GP Suspected
Cancer
Referral Guidelines
Advice Pack
JULY 2012
CONTENTS
SECTION:
PAGE:
Introduction
1
The Advice Pack
1
Sending the Referral
1
Referral Guidelines for Suspected Haematological Malignancies
3
Referral Guidelines for Suspected Brain/CNS Cancer
5
Referral Guidelines for Suspected Breast Cancer
6
Referral Guidelines for Suspected Childrens Cancer
8
Referral Guidelines for Suspected Gynaecological Cancer
11
Referral Guidelines for Suspected Head and Neck Cancer
12
Referral Guidelines for Suspected Colorectal Cancer
14
Referral Guidelines for Suspected Lung Cancer
15
Referral Guidelines for Suspected Skin Cancer (Melanoma & Squamous Cell Carcinoma)
16
Referral Guideline for Suspected Upper GI Cancer
18
Referral Guidelines for Suspected Urological Cancer
20
Referral Guidelines for Suspected Bone and Soft Tissue Sarcomas
(London and South East England Sarcoma Network)
22
List of Criteria for Urgent Referral for all Suspected Cancers
24
How to Make Referrals for Suspected Cancers
25
INTRODUCTION
The original ‘Urgent Suspected Cancer’ referral guidelines, launched by the Department of
Health in 2001 were a radical departure from the usual referral practice within the NHS. GPs
were required to fax an ‘Urgent Suspected Cancer’ referral to a designated cancer unit within
24 hours of seeing the patient and of making the decision to refer. Failure to refer people
who fulfilled the criteria, or to refer within 24 hours, is technically considered to be a breach
of the GPs Terms & Conditions of Service.
In 2006, the original criteria and how GPs used them was reviewed. The number of referrals
had dramatically increased though the percentage of people diagnosed with cancer through
this route stayed at about 30%. This meant that 70% of cancers were diagnosed through
other – often significantly slower - routes. NICE felt it was appropriate to review the original
guidelines and develop them in ways that would increase the likelihood of diagnosing cancer
earlier and in doing so increase the chances of treatment being successful.
The Cancer Reform Strategy December 2007 introduced new and changed commitments in
terms of service standards for cancer patients that must be met. The Data Set Change
Notice issued by the Department of Health in August 2008, informed us all that from 1st
January 2009, the monitoring of two week referrals would commence from the date that the
referral is received by the provider trust.
THE ADVICE PACK
This pack contains the criteria and guidelines for each cancer type. These are based on the
NICE guidelines with minor additions/adjustments where necessary based on the clinical
experience and expertise available within the South West London Cancer Network.
The criteria allow GPs scope to investigate patients urgently before referral.
acknowledge the need to respond to patient anxiety.
They also
There are tumour specific referral forms though, at the request of many GPs, there is also a
generic referral form. Each referral criterion has a designated ‘code’. When using the
generic referral form, insert the cancer site and code in the appropriate boxes. The codes
are included on the back of the form for ease of use and are also listed at the back of this
pack.
Note: Please destroy all pre-existing ‘Urgent Suspected Cancer’ referral forms
Cancer Units may initially ask for more information should a referral not meet one of the
criteria.
Note: Basal Cell Carcinomas of the skin should never be referred by the Urgent Suspected
Cancer route.
SENDING THE REFERRAL
Despite the changes in monitoring, the South West London Cancer Network (SWLCN) has
agreed that GPs should continue to fax the referral within 24 hours of making the decision to
refer. It is anticipated that there will be a Network wide approach in the future for referrals to
be sent electronically. In the meantime, it is possible to email referrals to the Royal Marsden
NHS Foundation Trust and the address is given at the end of this document.
Secondary provider trusts will be monitoring any delays between the decision to refer and
receipt of the referral. In the interest of speedy and equitable patient access, they will pass
any concerns to the Service Improvement Lead to be followed up.
Data will also be collected that includes details of patients who have been referred but are
unable to attend an appointment due to other personal commitments such as a holiday. GPs
are therefore asked to ensure that their patient is able to attend an appointment within
the two weeks from the referral being made. This is particularly important for patients
being referred with suspected testicular cancer or leukaemia or if the patient is a child. This
group of patients enter a 31 day pathway instead of a 62 day pathway which applies to all
other groups.
As from 1st January 2009, GPs have been expected to ensure that their patients have
received an appointment. If your patient has not received an appointment within 3 working
days of referral, you should contact the hospital to whom you sent the referral.
