Latest Guidance Updates:January 2022: updated recommendations in the gynaecological and lower gastrointestinal sections. |
Overview
These rapid referral guidelines—updated by Macmillan in January 2022—contain NICE referral guidelines for suspected cancer with accompanying notes from Macmillan advisers, and have been produced by GPs with the aim of providing support, guidance, and practical referral recommendations.
Macmillan’s rapid referral guidelines are based on NICE guidance whose remit covers England and Wales. This guideline supports all of the recommendations in the NICE guideline on suspected cancer: recognition and referral apart from those relating to specific childhood cancers. For more information on this endorsement, please see the 'into practice' section of the NICE website. GPs located in Scotland can access the Scottish Referral Guidelines for suspected cancer online.
Key
- Non-urgent: the timescale generally used for a referral or investigation that is not considered very urgent or urgent
- Urgent: to happen/be performed within 2 weeks
- Very urgent: to happen within 48 hours.
Head and Neck Cancers
Laryngeal Cancer
Urgent Referral
- Consider urgent referral (appointment within 2 weeks) for people aged 45 years or over with either:
- persistent unexplained hoarseness or
- an unexplained lump in the neck.
Oral Cancer
Urgent Referral
- Consider urgent referral (appointment within 2 weeks) for people with:
- an unexplained ulceration in the oral cavity that lasts for more than 3 weeks or
- a persistent and unexplained lump in the neck.
- Consider urgently referring (appointment within 2 weeks) people to a dentist for assessment if they have:
- an unexplained lump on the lip or in the oral cavity or
- a red or red-and-white patch in the oral cavity that's consistent with erythroplakia or erythroleukoplakia.
- A dentist should consider urgent referral (appointment within 2 weeks) for people with either of the following, after a dental surgeon has assessed and concluded the symptom is consistent with oral cancer:
- a lump on the lip or the oral cavity or
- a red or red-and-white patch in the oral cavity that is consistent with erythroplakia or erythroleukoplakia.
Thyroid Cancer
Urgent Referral
- Consider urgent referral (appointment within 2 weeks) for patients with an unexplained thyroid lump.
Skin Cancers
Malignant Melanoma
Urgent Referral
- Urgently refer (appointment within 2 weeks) if:
- a person presents with a suspicious pigmented skin lesion that has a weighted seven-point checklist score of three or more or
- a dermoscopy suggests malignant melanoma of the skin.
- Consider urgent referral (appointment within 2 weeks) for melanoma in patients with a pigmented or non-pigmented skin lesion that suggests nodular melanoma.
| Accompanying Notes The seven-point weighted checklist:
|
Squamous Cell Carcinoma
Urgent Referral
- Consider urgently referring (appointment within 2 weeks) if a person has a skin lesion that raises the suspicion of squamous cell carcinoma.
| Accompanying Notes Squamous cell carcinomas are usually raised lesions. They’re often described as being ulcerated, keratinised, or crusting lesions that typically grow on the head and neck, or the back of the hand. They occur commonly, and people who are immunocompromised or have had an organ transplant are more likely to develop them. If a person like this does develop a new skin lesion, urgently refer them. |
Basal Cell Carcinoma
Urgent Referral
- Only consider urgent referral (appointment within 2 weeks) if a person has a skin lesion that raises the suspicion of a basal cell carcinoma and there's concern a delay may have an unfavourable impact, because of the location or size of the lesion.
Non-urgent Referral
- Consider routine referral for people with a skin lesion that raises the suspicion of a basal cell carcinoma.
Accompanying Notes
|
Urological Cancers
Prostate Cancer
Urgent Referral
- Urgently refer men (appointment within 2 weeks) if either:
- their prostate feels malignant on digital rectal examination (DRE) or
- their prostate specific antigen (PSA) levels are above the age-specific reference range.
Non-urgent Investigation
- Consider a PSA test and DRE in men with any of the following:
- any lower urinary tract symptoms, such as nocturia, urinary frequency, hesitancy, urgency, or retention
- erectile dysfunction
- visible haematuria.
Accompanying Notes
|
Bladder Cancer
Urgent Referral
- Urgently refer people (appointment within 2 weeks) if they are:
- aged 45 years and over with either:
- unexplained visible haematuria without urinary tract infection or
- visible haematuria that persists or recurs after successful treatment of urinary tract infection
- aged 60 years or over with unexplained non-visible haematuria and either:
- dysuria or
- a raised white cell count on a blood test.
- aged 45 years and over with either:
Non-urgent Referral
- Consider referring people aged 60 years and over with recurrent or persistent urinary tract infection that is unexplained.
