Suspected cancer: recognition and referral

This guideline covers identifying children, young people and adults with symptoms that could be caused by cancer. It outlines appropriate investigations in primary care, and selection of people to refer for a specialist opinion. It aims to help people understand what to expect if they have symptoms that may suggest cancer.

# Introduction 

# Safeguarding children
Remember that child maltreatment:
is common
can present anywhere
may coexist with other health problems, including suspected cancer.
See NICE's guideline on child maltreatment for clinical features that may be associated with maltreatment.
People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations (although this may not apply to recommendations made before 2009; see the section on recommendation wording in guideline updates below). It also has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity) and safeguarding.

# How the guideline is organised
The recommendations in this guideline have been organised into 3 separate sections to help healthcare professionals find the relevant information easily. The recommendations for investigation and referral organised by site of suspected cancer are also presented in tables of recommendations organised by symptoms and investigation findings. Either section should be used in conjunction with the recommendations on patient support, safety netting and the diagnostic process.

# Recommendation wording in guideline updates
NICE began using standard wording to denote the strength of recommendations in guidelines that started development after January 2009. It does not apply to any recommendations ending  (see update information for details about how recommendations are labelled). In particular, for recommendations labelled  the word 'consider' may not necessarily be used to denote the strength of the recommendation.# Recommendations organised by site of cancer
Use this guideline to guide referrals. If still uncertain about whether a referral is needed, consider contacting a specialist (see the recommendations on the diagnostic process). Consider a review for people with any symptom associated with increased cancer risk who do not meet the criteria for referral or investigative action (see the recommendations on safety netting).

# Lung and pleural cancers

## Lung cancer
Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for lung cancer if they:
have chest Xray findings that suggest lung cancer or
are aged 40 and over with unexplained haemoptysis. 
Offer an urgent chest Xray (to be done within 2 weeks) to assess for lung cancer in people aged 40 and over if they have 2 or more of the following unexplained symptoms, or if they have ever smoked and have 1 or more of the following unexplained symptoms:
cough
fatigue
shortness of breath
chest pain
weight loss
appetite loss. 
Consider an urgent chest Xray (to be done within 2 weeks) to assess for lung cancer in people aged 40 and over with any of the following:
persistent or recurrent chest infection
finger clubbing
supraclavicular lymphadenopathy or persistent cervical lymphadenopathy
chest signs consistent with lung cancer
thrombocytosis. 

## Mesothelioma
Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for mesothelioma if they have chest Xray findings that suggest mesothelioma. 
Offer an urgent chest Xray (to be done within 2 weeks) to assess for mesothelioma in people aged 40 and over, if:
they have 2 or more of the following unexplained symptoms, or
they have 1 or more of the following unexplained symptoms and have ever smoked, or
they have 1 or more of the following unexplained symptoms and have been exposed to asbestos:
cough
fatigue
shortness of breath
chest pain
weight loss
appetite loss. 
Consider an urgent chest Xray (to be done within 2 weeks) to assess for mesothelioma in people aged 40 and over with either:
finger clubbing or
chest signs compatible with pleural disease. 

# Upper gastrointestinal tract cancers

## Oesophageal cancer
Offer urgent, direct access upper gastrointestinal endoscopy (to be done within 2 weeks) to assess for oesophageal cancer in people:
with dysphagia or
aged 55 and over with weight loss and any of the following:
upper abdominal pain
reflux
dyspepsia. 
Consider non-urgent direct access upper gastrointestinal endoscopy to assess for oesophageal cancer in people with haematemesis. 
Consider nonurgent direct access upper gastrointestinal endoscopy to assess for oesophageal cancer in people aged 55 or over with:
treatmentresistant dyspepsia or
upper abdominal pain with low haemoglobin levels or
raised platelet count with any of the following:
nausea
vomiting
weight loss
reflux
dyspepsia
upper abdominal pain, or
nausea or vomiting with any of the following:
weight loss
reflux
dyspepsia
upper abdominal pain. 

## Pancreatic cancer
Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for pancreatic cancer if they are aged 40 and over and have jaundice. 
Consider an urgent direct access CT scan (to be done within 2 weeks), or an urgent ultrasound scan if CT is not available, to assess for pancreatic cancer in people aged 60 and over with weight loss and any of the following:
diarrhoea
back pain
abdominal pain
nausea
vomiting
constipation
newonset diabetes. 