More information may be obtained by visiting the South West London Cancer Network
website:- http://www.swlcn.nhs.uk
Dr A Brzezicki
Primary Care Lead SWLCN
Referral Guidelines For Suspected Haematological Malignancies
KEY POINTS
Leukaemia: Acute and Chronic
 Approx 5,000 adult cases (all types) pa
 75% occur in people over 60 years, but all ages can be affected
 Risk factors include previous chemotherapy/radiotherapy and exposure to radiation
 Most cases are diagnosed as the result of a full blood count done because of symptoms or signs
 Some leukaemias present with lymphadenopathy and/or splenomegaly
Non Hodgkin’s Lymphoma
 Approx 7,000 cases pa
 67% of cases occur in people over 60 year, but all ages can be affected
 40% present with tumour outside lymph glands
Hodgkin’s Disease
 Approx 1,200 cases pa
 Over 50% occur below the age of 40
 95% present with lymph gland involvement
Myeloma
 Approx 3,000 cases pa
 99% are aged over 40
 95% are aged over 50
General advice
Combinations of the following signs and symptoms may suggest haematological cancer and warrant full examination and
further investigation (including full blood count and film) and maybe referral.
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Fatigue
Drenching night sweats
Fever
Generalised itching
Breathlessness
Bruising
Bleeding
Recurrent infections
Bone pain
Alcohol induced pain
Abdominal pain
Lymphadenopathy
Splenomegaly
NICE makes specific recommendations on how certain groups of patients should be investigated. These
include:Unexplained fatigue
 FBC
 Blood film
 ESR or CRP (as per local policy)
Unexplained lymphadenopathy
 FBC
 Blood film
 ESR or CRP (as per local policy)
Unexplained bruising, bleeding, purpura or symptoms suggesting anaemia
 FBC
 Blood film
 ESR or CRP (as per local policy)
 Clotting screen
Unexplained persistent bone pain
 FBC
 U&E
 X Ray
 Liver profile
 Bone profile
 PSA (in males)
 ESR or CRP (as per local policy)
 Paraprotein and urinary Bence Jones protein
Spinal cord compression or renal failure suspected of being caused by myeloma. Contact haematologist to
arrange immediate admission.
GUIDELINES FOR URGENT REFERRAL
 H 1 Patients with a blood count or blood film reported as acute leukaemia
 H 2 Patients with persistent unexplained splenomegaly
Additionally, investigation of/or urgent referral would be appropriate for: H 3 Patients with the following additional features of lymphadenopathy
o Persistence for 6 weeks or more
o Lymph nodes growing in size
o Lymph nodes greater than 2 cm inn size
o Widespread nature
o Associated splenomegaly
o Night sweats
o Weight loss
 H 4 Patients with suspected myeloma
MAKING URGENT APPOINTMENTS
Please use either the Haematology cancer proforma, or the generic cancer referral proforma. Please complete as fully
as possible, highlighting the referral criteria. Please ensure the referral reaches the hospital within 24 hours of the
decision to refer.
Referral Guidelines for Suspected Brain/CNS Cancer
KEY POINTS
Incidence:
Approx 3,500 cases pa.
Rare below 30 years, but relatively evenly distributed thereafter (peak at 60-69 years)
Age:
Typical presenting features
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Progressive neurological deficit developing over days to weeks
Seizures
Raised intra-cranial pressure
Cognitive and/or personality changes
Prevalence of symptoms amongst patients presenting with a brain tumour
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Focal neurological deficit >50%
Seizures 25-30%
Headaches25-30%
Papilloedema25-50%
Mental changes16-20%
Probability of having a brain tumour in the following situations
New onset seizures (any type) in adults 2-6%
New onset status epilepticus10%
Headache of non migrainous type <1%
General Recommendations
If a primary care professional has concerns about the interpretation of a patients neurological signs or symptoms, a
discussion with a local specialist should be considered. An alternative may be urgent access to CT scanning.
The absence of papilloedema does not exclude intra-cerebral pathology.
New neurological signs should raise the awareness of a brain tumour (see listed above).
In patients with new onset headache, present for at least 1 month, but not accompanied by features of raised intracranial
pressure, discussion with a specialist or referral (usually non urgent) should be considered.
GUIDELINES FOR URGENT REFERRAL
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CNS 1 Patients with CNS symptoms where a brain tumour is suspected.
MAKING URGENT APPOINTMENTS
e either the Brain and CNS cancer proforma, or the generic cancer referral proforma. Please
complete as fully as possible, highlighting the referral criteria. Please ensure the referral reaches the hospital within
24 hours of the decision to refer.
Referral Guidelines for Suspected Breast Cancer
From January 2010, all symptomatic breast patients must be referred under the two week
rule
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KEY POINTS
Breast Cancer is the commonest malignancy in women, approx. 32,000 cases p.a. An average GP with 1,500 patients will see one new case
a year.
Incidence rises with age. Only 5% of cases occur before 40 years, and only 2% before 35 years.