Renal Cancer
Urgent Referral
- Urgently refer people (appointment within 2 weeks) if they are aged 45 years and over with either:
- unexplained visible haematuria without urinary tract infection or
- visible haematuria that persists or recurs after successful treatment of urinary tract infection.
Testicular Cancer
Urgent Referral
- Consider urgent referral (appointment within 2 weeks) in men with any of the following changes in the testis:
- non-painful enlargement
- change in shape
- change in texture.
Direct Access Ultrasound
- Consider a direct access ultrasound scan in men with unexplained or persistent testicular symptoms.
Penile Cancer
Urgent Referral
- Consider urgent referral (appointment within 2 weeks) for men with any of the following (after a sexually transmitted infection [STI] has been ruled out as a cause, or they have completed treatment for an STI)
- a penile mass
- an ulcerated lesion
- unexplained or persistent symptoms affecting the foreskin or glans.
Lung Cancers
Lung and Pleural Cancers
Urgent Referral
- Urgently refer people (appointment within 2 weeks) if:
- chest X-ray findings suggest lung cancer or mesothelioma or
- they're aged 40 years or over and have unexplained haemoptysis.
Urgent Investigations
- Consider an urgent chest X-ray (to be performed within 2 weeks) for lung cancer or mesothelioma in people aged 40 years or over with any of the following:
- persistent or recurrent chest infection
- finger clubbing
- supraclavicular lymphadenopathy or persistent cervical lymphadenopathy
- chest signs consistent with lung cancer or pleural disease
- thrombocytosis.
- Offer an urgent chest X-ray (to be performed within 2 weeks) to the following people to assess for lung cancer or mesothelioma:
- aged 40 years or over who have never smoked and display two or more of the unexplained signs or symptoms listed below, or
- aged 40 years or over and have previously smoked and display one or more of the unexplained signs or symptoms listed below, or
- of any age who have been exposed to asbestos and display one or more of the signs or symptoms listed below:
- cough
- fatigue
- shortness of breath
- chest pain
- weight loss
- appetite loss.
| Accompanying Notes A normal chest X-ray does not exclude the possibility of a lung cancer diagnosis. This was shown in a large British Journal of General Practice study conducted in 2006. It revealed that 23% of chest X-rays done in a primary care setting for people with lung cancer were negative when performed within a year of diagnosis. |
Brain and Central Nervous System Cancers
Brain and Central Nervous System Cancer
Very Urgent Referral
- Consider very urgent referral (appointment within 48 hours) in children and young people with newly abnormal central neurological or cerebellar function.
Urgent Direct Access
- Consider urgent direct access MRI brain scan (appointment within 2 weeks) in adults with progressive, sub-acute loss of central neurological function.
| Accompanying Notes A ‘Normal’ Scan
|
Upper Gastrointestinal Cancers
Oesophageal and Gastric Cancer
O=oesophageal; G=gastricUrgent Referral For Endoscopy Within 2 Weeks
- Urgently refer people:
- of any age presenting with dysphagia (OG) or
- aged 55 years and over with weight loss and
- upper abdominal pain or
- reflux or
- dyspepsia (OG).
- Consider urgent referral (appointment within two weeks) for people with an upper abdominal mass consistent with stomach cancer (G).
Non-urgent Direct Access Endoscopy
- Consider non-urgent direct access endoscopy for people:
- of any age presenting with haematemesis (OG) or
- aged 55 years or over with:
- treatment resistant dyspepsia (OG) or
- upper abdominal pain and low haemoglobin (OG) or
- raised platelet count with any of the following:
- nausea
- vomiting
- reflux
- weight loss
- dyspepsia
- upper abdominal pain (OG) or
- nausea or vomiting with any of the following:
- weight loss
- reflux
- dyspepsia
- upper abdominal pain (OG).
Pancreatic Cancer
Urgent Referral
- Urgently refer (appointment within 2 weeks) people aged 40 years or over with jaundice.
Urgent Direct Access CT Scan or an Urgent Ultrasound Scan if CT Scan is Not Available
- Consider urgent direct access CT scan (within 2 weeks)—or ultrasound scan if CT scan is not available—for people aged 60 years or over displaying weight loss and any of the following:
- diarrhoea
- back pain
- abdominal pain
- nausea/vomiting
- constipation
- new-onset diabetes.
Gall Bladder
Urgent Direct Access
- Consider an urgent direct access ultrasound scan (within 2 weeks) to assess for gall bladder cancer in people with an upper abdominal mass consistent with an enlarged gall bladder.
