Suspected cancer: recognition and referral

Refer people using a suspected cancer pathway referral for lung cancer if they:

• have chest X‑ray findings that suggest lung cancer or

• are aged 40 and over with unexplained haemoptysis. [2015]

Offer an urgent chest X‑ray (to be done within 2 weeks) to assess for lung cancer in people aged 40 and over if they have 2 or more of the following unexplained symptoms, or if they have ever smoked and have 1 or more of the following unexplained symptoms:

• cough

• fatigue

• shortness of breath

• chest pain

• weight loss

• appetite loss. [2015]

Consider an urgent chest X‑ray (to be done within 2 weeks) to assess for lung cancer in people aged 40 and over with any of the following:

• persistent or recurrent chest infection

• finger clubbing

• supraclavicular lymphadenopathy or persistent cervical lymphadenopathy

• chest signs consistent with lung cancer

• thrombocytosis. [2015]

Refer people using a suspected cancer pathway referral for mesothelioma if they have chest X‑ray findings that suggest mesothelioma. [2015]

Offer an urgent chest X‑ray (to be done within 2 weeks) to assess for mesothelioma in people aged 40 and over, if:

• they have 2 or more of the following unexplained symptoms or

• they have 1 or more of the following unexplained symptoms and have ever smoked or

• they have 1 or more of the following unexplained symptoms and have been exposed to asbestos:

  • cough

  • fatigue

  • shortness of breath

  • chest pain

  • weight loss

  • appetite loss. [2015]

Consider an urgent chest X‑ray (to be done within 2 weeks) to assess for mesothelioma in people aged 40 and over with either:

• finger clubbing or

• chest signs compatible with pleural disease. [2015]

Offer urgent, direct access upper gastrointestinal endoscopy (to be done within 2 weeks) to assess for oesophageal cancer in people:

• with dysphagia or

• aged 55 and over with weight loss and any of the following:

  • upper abdominal pain

  • reflux

  • dyspepsia. [2015]

Consider non-urgent, direct access upper gastrointestinal endoscopy to assess for oesophageal cancer in people with haematemesis. [2015]

Consider non-urgent, direct access upper gastrointestinal endoscopy to assess for oesophageal cancer in people aged 55 or over with:

• treatment‑resistant dyspepsia or

• upper abdominal pain with low haemoglobin levels or

• raised platelet count with any of the following:

  • nausea

  • vomiting

  • weight loss

  • reflux

  • dyspepsia

  • upper abdominal pain or

• nausea or vomiting with any of the following:

  • weight loss

  • reflux

  • dyspepsia

  • upper abdominal pain. [2015]

Refer people using a suspected cancer pathway referral for pancreatic cancer if they are aged 40 and over and have jaundice. [2015]

Consider an urgent, direct access CT scan (to be done within 2 weeks), or an urgent ultrasound scan if CT is not available, to assess for pancreatic cancer in people aged 60 and over with weight loss and any of the following:

• diarrhoea

• back pain

• abdominal pain

• nausea

• vomiting

• constipation

• new‑onset diabetes. [2015]

Consider a suspected cancer pathway referral for people with an upper abdominal mass consistent with stomach cancer. [2015]

Offer urgent, direct access upper gastrointestinal endoscopy (to be done within 2 weeks) to assess for stomach cancer in people:

• with dysphagia or

• aged 55 and over with weight loss and any of the following:

  • upper abdominal pain

  • reflux

  • dyspepsia. [2015]

Consider non-urgent, direct access upper gastrointestinal endoscopy to assess for stomach cancer in people with haematemesis. [2015]

Consider non-urgent, direct access upper gastrointestinal endoscopy to assess for stomach cancer in people aged 55 or over with:

• treatment‑resistant dyspepsia or

• upper abdominal pain with low haemoglobin levels or

• raised platelet count with any of the following:

  • nausea

  • vomiting

  • weight loss

  • reflux

  • dyspepsia

  • upper abdominal pain or

• nausea or vomiting with any of the following:

  • weight loss

  • reflux

  • dyspepsia

  • upper abdominal pain. [2015]

Consider an urgent, direct access ultrasound scan (to be done within 2 weeks) to assess for gall bladder cancer in people with an upper abdominal mass consistent with an enlarged gall bladder. [2015]