The referral guidelines are designed to help identify women with a significant risk of breast cancer, who need to be seen within two weeks.
You may wish to refer women with other breast symptoms for specialist advice, but it is not expected that the Urgent Suspected Cancer
route be used for the following
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Discrete lump in women under 30 (unless truly exceptional)
Women with breast pain only, without a mass
Abscess
Asymmetric nodularity that persists at review after a period
Persistent or refilling cysts
Nipple discharge causes considerable anxiety. Urgent Suspected Cancer referrals should only be made in cases of spontaneous unilateral
bloody nipple discharge. Urgent referral is not needed for
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Multi-duct and bilateral nipple discharge
Single duct clear discharge.
If you are concerned a routine referral is appropriate.
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GUIDELINES FOR URGENT REFERRAL
Any of the following:
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BR 1 Age over 30 with a discrete lump which persists after her next period
BR 2 Discrete lump in a menopausal women
BR 3 In women under 30 ONLY IF
A lump which enlarges
A lump suspicious of cancer (fixed or hard)
Other major reasons for concern
BR 4 New lump or suspicious symptoms in a person previously diagnosed with breast cancer
BR 5 Unilateral eczematous skin or nipple change resistant to treatment
BR 6 Spontaneous unilateral bloody nipple discharge
BR 7 Men aged 0ver 50 with a breast mass
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MAKING URGENT APPOINTMENTS
he Breast cancer proforma, or the generic cancer referral proforma. Please
s possible highlighting the referral Criteria. The referral proforma must be
sure the fax reaches the hospital within 24 hours of the decision to refer.
Criteria for referral of women with a family history of breast cancer
Women with the following histories should be referred for further advice in the local family history clinic:
1 close maternal/paternal relative diagnosed with breast cancer at age 40 or under.
>2 close relatives on same side of family with breast cancer at any age
A history of both breast and primary ovary cancers in close relative/s
A history of bilateral breast cancer in a close relative
Male breast cancer in a close relative
Two cases of primary ovary cancer in close relatives
Complex history or pattern of unusual cancers in the family (with at least one case of breast cancer <50 years)
Women with an extremely high level of anxiety about the family history even if not judged at increased risk
Women with known Ashkenazi Jewish ancestry concerned about possible increased risk
(Close relative means 1st or 2nd degree on the maternal side i.e. mother, sister, aunt, grandmother, half sister, niece. On the
paternal side 3rd degree relatives such as first cousins, great grandmothers and great aunts are important to document and
count as close relatives)
Referral is most appropriate at age 40 when screening can be commenced. Most women can be reassured that their risk of
breast cancer under the age of 40 years is low.
A small group of women with very strong family histories or with very young affected relatives may benefit from earlier advice if
genetic testing could be considered in the family (screening for identified BRCA gene mutation carriers is advised from age30).
dance including a short summary can be obtained from www.nice.org.uk
April 2006
Referral Guidelines for Suspected Childrens Cancer
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KEY POINTS
Childhood cancer is rare and its presentation varied. Therefore in the case of a child presenting several times (3 or more) with the same
problem, but with no clear diagnosis an urgent referral should be made.
Incidence:
Approx. 1,200 children < 15 years p.a. Incidence 12 per 100,000
1 in 550 – 600 children will be affected by the age of 15 (similar to Down’s, diabetes or meningitis in
children)
Acute leukaemia accounts for 1/3 of all childhood cancers, brain/CNS for almost ¼
CHILDHOOD CANCER
NO OF CASES PER YEAR
PRINCIPLE AGE GROUP
AFFECTED
ALL
AML
310
60
280
2-4 years
Hodgkin’s
NHL
50
70
80
10-14 years
Wilm’s tumour
(nephroblastoma)
Bone Sarcoma
70
< 5 years
60
10-14 years
Germ Cell Tumours
30
< 1 year
Retinoblastoma
30
< 1 year
Neuroblastoma
80
< 4 years
Hepatoblastoma
10
< 1 year
Acute Leukaemia
Brain Tumours
Lymphoma
Soft tissue sarcoma
< 4 years
Risk Factors
There are associations between some conditions and childhood cancers. The possibility of cancer in these children should be born in mind.
Conditions associated with Childhood Tumours
CHILDHOOD TUMOUR
Leukaemia
CNS Tumours
Wilm’s
Soft tissue sarcoma
ASSOCIATION
Down’s syndrome
Neurofibromatosis Type 1
Aniridia, hemihypertrophy, Beckwith-Wiedemann Syndrome
Li Fraumeni syndrome (e.g. relatives with pre-menopausal breast cancer)
Retinoblastoma
May be familial/heritable (mainly bilateral tumours)
Hepatoblastoma
Familial adenomatous polyposis coli
April 2006
General Recommendations
Childhood cancer is rare and its presentation varied. Therefore in the case of a child presenting several times (3 or more) with the same
problem, but with no clear diagnosis an urgent referral should be made.