Liver Cancer
Urgent Direct Access
- Consider an urgent direct access ultrasound scan (within 2 weeks) to assess for liver cancer in people with an upper abdominal mass consistent with an enlarged liver.
| Accompanying Notes Consider that 10% of pancreatic cancers are missed by abdomen ultrasounds, while tumours smaller than 3 cm will not be visible using an ultrasound. An additional benefit of CT scan is that it can determine what stage a cancer is at. |
Bone and Sarcoma Cancers
Bone Sarcoma
Very Urgent Direct Access
- Consider a very urgent direct access X-ray (appointment within 48 hours) for any child or young person with unexplained:
- bone swelling or
- bone pain.
Very Urgent Referral
- Consider very urgent referral in children and young people (appointment within 48 hours) with an X-ray that suggests the possibility of bone sarcoma.
Urgent Referral
- Consider urgent referral (appointment within 2 weeks) in adults with an X-ray that suggests the possibility of bone sarcoma.
Soft Tissue Sarcoma
Very Urgent Direct Access
- Consider very urgent direct access ultrasound scan (performed within 48 hours) for children and young people with an unexplained lump that is increasing in size.
Urgent Direct Access
- Consider urgent direct access ultrasound scan (performed within 2 weeks) for adults with an unexplained lump that is increasing in size.
Very Urgent Referral
- Consider very urgent referral (within 48 hours) in children or young people with:
- ultrasound scan findings that are suggestive of soft-tissue sarcoma or
- ultrasound scan findings that are uncertain and clinical concern persists.
Urgent Referral
- Consider urgent referral (within 2 weeks) for adults with:
- ultrasound scan findings that are suggestive of soft-tissue sarcoma or
- ultrasound scan findings that are uncertain and clinical concern persists.
Breast Cancers
Breast Cancer
Urgent Referral
- Urgently refer people (appointment within 2 weeks) if they are:
- aged 30 years and over with an unexplained breast lump (with or without pain) or
- aged 50 years and over with any unilateral nipple changes of concern including discharge or retraction.
- of any age with skin changes suggestive of breast cancer or
- aged 30 years or over with an unexplained lump in the axilla.
Non-urgent Referral
- Consider non-urgent referral in people under the age of 30 years with an unexplained breast lump (with or without pain).
Haematological Cancers
Leukaemia
Very Urgent Investigation
- Refer children and young people for immediate specialist assessment for leukaemia if they have:
- unexplained petechiae or
- hepatosplenomegaly.
- Offer a very urgent full blood count (within 48 hours) in children and young people with any of the following unexplained signs or symptoms:
- pallor
- persistent fatigue
- fever
- persistent infection
- generalised lymphadenopathy
- persistent or unexplained bone pain
- bruising
- bleeding.
- Consider a very urgent full blood count (within 48 hours) in adults with any of the following unexplained signs or symptoms:
- pallor
- persistent fatigue
- fever
- persistent or recurrent infection
- generalised lymphadenopathy
- bruising
- bleeding
- petechiae
- hepatosplenomegaly.
Accompanying Notes Immediately refer adults, children, and young people with a blood count or blood film reported as acute leukaemia. |
Myeloma
Urgent Investigation
- Offer a full blood count, blood tests for calcium and plasma viscosity, or erythrocyte sedimentation rate (ESR) to people aged 60 years and over with:
- persistent bone pain (particularly back pain) or
- an unexplained fracture.
- Offer a very urgent protein electrophoresis and a Bence-Jones protein urine test (within 48 hours) to people aged 60 years and over with:
- hypercalcaemia or leukopenia and
- presentation that is consistent with possible myeloma.
- Consider a very urgent protein electrophoresis and Bence–Jones protein urine test (within 48 hours) for people with:
- raised plasma viscosity or ESR at levels consistent with possible myeloma and
- presentation consistent with possible myeloma.
Urgent Referral
- Urgently refer people (appointment within 2 weeks) if the results of protein electrophoresis or Bence–Jones protein urine test suggest myeloma.
Lymphoma
Immediate Specialist Assessment
- Consider very urgent referral (appointment within 48 hours) in children and young people with:
- unexplained lymphadenopathy or
- splenomegaly.
- Take into account associated symptoms, particularly:
- fever
- night sweats
- shortness of breath
- pruritus
- weight loss.
Urgent Referral
- Consider urgent referral (appointment within 2 weeks) for adults presenting with:
- unexplained lymphadenopathy or
- splenomegaly.