## Stomach cancer
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for people with an upper abdominal mass consistent with stomach cancer. 
Offer urgent direct access upper gastrointestinal endoscopy (to be done within 2 weeks) to assess for stomach cancer in people:
with dysphagia or
aged 55 and over with weight loss and any of the following:
upper abdominal pain
reflux
dyspepsia. 
Consider nonurgent direct access upper gastrointestinal endoscopy to assess for stomach cancer in people with haematemesis. 
Consider nonurgent direct access upper gastrointestinal endoscopy to assess for stomach cancer in people aged 55 or over with:
treatmentresistant dyspepsia or
upper abdominal pain with low haemoglobin levels or
raised platelet count with any of the following:
nausea
vomiting
weight loss
reflux
dyspepsia
upper abdominal pain, or
nausea or vomiting with any of the following:
weight loss
reflux
dyspepsia
upper abdominal pain. 

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

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

# Lower gastrointestinal tract cancers

## Colorectal cancer
Refer adults using a suspected cancer pathway referral (for an appointment within 2 weeks) for colorectal cancer if:
they are aged 40 and over with unexplained weight loss and abdominal pain or
they are aged 50 and over with unexplained rectal bleeding or
they are aged 60 and over with:
irondeficiency anaemia or
changes in their bowel habit, or
tests show occult blood in their faeces. 
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for colorectal cancer in adults with a rectal or abdominal mass. 
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for colorectal cancer in adults aged under 50 with rectal bleeding and any of the following unexplained symptoms or findings:
abdominal pain
change in bowel habit
weight loss
irondeficiency anaemia. 
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 and over with unexplained:
abdominal pain or
weight loss, or
are aged under 60 with:
changes in their bowel habit or
iron-deficiency anaemia, or
are aged 60 and over and have anaemia even in the absence of iron deficiency. 

## Anal cancer
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for anal cancer in people with an unexplained anal mass or unexplained anal ulceration. 

# Breast cancer
Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for breast cancer if they are:
aged 30 and over and have an unexplained breast lump with or without pain or
aged 50 and over with any of the following symptoms in one nipple only:
discharge
retraction
-ther changes of concern. 
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for breast cancer in people:
with skin changes that suggest breast cancer or
aged 30 and over with an unexplained lump in the axilla. 
Consider non-urgent referral in people aged under 30 with an unexplained breast lump with or without pain. See also recommendations 1.16.2 and 1.16.3 for information about seeking specialist advice. 

# Gynaecological cancers

## Ovarian cancer
The recommendations in this section have been incorporated from NICE's guideline on ovarian cancer and have not been updated. The recommendations for ovarian cancer apply to women aged 18 and over.
Make an urgent referral to a gynaecological cancer service if physical examination identifies ascites and/or a pelvic or abdominal mass (which is not obviously uterine fibroids). 
Carry out tests in primary care (see recommendations 1.5.6 to 1.5.9) if a woman (especially if aged 50 or over) reports having any of the following symptoms on a persistent or frequent basis  particularly more than 12 times per month:
persistent abdominal distension (women often refer to this as 'bloating')
feeling full (early satiety) and/or loss of appetite
pelvic or abdominal pain
increased urinary urgency and/or frequency. 
Consider carrying out tests in primary care (see recommendations 1.5.6 to 1.5.9) if a woman reports unexplained weight loss, fatigue or changes in bowel habit. 
Advise any woman who is not suspected of having ovarian cancer to return to her GP if her symptoms become more frequent and/or persistent. 
Carry out appropriate tests for ovarian cancer (see recommendations 1.5.6 to 1.5.9) in any woman aged 50 or over who has experienced symptoms within the last 12 months that suggest irritable bowel syndrome (IBS), because IBS rarely presents for the first time in women of this age. (See NICE's guideline on irritable bowel syndrome in adults). 
Measure serum CA125 in primary care in women with symptoms that suggest ovarian cancer (see recommendations 1.5.1 to 1.5.5). 
If serum CA125 is 35 IU/ml or greater, arrange an ultrasound scan of the abdomen and pelvis. 
If the ultrasound suggests ovarian cancer, make an urgent referral to a gynaecological cancer service. 
For any woman who has normal serum CA125 (less than 35 IU/ml), or CA125 of 35 IU/ml or greater but a normal ultrasound:
assess her carefully for other clinical causes of her symptoms and investigate if appropriate
if no other clinical cause is apparent, advise her to return to her GP if her symptoms become more frequent and/or persistent. 

## Endometrial cancer
Refer women using a suspected cancer pathway referral (for an appointment within 2 weeks) for endometrial cancer if they are aged 55 and over with postmenopausal bleeding (unexplained vaginal bleeding more than 12 months after menstruation has stopped because of the menopause). 
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for endometrial cancer in women aged under 55 with postmenopausal bleeding. 
Consider a direct access ultrasound scan to assess for endometrial cancer in women aged 55 and over with:
unexplained symptoms of vaginal discharge who:
are presenting with these symptoms for the first time or
have thrombocytosis or
report haematuria, or
visible haematuria and:
low haemoglobin levels or
thrombocytosis, or
high blood glucose levels. 