Consider an urgent, direct access ultrasound scan (to be done within 2 weeks) to assess for liver cancer in people with an upper abdominal mass consistent with an enlarged liver. [2015]

Offer quantitative faecal immunochemical testing (FIT) using HM‑JACKarc or OC‑Sensor to guide referral for suspected colorectal cancer in adults:

• with an abdominal mass or

• with a change in bowel habit or

• with iron-deficiency anaemia or

• aged 40 and over with unexplained weight loss and abdominal pain or

• aged under 50 with rectal bleeding and either of the following unexplained symptoms:

  • abdominal pain

  • weight loss or

• aged 50 and over with any of the following unexplained symptoms:

  • rectal bleeding

  • abdominal pain

  • weight loss or

• aged 60 and over with anaemia even in the absence of iron deficiency.
  
  FIT should be offered even if the person has previously had a negative FIT result through the NHS bowel cancer screening programme. People with a rectal mass, an unexplained anal mass or unexplained anal ulceration do not need to be offered FIT before referral is considered. [2023]

Refer adults using a suspected cancer pathway referral for colorectal cancer if they have a FIT result of at least 10 micrograms of haemoglobin per gram of faeces. [2023]

For people who have not returned a faecal sample or who have a FIT result below 10 micrograms of haemoglobin per gram of faeces:

• safety netting processes should be in place

• referral to an appropriate secondary care pathway should not be delayed if there is strong clinical concern of cancer because of ongoing unexplained symptoms (for example, abdominal mass). [2023]

Clinicians should consider if people need additional help, information or support to return their sample. [2023]

Consider a suspected cancer pathway referral for colorectal cancer in adults with a rectal mass. [2015, amended 2023]

Consider a suspected cancer pathway referral for anal cancer in people with an unexplained anal mass or unexplained anal ulceration. [2015]

Make a referral to a gynaecological cancer service using a suspected cancer pathway referral if physical examination identifies ascites and/or a pelvic or abdominal mass (which is not obviously uterine fibroids). [2011, amended 2020]

Carry out tests in primary care (see recommendations 1.5.6 to 1.5.9) if a woman (especially if aged 50 or over) reports having any of the following symptoms on a persistent or frequent basis – particularly more than 12 times per month:

• persistent abdominal distension (women often refer to this as 'bloating')

• feeling full (early satiety) and/or loss of appetite

• pelvic or abdominal pain

• increased urinary urgency and/or frequency. [2011]

Consider carrying out tests in primary care (see recommendations 1.5.6 to 1.5.9) if a woman reports unexplained weight loss, fatigue or changes in bowel habit. [2011]

Advise any woman who is not suspected of having ovarian cancer to return to her GP if her symptoms become more frequent and/or persistent. [2011]

Carry out appropriate tests for ovarian cancer (see recommendations 1.5.6 to 1.5.9) in any woman aged 50 or over who has experienced symptoms within the last 12 months that suggest irritable bowel syndrome (IBS), because IBS rarely presents for the first time in women of this age. (See NICE's guideline on irritable bowel syndrome in adults). [2011]

Measure serum CA125 in primary care in women with symptoms that suggest ovarian cancer (see recommendations 1.5.1 to 1.5.5). [2011]

If serum CA125 is 35 IU/ml or greater, arrange an ultrasound scan of the abdomen and pelvis. [2011]

If the ultrasound suggests ovarian cancer, make a referral to a gynaecological cancer service using a suspected cancer pathway referral. [2011, amended 2020]

For any woman who has 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. [2011]

Refer women using a suspected cancer pathway referral for endometrial cancer if they are aged 55 and over with post‑menopausal bleeding (unexplained vaginal bleeding more than 12 months after menstruation has stopped because of the menopause). [2015]

Consider a suspected cancer pathway referral for endometrial cancer in women aged under 55 with post‑menopausal bleeding. [2015]

Consider a direct access ultrasound scan to assess for endometrial cancer in women aged 55 and over with:

• unexplained symptoms of vaginal discharge who:

  • are presenting with these symptoms for the first time or

  • have thrombocytosis or

  • report haematuria or

• visible haematuria and:

  • low haemoglobin levels or

  • thrombocytosis or

  • high blood glucose levels. [2015]

Consider a suspected cancer pathway referral for women if, on examination, the appearance of their cervix is consistent with cervical cancer. [2015]

Consider a suspected cancer pathway referral for vulval cancer in women with an unexplained vulval lump, ulceration or bleeding. [2015]