The parent is the best observer of the child’s symptoms. The primary health care professional should take note of parental insight and
knowledge when considering urgent referral.
Persistent parental anxiety should be sufficient reason for referral of a child or young person, even when the primary health care professional
considers the symptoms are most likely to have a benign cause.
Persistent pain in a child or a young person can be due to cancer and is an indication for an examination, investigation with a full blood count
and film and consideration of referral.
Good communications between health care professionals, parents and children is important, as is support of the child and his/her parents or
carers.
Specific Recommendations
Leukaemia
Children usually present with a relatively short history of weeks rather than months. The presence of one or more of the following symptoms
or signs requires investigation with a full blood count and blood film.
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Pallor
Fatigue
Unexplained irritability
Unexplained fever
Persistent or recurrent upper respiratory track infections
Generalised lymphadenopathy
Persistent or unexplained bone pain
Unexplained bruising
The presence of the following require immediate referral
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Unexplained petechiae
Hepatospleomegaly
Lymphomas
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Hodgkin’s lymphoma usually presents with non-tender cervical and or supra-clavicular lymphadenopathy. The history is long
(months). Only a minority have systemic symptoms (itch, night sweats or fever).
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Non-Hodgkin’s lymphoma typically shows a more rapid progression of symptoms, and may present with lymphadenopathy,
breathlessness, SVC obstruction or abdominal distension.
Neuroblastoma
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Majority have symptoms of metastatic disease which may be indistinguishable clinically from acute leukaemia
Infants under one year may have localised abdominal or thoracic masses.
Wilm’s tumour (nephroblastoma)
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Abdominal mass +/= pain
Haematuria (rare)
April 2006
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Mass at almost any site
Bone tumours
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Limbs are most common sites
Persistent bone pain
Plain x-ray usually helpful
Retinoblastoma
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Family history (in approx. 15%)
White papillary reflex
Squint
Gonadal tumours
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Testicular/paratesticular masses can be difficult to differentiate – any non transilluminable mass associated with the testis is
significant
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GUIDELINES FOR URGENT REFERRAL
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CH 1Abnormal blood count suggesting further investigation
CH 2Lymphadenopathy, if one or more of the following are present (particularly in the absence of local
Infection
Lymph nodes are non-tender, firm or hard
Lymph nodes are greater than 2 cm in size
Lymph nodes are progressively enlarging
Other features of general ill health, fever or weight loss
Axillary node involvement (in absence of local infection or dermatitis)
Supra-clavicular node involvement
CH 3Shortness of breath, in association of the above signs, particularly if not responding to
bronchodilators
CH 4Persistent parental anxiety
CH 5Recurrent presentation (3 times or more) with the same symptoms and no diagnosis
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MAKING URGENT APPOINTMENTS
he Children’s cancer proforma, or the generic cancer referral proforma.
you fully inform and include parents and carers in all referral decisions.
Please complete as fully as possible highlighting the referral Criteria. Please ensure the referral reaches the hospital within
24 hours of the decision to refer.
April 2006
Referral Guidelines for Suspected Gynaecological Cancers
KEY POINTS
Ovarian Cancers
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5,400 cases p.a.
Uncommon below 40years (5%)
Symptoms - often vague non specific abdominal pain
90% have a palpable pelvic mass at time of diagnosis
Usually diagnosed late
Endometrial Cancer
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3,900 cases p.a.
95% of cases present with post-menopausal bleeding
Uncommon in pre-menopausal women (5%)
Cervical Cancer
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3,400 cases p.a.
Incidence similar across all age groups > 30
Screening programme to identify precursor lesions
Typically present with postmenopausal, post coital or persistent inter-menstrual bleeding
80% diagnosed on speculum examination
Up to 40% screen detected
Any suspicious lesion is an indication for urgent referral – do not wait for a cervical smear result
Vulval Cancer
1,000 cases p.a.
Most occur in women over 65 years
Usually presents with bleeding, discomfort, itch or a burning sensation
90% have a visible tumour on clinical examination
GUIDELINES FOR URGENT REFERRAL
Any of the following:
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GY 1 Lesions suspicious of cancer on cervix or vagina on speculum examination
GY 2 Lesions suspicious of cancer on clinical examination of the vulva
GY 3 Palpable abdominal or pelvic mass (not obviously fibroids)
GY 4 Suspicious pelvic mass on ultrasound
GY 5 Post menopausal bleeding in a woman not on HRT
GY 6 Persistent or unexplained post menopausal bleeding in a woman on HRT, after cessation of the HRT for 6 weeks
GY7 Post menopausal bleeding in a women taking Tamoxifen
GY 8 Persistent intermenstrual bleeding and a negative pelvic examination
In women over 45 with persistent abdominal pain or distension, ovarian cancer should be considered and a pelvic examination performed.
