Referral guidelines for suspected cancer

National Institute for Health and Care Excellence

Referral times

• The referral times used in this guideline are as follows:
• • immediate: an acute admission or referral occurring within a few hours, or even more quickly if necessary
  • urgent: the patient is seen within the national target for urgent referrals (currently 2 weeks)
  • non-urgent: all other referrals

Lung cancer

• Refer a patient who presents with symptoms suggestive of lung cancer to a team specialising in the management of lung cancer, depending on local arrangements

Immediate referral

• Consider immediate referral for patients with:
• • signs of superior vena caval obstruction (swelling of the face/neck with fixed elevation of jugular venous pressure)
  • stridor

Urgent referral

• Refer urgently patients with:
• • persistent haemoptysis (in smokers or ex-smokers aged 40 years and older)
  • a chest X-ray suggestive of lung cancer (including pleural effusion and slowly resolving consolidation)
  • a normal chest X-ray where there is a high suspicion of lung cancer
  • a history of asbestos exposure and recent onset of chest pain, shortness of breath or unexplained systemic symptoms where a chest X-ray indicates pleural effusion, pleural mass or any suspicious lung pathology

Urgent chest X-ray

• Refer urgently for chest X-ray (the report should be returned within 5 days) for patients with any of the following:
  • haemoptysis
  • unexplained or persistent (longer than 3 weeks):
  • • chest and/or shoulder pain
    • dyspnoea
    • weight loss
    • chest signs
    • hoarseness
    • finger clubbing
    • cervical or supraclavicular lymphadenopathy
    • cough
    • features suggestive of metastasis from a lung cancer (for example, secondaries in the brain, bone, liver, skin)
  • underlying chronic respiratory problems with unexplained changes in existing symptoms

Upper gastrointestinal cancer

• Refer a patient who presents with symptoms suggestive of upper gastrointestinal cancer to a team specialising in the management of upper gastrointestinal cancer, depending on local arrangements

• Helicobacter pylori status should not affect the decision to refer for suspected cancer

• Note that for patients under 55 years, referral for endoscopy is not necessary in the absence of alarm symptoms

• Patients being referred urgently for endoscopy should ideally be free from acid suppression medication, including proton pump inhibitors or H₂ receptor agonists, for a minimum of 2 weeks

Urgent referral for endoscopy /referral to specialist

• Refer urgently for endoscopy, or to a specialist, patients of any age with dyspepsia and any of the following:
• • chronic gastrointestinal bleeding
  • dysphagia
  • progressive unintentional weight loss
  • persistent vomiting
  • iron deficiency anaemia
  • epigastric mass
  • suspicious barium meal result

Urgent referral

• Refer urgently patients presenting with:
• • dysphagia
  • unexplained upper abdominal pain and weight loss, with or without back pain
  • upper abdominal mass without dyspepsia
  • obstructive jaundice (depending on clinical state) — consider urgent ultrasound if available

• Consider urgent referral for patients presenting with:
• • persistent vomiting and weight loss in the absence of dyspepsia
  • unexplained weight loss or iron deficiency anaemia in the absence of dyspepsia
  • unexplained worsening of dyspepsia and:
  • • Barrett’s oesophagus
    • known dysplasia, atrophic gastritis or intestinal metaplasia
    • peptic ulcer surgery over 20 years ago

Urgent endoscopy

• Refer urgently for endoscopy patients aged 55 years and older with unexplained and persistent recent-onset dyspepsia alone

Lower gastrointestinal cancer

• Refer a patient who presents with symptoms suggestive of colorectal or anal cancer to a team specialising in the management of lower gastrointestinal cancer, depending on local arrangements

• In a patient with equivocal symptoms who is not unduly anxious, it is reasonable to ‘treat, watch and wait’

Urgent referral

• Refer urgently patients:
• • aged 40 years and older, reporting rectal bleeding with a change of bowel habit towards looser stools and/or increased stool frequency persisting 6 weeks or more
  • aged 60 years and older, with rectal bleeding persisting for 6 weeks or more without a change in bowel habit and without anal symptoms
  • aged 60 years and older, with a change in bowel habit to looser stools and/or more frequent stools persisting for 6 weeks or more without rectal bleeding
  • of any age with a right lower abdominal mass consistent with involvement of the large bowel
  • of any age with a palpable rectal mass (intraluminal and not pelvic; a pelvic mass outside the bowel would warrant an urgent referral to a urologist or gynaecologist)
  • who are men of any age with unexplained iron deficiency anaemia and a haemoglobin of 11 g/100 ml or below
  • who are non-menstruating women with unexplained iron deficiency anaemia and a haemoglobin of 10 g/100 ml or below

