats, shortness of breath, pruritus or weight loss [1.10.9] [1.10.11]

Separate recommendations have been made for adults and for children and young people to reflect that there are different referral pathways. In practice young people (aged 16 to 24) may be referred using either pathway depending on their age and local arrangements

Lymphadenopathy (generalised) in children and young people

Leukaemia

Offer a very urgent full blood count (within 48 hours) [1.10.3]

Night sweats with lymphadenopathy (unexplained) in children and young people

Non‑Hodgkin's lymphoma or Hodgkin's lymphoma

Consider a very urgent referral (for an appointment within 48 hours) for specialist assessment. When considering referral, take into account any associated symptoms [1.10.9] [1.10.11]

Separate recommendations have been made for adults and for children and young people to reflect that there are different referral pathways. In practice young people (aged 16 to 24) may be referred using either pathway depending on their age and local arrangements

Night sweats with splenomegaly (unexplained) in children and young people

Non‑Hodgkin's lymphoma

Consider a very urgent referral (for an appointment within 48 hours) for specialist assessment. When considering referral, take into account any associated symptoms [1.10.9]

Separate recommendations have been made for adults and for children and young people to reflect that there are different referral pathways. In practice young people (aged 16 to 24) may be referred using either pathway depending on their age and local arrangements

Pruritus with lymphadenopathy (unexplained) in children and young people

Non‑Hodgkin's lymphoma or Hodgkin's lymphoma

Consider a very urgent referral (for an appointment within 48 hours) for specialist assessment. When considering referral, take into account any associated symptoms [1.10.9] [1.10.11]

Separate recommendations have been made for adults and for children and young people to reflect that there are different referral pathways. In practice young people (aged 16 to 24) may be referred using either pathway depending on their age and local arrangements

Pruritus with splenomegaly (unexplained) in children and young people

Non‑Hodgkin's lymphoma

Consider a very urgent referral (for an appointment within 48 hours) for specialist assessment. When considering referral, take into account any associated symptoms [1.10.9]

Separate recommendations have been made for adults and for children and young people to reflect that there are different referral pathways. In practice young people (aged 16 to 24) may be referred using either pathway depending on their age and local arrangements

Weight loss with lymphadenopathy (unexplained) in children and young people

Non‑Hodgkin's lymphoma or Hodgkin's lymphoma

Consider a very urgent referral (for an appointment within 48 hours) for specialist assessment in children and young people. When considering referral, take into account any associated symptoms [1.10.9] [1.10.11]

Separate recommendations have been made for adults and for children and young people to reflect that there are different referral pathways. In practice young people (aged 16 to 24) may be referred using either pathway depending on their age and local arrangements

Weight loss with splenomegaly (unexplained) in children and young people

Non‑Hodgkin's lymphoma

Consider a very urgent referral (for an appointment within 48 hours) for specialist assessment. When considering referral, take into account any associated symptoms [1.10.9]

Separate recommendations have been made for adults and for children and young people to reflect that there are different referral pathways. In practice young people (aged 16 to 24) may be referred using either pathway depending on their age and local arrangements

Ocular examination
Examination findings and specific features Possible cancer Recommendation

Absent fundal ('red') reflex in children

Retinoblastoma

Consider referral for ophthalmological assessment using a suspected cancer pathway referral [1.12.2]

Parental concern
Symptom and specific features Possible cancer Recommendation

Parental or carer insight, concern or anxiety about the child's or young person's symptoms (persistent)

Childhood cancer

Take into account the insight and knowledge of parents and carers when considering making a referral for suspected cancer in a child or young person

Consider referral for children if their parent or carer has persistent concern or anxiety about the child's symptoms, even if the symptoms are most likely to have a benign cause [1.13.1]

Primary care investigations
Symptom and specific features Possible cancer Recommendation

Ultrasound scan suggests soft tissue sarcoma or is uncertain and clinical concern persists in children and young people

Soft tissue sarcoma

Consider a very urgent referral (for an appointment within 48 hours) for specialist assessment [1.11.7]

Separate recommendations have been made for adults and for children and young people to reflect that there are different referral pathways. In practice young people (aged 16 to 24) may be referred using either pathway depending on their age and local arrangements

X‑ray suggests the possibility of bone sarcoma in children and young people

Bone sarcoma

Consider a very urgent referral (for an appointment within 48 hours) for specialist assessment [1.11.2]

Separate recommendations have been made for adults and for children and young people to reflect that there are different referral pathways. In practice young people (aged 16 to 24) may be referred using either pathway depending on their age and local arrangements