If you find a pelvic mass on examination, which does not appear to be fibroids, bowel or urological in origin, referral for an urgent pelvic
ultrasound is a reasonable alternative to a Gynaecological specialist.
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MAKING URGENT APPOINTMENTS
Gynaecological cancer proforma, or the generic cancer referral proforma.
Please complete as fully as possible highlighting the referral Criteria. Please ensure the referral reaches the hospital within 24 hours of
the decision to refer.
April 2006
Referral Guidelines for Suspected Head & Neck Cancer
KEY POINTS
Incidence:
Approximate total: 7,000 cases
Mouth, lip, pharynx:3,600 cases p.a.Larynx2,000 cases p.a.
Thyroid:1,000 cases p.a.Salivary:700 cases p.a.
Risk Factors
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Smoking
Chewing Betel, Gutka or Pan
Alcohol, heavy drinking
Male gender
Age > 45
General Recommendations
Oral Cancer
Any patient with persistent symptoms or signs related to the oral cavity, which do not resolve within 6 weeks should be referred urgently –
unless clearly benign.
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Patients with unexplained red and white patches (including suspected lichen planus) of the oral mucosa that are
Painfulor
Swollenor
Bleeding
Need urgent referral
If these signs are absent, a routine non urgent referral can be made. Diagnosed lichen planus should be monitored for life by their dental
practitioner as part of routine dental follow up.
Unexplained oral ulceration or mass of 3 weeks duration or more need urgent referral.
Patients with unexplained tooth mobility persisting for more than 3 weeks should be referred urgently to their general dental practitioner. An
urgent cancer referral should not be made.
People with hoarseness lasting for more than 3 weeks, particularly if smokers, heavy drinkers and aged over 50, should be investigated in
the first instance with an urgent chest x-ray. If positive an urgent referral to a chest physician should be made (see Lung Cancer sheet).
People with a negative chest x ray should be referred urgently to a head and neck cancer specialist.
hoarseness (see above) investigations for head and neck cancer should not be made
ey can delay referral.
In patients with a thyroid swelling, without the specific criteria in the urgent referral guidelines below, the primary care physician should
request thyroid function tests. People with hyper or hypothyroidism and an associated goitre are very unlikely to have thyroid cancer. If
referral is needed, this can be to an endocrinologist in a routine manner. People who are euthyroid, without any specific urgent referral
criteria should be referred non-urgently (if referral is needed).
h symptoms of tracheal compression, including stridor due to a thyroid swelling
mediately (A&E).
such as ultrasounds or isotope scanning is not recommended in primary care as this
ay in referral.
GUIDELINES FOR URGENT REFERRAL
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HN 1 Any patient with persistent symptoms or signs related to the oral cavity, which does not resolve within weeks should be referred
urgently – unless clearly benign.
NH 2 Patients with unexplained red and white patches (including suspected lichen planus) of the oral mucosa that are
April 2006
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Painfulor
Swollenor
Bleeding
HN 3 Unexplained oral ulceration or mass of 3 weeks duration or more need urgent referral.
HN 4 Hoarseness of more than 3 weeks (with normal chest x-ray)
HN 5 Persistent, unexplained parotid or submandibular gland swellings
HN 6 Persistent, unexplained sore or painful throat
HN 7 Unilateral head or neck pain for more than 4 weeks, with ear ache (but normal otoscopy).
HN 8 Thyroid swelling with any of the following
Solitary nodule increasing in size
History of neck radiation
Family History of an endocrine tumour
Unexplained hoarseness or voice changes
Cervical lymphadenopathy
Pre-pubertal patients
Patients aged 65+
MAKING URGENT APPOINTMENTS
Please use either the Head and Neck cancer proforma, or the generic cancer referral proforma. Please complete as fully as possible
highlighting the referral Criteria. Please ensure the referral reaches the hospital within 24 hours of the decision to refer.
Referral Guidelines for Suspected Colorectal Cancer
(Lower Gastrointestinal Cancer)
KEY POINTS
Incidence:Approx. 30,000 cases p.a.
Age:99% aged > 40 years
85% aged > 60 years
In patients less than 40 an urgent referral with rectal bleeding, in the absence of any other suspicious signs or symptoms does not
warrant an urgent suspected cancer referral.