Breast cancer

• Refer a patient who presents with symptoms suggestive of breast cancer to a team specialising in the management of breast cancer

• In general:
• • convey optimism about the effectiveness of breast cancer treatments and survival of breast cancer patients
  • discuss the information and support needs of your patient and respond sensitively
  • encourage all patients, including women over 50 years old, to be breast aware

• Always take the patient’s history into account. For example, it may be appropriate, in discussion with a specialist, to agree referral within a few days in a patient who reports a lump or other symptom that has been present for several months

Urgent referral

• Refer urgently patients:
• • of any age with a discrete, hard lump with fixation, with or without skin tethering
  • who are female, aged 30 years and older with a discrete lump that persists after their next period, or presents after menopause
  • who are female, aged younger than 30 years:
  • • with a lump that enlarges
    • with a lump that is fixed and hard
    • in whom there are other reasons for concern such as family history
  • of any age, with previous breast cancer, who present with a further lump or suspicious symptoms
  • with unilateral eczematous skin or nipple change that does not respond to topical treatment
  • with nipple distortion of recent onset
  • with spontaneous unilateral bloody nipple discharge
  • who are male, aged 50 years and older with a unilateral, firm subareolar mass with or without nipple distortion or associated skin changes

Non-urgent referral

• Consider non-urgent referral in:
• • women aged younger than 30 years with a lump
  • patients with breast pain and no palpable abnormality, when initial treatment fails and/or with unexplained persistent symptoms. (Use of mammography in these patients is not recommended)

Gynaecological cancer

• Refer a patient who presents with symptoms suggesting gynaecological cancer to a team specialising in the management of gynaecological cancer, depending on local arrangements

Urgent referral

• Refer urgently patients:
• • with clinical features suggestive of cervical cancer on examination. A smear test is not required before referral, and a previous negative result should not delay referral
  • not on hormone replacement therapy with postmenopausal bleeding
  • on hormone replacement therapy with persistent or unexplained postmenopausal bleeding after cessation of hormone replacement therapy for 6 weeks
  • taking tamoxifen with postmenopausal bleeding
  • with an unexplained vulval lump
  • with vulval bleeding due to ulceration

• Consider urgent referral for patients with persistent intermenstrual bleeding and negative pelvic examination

• Refer urgently for an ultrasound scan patients:
• • with a palpable abdominal or pelvic mass on examination that is not obviously uterine fibroids or not of gastrointestinal or urological origin. If the scan is suggestive of cancer, an urgent referral should be made. If urgent ultrasound is not available, an urgent referral should be made

Urological cancer

• Refer a patient who presents with symptoms or signs suggestive of a urological cancer to a team specialising in the management of urological cancer, depending on local arrangements

Prostate

• Refer urgently patients:
• • with a hard, irregular prostate typical of a prostate carcinoma. Prostate-specific antigen (PSA) should be measured and the result should accompany the referral. (An urgent referral is not needed if the prostate is simply enlarged and the PSA is in the age-specific reference range)
  • with a normal prostate, but rising/raised age-specific PSA, with or without lower urinary tract symptoms. (In patients compromised by other comorbidities, a discussion with the patient or carers and/or a specialist may be more appropriate)
  • with symptoms and high PSA levels

• The age-specific cut-off PSA measurements recommended by the Prostate Cancer Risk Management Programme are as follows: aged 50–59≥3.0 ng/ml; aged 60–69≥4.0 ng/ml; aged 70 and over ≥5.0 ng/ml. (Note that there are no age-specific reference ranges for men over 80 years. Nearly all men of this age have at least a focus of cancer in the prostate. Prostate cancer only needs to be diagnosed in this age group if it is likely to need palliative treatment)

Bladder and renal

• Refer urgently patients:
• • of any age with painless macroscopic haematuria
  • aged 40 years and older who present with recurrent or persistent urinary tract infection associated with haematuria
  • aged 50 years and older who are found to have unexplained microscopic haematuria
  • with an abdominal mass identified clinically or on imaging that is thought to arise from the urinary tract