Consider a suspected cancer pathway referral for vaginal cancer in women with an unexplained palpable mass in or at the entrance to the vagina. [2015]

Refer people using a suspected cancer pathway referral for prostate cancer if their prostate feels malignant on digital rectal examination. [2015]

Consider a prostate‑specific antigen (PSA) test and digital rectal examination to assess for prostate cancer in people with:

• any lower urinary tract symptoms, such as nocturia, urinary frequency, hesitancy, urgency or retention or

• erectile dysfunction or

• visible haematuria. [2015]

Consider referring people with possible symptoms of prostate cancer, as specified in recommendation 1.6.2, using a suspected cancer pathway referral for prostate cancer if their PSA levels are above the threshold for their age in table 1. Take into account the person's preferences and any comorbidities when making the decision. [2021]

Refer people using a suspected cancer pathway referral for bladder cancer if they are:

• aged 45 and over and have:

  • unexplained visible haematuria without urinary tract infection or

  • visible haematuria that persists or recurs after successful treatment of urinary tract infection or

• aged 60 and over and have unexplained non‑visible haematuria and either dysuria or a raised white cell count on a blood test. [2015]

Consider non-urgent referral for bladder cancer in people aged 60 and over with recurrent or persistent unexplained urinary tract infection. [2015]

Refer people using a suspected cancer pathway referral for renal cancer if they are aged 45 and over and have:

• unexplained visible haematuria without urinary tract infection or

• visible haematuria that persists or recurs after successful treatment of urinary tract infection. [2015]

Consider a suspected cancer pathway referral for testicular cancer in men if they have a non‑painful enlargement or change in shape or texture of the testis. [2015]

Consider a direct access ultrasound scan for testicular cancer in men with unexplained or persistent testicular symptoms. [2015]

Consider a suspected cancer pathway referral for penile cancer in men if they have:

• a penile mass or ulcerated lesion, when a sexually transmitted infection has been excluded as a cause or

• a persistent penile lesion after treatment for a sexually transmitted infection has been completed. [2015]

Consider a suspected cancer pathway referral for penile cancer in men with unexplained or persistent symptoms affecting the foreskin or glans. [2015]

Refer people using a suspected cancer pathway referral for melanoma if they have a suspicious pigmented skin lesion with a weighted 7‑point checklist score of 3 or more. [2015]

Refer people using a suspected cancer pathway referral if dermoscopy suggests melanoma of the skin. [2015]

Consider a suspected cancer pathway referral for melanoma in people with a pigmented or non‑pigmented skin lesion that suggests nodular melanoma. [2015]

Consider a suspected cancer pathway referral for people with a skin lesion that raises the suspicion of squamous cell carcinoma. [2015]

Consider routine referral for people if they have a skin lesion that raises the suspicion of a basal cell carcinoma. (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].) [2015]

Only consider a suspected cancer pathway referral for people with a skin lesion that raises the suspicion of a basal cell carcinoma if there is particular concern that a delay may have a significant impact, because of factors such as lesion site or size. [2015]

Follow NICE's guidance on improving outcomes for people with skin tumours including melanoma for advice on who should excise suspected basal cell carcinomas. [2015]

Consider a suspected cancer pathway referral for laryngeal cancer in people aged 45 and over with:

• persistent unexplained hoarseness or

• an unexplained lump in the neck. [2015]

Consider a suspected cancer pathway referral for oral cancer in people with either:

• unexplained ulceration in the oral cavity lasting for more than 3 weeks or

• a persistent and unexplained lump in the neck. [2015]

Consider an urgent referral (for an appointment within 2 weeks) for assessment for possible oral cancer by a dentist in people who have either:

• a lump on the lip or in the oral cavity or

• a red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia. [2015]

Consider a suspected cancer pathway referral by the dentist for oral cancer in people when assessed by a dentist as having either:

• a lump on the lip or in the oral cavity consistent with oral cancer or

• a red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia. [2015]

Consider a suspected cancer pathway referral for thyroid cancer in people with an unexplained thyroid lump. [2015]

Consider an urgent, direct access, MRI scan of the brain (or CT scan if MRI is contraindicated; to be done within 2 weeks) to assess for brain or central nervous system cancer in adults with progressive, sub‑acute loss of central neurological function. [2015]