Risk Factors
Ulcerative colitis or a past history of ulcerative colitis
(There is insufficient evidence to suggest that a positive family history of colorectal cancer can be used as a criterion to assist in the decision
about referral of a symptomatic patient)
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Rectal bleeding persistently without anal symptoms
Change in bowel habit – most commonly increased frequency and/or looser stools persistent for at least six weeks
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A significant iron deficiency anaemia
Clear signs of intestinal obstruction
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Clinical examination
A definite right-sided abdominal mass
A definite rectal mass (intra-luminal, not pelvic)
General Recommendations
In patients with equivocal symptoms who are not unduly anxious it is reasonable to use a period of “treat, watch and wait” as a method of
management.
In patients with unexplained symptoms related to the lower GI tract, a digital rectal examination should always be carried out (provided this is
acceptable to the patient).
In patients less than 40 an urgent referral with rectal bleeding, in the absence of any other suspicious signs does not warrant an urgent
suspected cancer referral. If a referral is required, this can be made in the routine manner.
GUIDELINES FOR URGENT REFERRAL
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LGI 1 Patients aged 40+ with rectal bleeding and a change of bowel habit (looser stools) for 6 weeks or more
LGI 2 Patients 60+ with rectal bleeding for 6 weeks or more, without a change in bowel habit and without anal symptoms
LGI 3 Patients 60+ with a change of bowel habit (looser stools) for 6 weeks or more without rectal bleeding
LGI 4 Lower abdominal mass consistent with large bowel involvement
LGI 5 Palpable rectal mass (intraluminal) at any age
LGI 6 Men of any age with unexplained iron deficiency anaemia, Hb 11.0 g/dl or less
April 2006
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LGI 7 Non menstruating women with unexplained iron deficiency anaemia, Hb 10.0 g/dl or less
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MAKING URGENT APPOINTMENTS
Lower G.I. cancer proforma, or the generic cancer referral proforma. Please complete
as fully as possible highlighting the referral Criteria. Please ensure the referral reaches the hospital within 24 hours of the decision to
refer.
April 2006
Referral Guidelines for Suspected Lung Cancer
KEY POINTS
Incidence:The commonest cancer in England and Wales, about 37,000 cases p.a.
Age:Only 1% of cases occur before 40 years. 85% of cases occur over 60 years.
Over 90% are smokers or ex smokers. Those with smoking related chronic lung disease (COPD), or a history of asbestos exposure or a
previous history of cancer (especially head and beck cancer) are at higher risk
tients are symptomatic at the time of diagnosis. Chest X Ray findings are abnormal
symptomatic patients.
chest x-ray does not exclude a diagnosis of lung cancer.
arely indicated prior to referral for a specialist opinion
GUIDELINES FOR URGENT REFERRAL
where lung cancer is suspected it is appropriate to arrange an urgent chest x-ray
gent Suspected Cancer referral to a chest physician. Recurrent chest infections should
cially suspicious and patients should have a chest X Ray
a Chest X-ray
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Haemoptysis
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Unexplained changes in existing symptoms in patients with chronic respiratory problems, or new persistent problems (more than 3
weeks)
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Cough
Chest or shoulder pain
Dyspnoea
Weight loss
Chest signs
Hoarseness
Finger clubbing
Features suggesting a metastasis from the lung
Persistent cervical or supraclavicular lymphadenopathy
Fatigue
Urgent Suspected Cancer 2 week wait faxed referral to Chest Physician
Any of the following:
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LG1Chest x-ray suggestive or suspicious of lung cancer
LG2Persistent haemoptysis in smokers/ex-smokers over 40 years of age
LG3Signs of superior vena caval obstruction
LG4Stridor (consider emergency referral for admission)
MAKING URGENT APPOINTMENTS
lung cancer proforma, or the generic cancer referral proforma. Please complete as
fully as possible highlighting the referral Criteria. Please ensure the referral reaches the hospital within 24 hours of the decision to
refer.
April 2006
Referral Guidelines for Suspected Skin Cancer
(Melanoma and Squamous Cell Carcinoma)
Melanoma
KEY POINTS
Incidence:Approx. 4,000 cases p.a.
Age:Affects all adult groups
Risk FactorsExcessive UV exposure
Fair skin; poor tanning ability
Large number of benign melanocyctic naevi
Family history
Dysplastic naevi syndrome
Commonest LocationsWomen50% on lower leg
Men33% on the back
General Recommendations
A patient presenting with a suspected melanoma should be referred to a specialist skin cancer team. Biopsy or attempted excision should
not be carried out in Primary Care. Any melanoma excision in primary care will result in an investigation into why this has taken place.
The weighted 7 point check list should be used to assess pigmented lesions
Major features2 points
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Change in size
Irregular shape
Irregular colour
Minor features1 point
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Largest diameter 7mm or more
Inflammation
Oozing
Change in sensation
Suspicion is greater for lesions scoring 3 points or more. However, any one feature is adequate to prompt an urgent referral if the concerns
about cancer are strong.