Testicular

• Refer urgently patients with a swelling or mass in the body of the testis

Penile

• Refer urgently patients with symptoms or signs of penile cancer. These include progressive ulceration or a mass in the glans or prepuce particularly, but can involve the skin of the penile shaft. (Lumps within the corpora cavernosa can indicate Peyronie’s disease, which does not require urgent referral)

Non-urgent referral

• Refer non-urgently patients under 50 years of age with microscopic haematuria. Patients with proteinuria or raised serum creatinine should be referred to a renal physician. If there is no proteinuria and serum creatinine is normal, a non-urgent referral to a urologist should be made

Haematological cancer

• Refer a patient who presents with symptoms suggesting haematological cancer to a team specialising in the management of haematological cancer, depending on local arrangements

• Be aware that haematological cancers can present with a variety of symptoms that may have a number of different clinical explanations

• Combinations of the following symptoms and signs warrant full examination, further investigation (including a blood count and film) and possible referral:
• • fatigue
  • drenching night sweats
  • fever
  • weight loss
  • generalised itching
  • breathlessness
  • bruising
  • bleeding
  • recurrent infections
  • bone pain
  • alcohol-induced pain
  • abdominal pain
  • lymphadenopathy
  • splenomegaly

• The urgency of referral depends on the symptom severity and findings of investigations

Immediate referral

• Refer immediately patients:
• • with a blood count/film reported as acute leukaemia
  • with spinal cord compression or renal failure suspected of being caused by myeloma

Urgent referral

• Refer urgently patients with persistent unexplained splenomegaly

Skin cancer

• Refer a patient presenting with skin lesions suggestive of skin cancer or in whom a biopsy has confirmed skin cancer to a team specialising in skin cancer

• Refer patients with persistent or slowly evolving unresponsive skin conditions with uncertain diagnosis to a dermatologist

• If you perform minor surgery you should have received appropriate accredited training in relevant aspects of skin surgery including cryotherapy, curettage, and incisional and excisional biopsy techniques, and should undertake appropriate continuing professional development

Melanoma

• Change is a key element in diagnosing malignant melanoma. For low-suspicion lesions, undertake careful monitoring for change using the 7-point checklist (see below) for 8 weeks. Make measurements with photographs and a marker scale and/or ruler

• Be aware of and use the 7-point weighted checklist for assessment of pigmented skin lesions
• • major features of lesions:
  • • change in size
    • irregular shape
    • irregular colour
  • minor features of lesions:
  • • largest diameter 7 mm or more
    • inflammation
    • oozing
    • change in sensation

• Lesions scoring 3 points or more (based on major features scoring 2 points each and minor features scoring 1 point each) in the 7-point checklist above are suspicious. (If you strongly suspect cancer any one feature is adequate to prompt urgent referral)

• Refer urgently patients:
• • with a lesion suspected to be melanoma. (Excision in primary care should be avoided)

Squamous cell carcinomas

• Refer urgently patients:
• • with non-healing keratinizing or crusted tumours larger than 1 cm with significant induration on palpation. They are commonly found on the face, scalp or back of the hand with a documented expansion over 8 weeks
  • who have had an organ transplant and develop new or growing cutaneous lesions as squamous cell carcinoma is common with immunosuppression but may be atypical and aggressive
  • with histological diagnosis of a squamous cell carcinoma

Non-urgent referral

• Basal cell carcinomas are slow growing, usually without significant expansion over 2 months, and usually occur on the face. If basal cell carcinoma is suspected, refer non-urgently

Head and neck cancer including thyroid cancer

• Refer a patient who presents with symptoms suggestive of head and neck or thyroid cancer to an appropriate specialist or the neck lump clinic, depending on local arrangements

Urgent referral

• Refer urgently patients with:
• • an unexplained lump in the neck, of recent onset, or a previously undiagnosed lump that has changed over a period of 3 to 6 weeks
  • an unexplained persistent swelling in the parotid or submandibular gland
  • an unexplained persistent sore or painful throat
  • unilateral unexplained pain in the head and neck area for more than 4 weeks, associated with otalgia (ear ache) but a normal otoscopy
  • unexplained ulceration of the oral mucosa or mass persisting for more than 3 weeks
  • unexplained red and white patches (including suspected lichen planus) of the oral mucosa that are painful or swollen or bleeding

• For patients with persistent symptoms or signs related to the oral cavity in whom a definitive diagnosis of a benign lesion cannot be made, refer or follow up until the symptoms and signs disappear. If the symptoms and signs have not disappeared after 6 weeks, make an urgent referral

Referral to a dentist

• Refer urgently to a dentist patients with unexplained tooth mobility persisting for more than 3 weeks

• Monitor for oral cancer patients with confirmed oral lichen planus, as part of routine dental examination.