Consider a very urgent referral (for an appointment within 48 hours) for suspected brain or central nervous system cancer in children and young people with newly abnormal cerebellar or other central neurological function. [2015]

Consider a very urgent full blood count (within 48 hours) to assess for leukaemia in adults with any of the following:

• pallor

• persistent fatigue

• unexplained fever

• unexplained persistent or recurrent infection

• generalised lymphadenopathy

• unexplained bruising

• unexplained bleeding

• unexplained petechiae

• hepatosplenomegaly. [2015]

Refer children and young people for immediate specialist assessment for leukaemia if they have unexplained petechiae or hepatosplenomegaly. [2015]

Offer a very urgent full blood count (within 48 hours) to assess for leukaemia in children and young people with any of the following:

• pallor

• persistent fatigue

• unexplained fever

• unexplained persistent infection

• generalised lymphadenopathy

• persistent or unexplained bone pain

• unexplained bruising

• unexplained bleeding. [2015]

Offer a full blood count and blood tests for calcium and plasma viscosity or erythrocyte sedimentation rate to assess for myeloma in people aged 60 and over with persistent bone pain, particularly back pain, or unexplained fracture. [2015]

Offer very urgent protein electrophoresis and a Bence–Jones protein urine test (within 48 hours) to assess for myeloma in people aged 60 and over with hypercalcaemia or leukopenia and a presentation that is consistent with possible myeloma. [2015]

Consider very urgent protein electrophoresis and a Bence–Jones protein urine test (within 48 hours) to assess for myeloma if the plasma viscosity or erythrocyte sedimentation rate and presentation are consistent with possible myeloma. [2015]

Refer people using a suspected cancer pathway referral if the results of protein electrophoresis or a Bence–Jones protein urine test suggest myeloma. [2015]

Consider a suspected cancer pathway referral for adults if an X‑ray suggests the possibility of bone sarcoma. [2015]

Consider a very urgent referral (for an appointment within 48 hours) for specialist assessment for children and young people if an X‑ray suggests the possibility of bone sarcoma. [2015]

Consider a very urgent direct access X‑ray (to be done within 48 hours) to assess for bone sarcoma in children and young people with unexplained bone swelling or pain. [2015]

Consider an urgent, direct access ultrasound scan (to be done within 2 weeks) to assess for soft tissue sarcoma in adults with an unexplained lump that is increasing in size. [2015]

Consider a suspected cancer pathway referral for adults if they have ultrasound scan findings that are suggestive of soft tissue sarcoma or if ultrasound findings are uncertain and clinical concern persists. [2015]

Consider a very urgent, direct access ultrasound scan (to be done within 48 hours) to assess for soft tissue sarcoma in children and young people with an unexplained lump that is increasing in size. [2015]

Consider a very urgent referral (for an appointment within 48 hours) for children and young people if they have ultrasound scan findings that are suggestive of soft tissue sarcoma or if ultrasound findings are uncertain and clinical concern persists. [2015]

Consider very urgent referral (for an appointment within 48 hours) for specialist assessment for neuroblastoma in children with a palpable abdominal mass or unexplained enlarged abdominal organ. [2015]

Consider referral for ophthalmological assessment using a suspected cancer pathway referral for retinoblastoma in children with an absent fundal ('red') reflex. If there is new-onset squint that occurs together with an absent fundal ('red') reflex, see the recommendation on new-onset squint with loss of fundal 'red' reflex in NICE's guideline on suspected neurological conditions. [2015]

Consider very urgent referral (for an appointment within 48 hours) for specialist assessment for Wilms' tumour in children with any of the following:

• a palpable abdominal mass

• an unexplained enlarged abdominal organ

• unexplained visible haematuria. [2015]

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. [2015]

For people with unexplained weight loss, which is a symptom of several cancers including colorectal, gastro‑oesophageal, lung, prostate, pancreatic and urological cancer:

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

• offer urgent investigation or a suspected cancer pathway referral. [2015]

For people with unexplained appetite loss, which is a symptom of several cancers including lung, oesophageal, stomach, colorectal, pancreatic, bladder and renal cancer:

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

• offer urgent investigation or a suspected cancer pathway referral. [2015]

For people with deep vein thrombosis, which is associated with several cancers including urogenital, breast, colorectal and lung cancer:

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

• consider urgent investigation or a suspected cancer pathway referral. [2015]