Squamous Cell Carcinoma
KEY POINTS
Incidence:Approx. 9,000 – 10,000 cases p.a.
Age:Rare in people under 60 years (unless immunosuppressed)
Risk FactorsLifetime excessive UV exposure
Multiple small actinic lesions
Fair skin; poor tanning ability
Transplant recipients
April 2006
Commonest LocationsBoth sexesFace, back of hand
WomenLower leg
MenScalp, ear
General Recommendations
Squamous cell carcinomas present as keratising or crusted tumours that may ulcerate. Non healing lesions larger than 1 cm with significant
induration on palpation may be squamous cell carcinomas. SSC should not be excised or biopsied in primary care and must be referred as
an urgent suspected cancer referral to a specialist dermatology service. . Any melanoma excision in primary care will result in an
investigation into why this has taken place.
Basal Cell Carcinomas
Basal cell carcinomas are slow growing, usually without significant expansion over 2 months. They usually occur on the face.
Suspected basal cell carcinoma should never be referred as a two week rule or using the urgent suspected cancer pathway.
The Skin Improving outcome guidance (IOG) has now clearly further defined the referral rout for BCC. It is important that only suitably
approved and accredited practitioners operate on BCCs.
No BCC should be biopsied or operated on in primary care (unless specifically accredited).
The table below gives details on how precancerous lesions and BCCs should be managed. It is important to note that all BCC lesions
excised by non-accredited practitioners will result in an investigation as to why this has happened.
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Actinic keratoses and precancerous lesions may be dealt with by any
GP
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Suspected BCC must be referred to a specialist service using the locally agreed pathway (and not be treated in primary care )
Low risk BCCs can be referred to an appropriately accredited GP for further management including excision where appropriate
High risk BCCs must be referred to a specialist dermatology service
Definitions of low risk BCCs are –
It is not on the face or neck
Is less than 2cm in size
Is not recurrent BCC
GUIDELINES FOR URGENT REFERRAL
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SK 1Any lesion suggestive of skin cancer
SK 2Any lesion confirmed on biopsy to be cancer
SK 3Any lesion suspected to be a melanoma
SK 4 Non healing lesions larger than 1 cm, with induration and present for over 8 weeks
MAKING URGENT APPOINTMENTS
Skin cancer proforma, or the generic cancer referral proforma. Please complete
as fully as possible highlighting the referral Criteria. Please ensure the referral reaches the hospital within 24 hours of the decision to
refer.
April 2006
Referral Guidelines for Suspected Upper GI Cancer
KEY POINTS
Incidence:OesophagusApprox 6,000 cases p.a.
StomachApprox 10,000 cases p.a.
PancreasApprox 6,000 cases p.a.
The incidence of stomach cancer is decreasing, whereas the incidence of oesophageal cancer is increasing. Tumours at the junction
between the stomach and oesophagus are increasing particularly rapidly.
Age:For all three tumours 99% of cases occur in people aged over 40
90% stomach cancers in over 55 years
The chances of a dyspeptic patient under the age of 55 having gastric cancer is one in a million.
In patients less than 55 endoscopic urgent investigation of dyspepsia is NOT necessary in the absence of alarm symptoms
Smoking
Alcohol
ancer Patients
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Any G.I. CancerWeight loss60%
Anaemia50%
Vomiting25%
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OesophagusHeartburn80%
Reflux50%
Dysphagia85%
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StomachEpigastric pain90%
Dysphagia40%
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PancreasJaundice80%
Dysphagia is a relatively uncommon symptom in a community/ general practice setting. Patients with difficulty in swallowing food should
always be referred for further investigations.
The index of suspicion of cancer is very considerably raised if dyspepsia is combined with an “alarm” symptom (weight loss, vomiting, and
anaemia.) In patients aged over 55 years with unexplained and persistent recent onset of dyspepsia alone, an urgent referral is warranted.
In this context “unexplained” means a new symptom, and NOT a recurrent episode. In addition common precipitants of dyspepsia, such as
NSAID ingestion should be excluded.
In patients less than 55 urgent endoscopic investigation of dyspepsia is NOT necessary in the absence of alarm symptoms
Local protocols will determine whether a patient is seen in a clinic first, or referred directly for endoscopy.
