Recommendations organised by symptom and findings of primary care investigations | Suspected cancer: recognition and referral | Guidance

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

**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]

**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