- Take into account associated symptoms, particularly:
- fever
- night sweats
- shortness of breath
- pruritus
- weight loss
- alcohol-induced lymph node pain.
Gynaecological Cancers
Ovarian Cancer
Urgent Referral
- Urgently refer (appointment within 2 weeks) if physical examination identifies any of the following:
- ascites
- pelvic or abdominal mass (which is not obviously uterine fibroids).
Urgent Investigation
- Arrange CA125 and/or ultrasound tests in women (especially if 50 years or over) who persistently or frequently (particularly more than 12 times per month) experience the following:
- persistent abdominal distension (bloating)
- early satiety and/or loss of appetite
- pelvic or abdominal pain
- increased urinary urgency and/or frequency
- new onset symptoms suggestive of irritable bowel syndrome (IBS; as IBS rarely presents for the first time in women of this age)
- Consider CA125 and/or ultrasound tests if a woman reports any of the following:
- unexplained weight loss
- fatigue
- changes in bowel habit (though colorectal cancer is a more common malignant cause).
Urgent Referral
- If the ultrasound suggests ovarian cancer, make an urgent referral to a gynaecological cancer service.
Algorithm 1: Referral Pathway for Suspected Ovarian Cancer
Endometrial Cancer
Urgent Referral
- Urgently refer women (appointment within 2 weeks) if they are aged 55 years and over with post-menopausal bleeding (unexplained vaginal bleeding more than 12 months after menstruation has stopped due to the menopause).
- Consider urgently referring (appointment within 2 weeks) women aged under 55 years with post-menopausal bleeding.
Direct access ultrasound
- Consider direct access ultrasound in women aged 55 years and over with unexplained symptoms of vaginal discharge who:
- are presenting with these symptoms for the first time or
- have thrombocytosis or
- report haematuria.
- Consider direct access ultrasound in women aged 55 years and over presenting with visible haematuria and any of the following:
- low haemoglobin
- thrombocytosis
- high blood glucose level.
Cervical Cancer
Urgent Referral
- Consider urgent referral (appointment within 2 weeks) if the appearance of the woman’s cervix is consistent with cervical cancer.
| Accompanying Notes A smear test is not required before referral, and a previous negative result should not delay referral. |
Vulval Cancer
Urgent Referral
- Consider urgently referring (appointment within 2 weeks) women with any of the following unexplained vulval signs or symptoms:
- a vulval lump
- ulceration
- bleeding.
Vaginal Cancer
Urgent Referral
- Consider urgently referring (appointment within 2 weeks) women with an unexplained palpable mass in or at the entrance to the vagina.
Lower Gastrointestinal Cancers
Colorectal Cancer
Urgent Referral
- Urgently refer (appointment within 2 weeks) people:
- aged 40 years and over with unexplained weight loss and abdominal pain
- aged 50 years and over with unexplained rectal bleeding
- aged 60 years and over with either:
- iron deficiency anaemia or
- alteration in bowel habit
- who have positively tested for occult blood in their faeces.
- Consider urgent referral (appointment within 2 weeks) for people:
- of any age with a rectal or abdominal mass
- aged under 50 years with rectal bleeding and any of the following unexplained signs or symptoms:
- abdominal pain
- altered bowel habit
- weight loss
- iron deficiency anaemia.
Faecal Immunochemical Testing
- Offer testing with quantitative faecal immunochemical tests (see the NICE diagnostics guidance on quantitative faecal immunochemical tests to guide referral for colorectal cancer in primary care) to assess for colorectal cancer in adults without rectal bleeding who:
- are aged 50 or over with unexplained:
- abdominal pain or
- weight loss
- are aged under 60 years with either:
- changes in bowel habit or
- iron deficiency
- are aged 60 years or over with anaemia, even in the absence of iron deficiency.
- are aged 50 or over with unexplained:
| Accompanying Notes If clinical concern persists, consider faecal immunochemical testing in people who do not fall into the above categories, but who present with signs or symptoms that would benefit from further investigation. |
Anal Cancer
Urgent Referral
- Consider urgent referral (appointment within 2 weeks) for people with either:
- an unexplained anal mass or
- unexplained anal ulceration.
Glossary
- Children: from birth to 15 years
- Direct access: when a test is performed and primary care retain clinical responsibility throughout, including acting on the result
- Immediate: an acute admission or referral occurring within a few hours, or even more quickly if necessary
- Suspected cancer pathway referral: the patient is seen within the national target for cancer referrals (2 weeks at the time of publication of the 2015 NICE guidance)
- Young people: aged 16–24 years.
References
References