April 2006
GUIDELINES FOR URGENT REFERRAL
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UGI 1Patients of any age with dyspepsia AND with any of the following
Chronic GI bleeding
Dysphagia
Progressive unintentional weight loss
Persistent vomiting
Iron deficiency anaemia
Epigastric mass
Suspicious barium meal result
UGI 2Patients aged over 55 with unexplained persistent recent onset dyspepsia
UGI 3 Dyspepsia that occurs within 5 seconds of having commenced swallowing
UGI 4 Unexplained weight loss (and no dyspepsia)
UGI 5 Iron deficiency anaemia (and no dyspepsia)
UGI 6 Persistent vomiting and weight loss (and no dyspepsia)
UGI 7 Patients presenting with:
Unexplained upper abdominal pain and weight loss (+/- back pain
An upper abdominal mass (+/- dyspepsia)
UGI 8 Obstructive jaundice
UGI 9 Dysphagia
MAKING URGENT APPOINTMENTS
Upper G.I. cancer proforma, or the generic cancer referral proforma. Please complete
as fully as possible highlighting the referral Criteria. Please ensure the referral reaches the hospital within 24 hours of the decision to
refer.
April 2006
Referral Guidelines for Suspected Urological Cancer
KEY POINTS
Incidence:
Prostate 16,000 cases p.a. Testis1,400 cases p.a.
Bladder 12,000 cases p.a. Penis 360 cases p.a.
Kidney 4,400 cases p.a.
Prostate Cancer
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99% of cases occur in men over 50 years
25% of cases occur in men under 75 with a life expectancy greater than 10 years
Lower urinary tract symptoms are common in this age group and not a reason to suspect cancer
PSA is age specific – refer based on the values on the referral proforma
PSA testing of asymptomatic men or PSA screening is not national policy. PSA testing and screening should only be carried out
after full counselling and provision of written information.
Urinary tract infections should be excluded before carrying out PSA testing, especially in men with lower urinary tract symptoms
(prostatism).
PSA testing should be postponed for 1 month after treatment of a proven UTI.
If there is doubt whether to refer an asymptomatic man with a borderline PSA, the PSA test should be repeated after an interval of
1-3 months. If the second test shows the PSA is rising, an urgent referral should be made.
It is not necessary to refer men aged >80 for diagnosis of prostate cancer, unless a diagnosis is required to decide on palliative care
management.
There is no age specific PSA for men over 80. Nearly all these men have at least one focus of cancer in the prostate
Bladder/Urothelial Cancer
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95% affect the bladder. 5% affect the upper tracts
90% present as macroscopic haematuria
5-10% present as microscopic haematuria
The new guidelines encourage the exclusion of a UTI before a referral is made. Please include the results and details of any
MSU in your urgent referral. Male and female patients with symptoms of a UTI and macroscopic haematuria should be investigated
and treated before a decision to refer is made. If infection is not confirmed an urgent referral should be made.
Similarly, results such as U&E and presence of proteinuria and other co-morbidities such as hypertension and diabetes are
very helpful.
Patients under 50 with microscopic haematuria should have their urine tested for protein and a serum creatinine performed
before referral. If there is proteinuria, or the creatinine is raised a routine referral to a renal physician should be made (NOT
to a urologist)
Kidney Cancer
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o
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Macroscopic haematuria is the commonest presenting symptom
Others include:
Loin pain
Renal masses
Microscopic haematuria
Anaemia
Weight loss
Pyrexia
Testicular Cancer
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Scrotal swellings are common in general practice
An urgent ultrasound should be considered in men with a scrotal mass that does not transilluminate and/or when the body of the
testis cannot be distinguished
Solid swellings of the body of the testis have a high probability of being cancer (>50%)
Indeterminate swellings of the testis have a low probability of being cancer, especially in men over 55 years.
April 2006
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An ultrasound prior to referral should be considered.
Swellings outside the body of the testis are rarely cancer and do not need to be referred urgently
Penile Cancer
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Signs of penile cancer include progressive ulceration or mass in the glands or prepuce, but can include the skin of the shaft of the
penis.
Lumps within the corpus cavernosa not involving penile skin are usually not cancer but indicate Peyronie’s Disease and do not
require urgent referral
GUIDELINES FOR URGENT REFERRAL
UR 1 Clinically malignant prostate on rectal examination. PSA result to be sent with referral
UR 2 Raised or rising age specific PSA with or without lower urinary tract symptoms
UR 3 Macroscopic haematuria in male or female patients of any age
UR 4 Microscopic haematuria in male or female patients over 50 years of age
UR 5 Recurrent or persistent urinary tract infection and haematuria in male or female patients over 40 years of age
UR 6 Palpable renal mass or solid renal mass on radiological imaging
UR 7 Swelling or mass in the body of the testis
UR 8 Symptoms or signs of penile cancer
MAKING URGENT APPOINTMENTS
her the urological cancer proforma, or the generic cancer referral proforma. Please complete
as fully as possible highlighting the referral criteria. Please ensure the referral reaches the hospital within 24 hours of the
decision to refer.
April 2006