• Advise all patients, including those with dentures, to have regular dental checkups

Referral for a chest X-ray

• Refer urgently for chest X-ray patients with hoarseness persisting for more than 3 weeks, particularly smokers aged older than 50 years and heavy drinkers

• If there is a positive finding, refer urgently to a team specialising in the management of lung cancer. If there is a negative finding, refer urgently to a team specialising in head and neck cancer

Non-urgent referral

• Refer non-urgently a patient with unexplained red and white patches of the oral mucosa that are not painful, swollen or bleeding (including suspected lichen planus)

Thyroid cancer

• Refer immediately patients with symptoms of tracheal compression including stridor due to thyroid swelling

• Refer urgently patients with a thyroid swelling associated with any of the following:
• • a solitary nodule increasing in size
  • a history of neck irradiation
  • a family history of an endocrine tumour
  • unexplained hoarseness or voice changes
  • cervical lymphadenopathy
  • very young (pre-pubertal) patient
  • patient aged 65 years and older

Brain and CNS cancer

• Refer a patient who presents with symptoms suggestive of brain or CNS cancer to an appropriate specialist, depending on local arrangements

• Discuss any concerns about a patient’s symptoms and/or signs with a local specialist. If rapid access to scanning is available, consider as an alternative to referral

• Re-assessment and re-examination is required if the patient does not progress according to expectations

Urgent referral

• Refer urgently patients with:
• • symptoms related to the CNS, including:
  • • progressive neurological deficit
    • new-onset seizures
    • headaches
    • mental changes
    • cranial nerve palsy
    • unilateral sensorineural deafness in whom a brain tumour is suspected
  • headaches of recent onset accompanied by features suggestive of raised intracranial pressure, for example:
  • • vomiting
    • drowsiness
    • posture-related headache
    • pulse-synchronous tinnitus or by other focal or non-focal neurological symptoms, for example blackout, change in personality or memory
  • a new, qualitatively different, unexplained headache that becomes progressively severe
  • suspected recent-onset seizures (refer to neurologist)

• Consider urgent referral (to an appropriate specialist) in patients with rapid progression of:
• • subacute focal neurological deficit
  • unexplained cognitive impairment, behavioural disturbance or slowness, or a combination of these
  • personality changes confirmed by a witness and for which there is no reasonable explanation even in the absence of the other symptoms and signs of a brain tumour

Non-urgent referral

• Consider non-urgent referral or discussion with specialist for:
• • unexplained headaches of recent onset:
  • • present for at least 1 month
    • not accompanied by features suggestive of raised intracranial pressure

Bone cancer and sarcoma

• Refer a patient who presents with symptoms suggesting bone cancer or sarcoma to a team specialising in the management of bone cancer and sarcoma, or to a recognised bone cancer centre, depending on local arrangements

• If you have concerns about a patient’s symptoms and/or signs, consider a discussion with the local specialist

Bone tumours

• Refer for an immediate X-ray a patient with a suspected spontaneous fracture

• If the X-ray:
• • indicates possible bone cancer, refer urgently
  • is normal but symptoms persist, follow up and/or request repeat X-ray, bone function tests or referral

Soft tissue sarcoma

• Refer urgently if:
• • a patient presents with a palpable lump that is:
  • • greater than about 5 cm in diameter
    • deep to fascia, fixed or immobile
    • increasing in size
    • painful
    • a recurrence after previous excision

• If a patient has HIV, consider Kaposi’s sarcoma and make an urgent referral if suspected

Urgent investigation

• Urgently investigate increasing, unexplained or persistent bone pain or tenderness, particularly pain at rest (and especially if not in the joint), or an unexplained limp. In older people metastases, myeloma or lymphoma, as well as sarcoma, should be considered

full guideline available from…
National Institute for Health and Care Excellence, Level 1A, City Tower, Piccadilly Plaza, Manchester, M1 4BT
guidance.nice.org.uk/

National Institute for Health and Care Excellence. Referral guidelines for suspected cancer. Quick Reference Guide. June 2005

First included: Jan 06.