## Cervical cancer
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for women if, on examination, the appearance of their cervix is consistent with cervical cancer. 

## Vulval cancer
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for vulval cancer in women with an unexplained vulval lump, ulceration or bleeding. 

## Vaginal cancer
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for vaginal cancer in women with an unexplained palpable mass in or at the entrance to the vagina. 

# Urological cancers

## Prostate cancer
Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for prostate cancer if their prostate feels malignant on digital rectal examination. 
Consider a prostatespecific antigen (PSA) test and digital rectal examination to assess for prostate cancer in people with:
any lower urinary tract symptoms, such as nocturia, urinary frequency, hesitancy, urgency or retention or
erectile dysfunction or
visible haematuria. 
Consider referring people with possible symptoms of prostate cancer, as specified in recommendation 1.6.2, using a suspected cancer pathway referral (for an appointment within 2 weeks) for prostate cancer if their PSA levels are above the threshold for their age in table 1. Take into account the person's preferences and any comorbidities when making the decision. 
Age (years)
Prostate-specific antigen threshold (micrograms/litre)
Below 40
Use clinical judgement
to 49
More than 2.5
to 59
More than 3.5
to 69
More than 4.5
to 79
More than 6.5
Above 79
Use clinical judgement
For a short explanation of why the committee made the 2021 recommendation and how it might affect practice, see the rationale and impact section on PSA testing for prostate cancer .
Full details of the evidence and the committee's discussion are in evidence review A: PSA testing for prostate cancer.
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## Bladder cancer
Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for bladder cancer if they are:
aged 45 and over and have:
unexplained visible haematuria without urinary tract infection or
visible haematuria that persists or recurs after successful treatment of urinary tract infection, or
aged 60 and over and have unexplained nonvisible haematuria and either dysuria or a raised white cell count on a blood test. 
Consider non-urgent referral for bladder cancer in people aged 60 and over with recurrent or persistent unexplained urinary tract infection. 

## Renal cancer
Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for renal cancer if they are aged 45 and over and have:
unexplained visible haematuria without urinary tract infection or
visible haematuria that persists or recurs after successful treatment of urinary tract infection. 

## Testicular cancer
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for testicular cancer in men if they have a nonpainful enlargement or change in shape or texture of the testis. 
Consider a direct access ultrasound scan for testicular cancer in men with unexplained or persistent testicular symptoms. 

## Penile cancer
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for penile cancer in men if they have:
a penile mass or ulcerated lesion, when a sexually transmitted infection has been excluded as a cause, or
a persistent penile lesion after treatment for a sexually transmitted infection has been completed. 
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for penile cancer in men with unexplained or persistent symptoms affecting the foreskin or glans. 

# Skin cancers

## Malignant melanoma of the skin
Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for melanoma if they have a suspicious pigmented skin lesion with a weighted 7point checklist score of 3 or more. 
Major features of the lesions (scoring 2 points each):
change in size
irregular shape
irregular colour.
Minor features of the lesions (scoring 1 point each):
largest diameter 7 mm or more
inflammation
-ozing
change in sensation.
Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) if dermoscopy suggests melanoma of the skin. 
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for melanoma in people with a pigmented or nonpigmented skin lesion that suggests nodular melanoma. 

## Squamous cell carcinoma
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for people with a skin lesion that raises the suspicion of squamous cell carcinoma. 

## Basal cell carcinoma
Consider routine referral for people if they have a skin lesion that raises the suspicion of a basal cell carcinoma. (Typical features of basal cell carcinoma include: an ulcer with a raised rolled edge; prominent fine blood vessels around a lesion; or a nodule on the skin .) 
Only consider a suspected cancer pathway referral (for an appointment within 2 weeks) for people with a skin lesion that raises the suspicion of a basal cell carcinoma if there is particular concern that a delay may have a significant impact, because of factors such as lesion site or size. 
Follow NICE's guidance on improving outcomes for people with skin tumours including melanoma for advice on who should excise suspected basal cell carcinomas. 

# Head and neck cancers

## Laryngeal cancer
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for laryngeal cancer in people aged 45 and over with:
persistent
                unexplained hoarseness or
an unexplained lump in the neck. 

## Oral cancer
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for oral cancer in people with either:
unexplained ulceration in the oral cavity lasting for more than 3 weeks or
a persistent and unexplained lump in the neck. 
Consider an urgent referral (for an appointment within 2 weeks) for assessment for possible oral cancer by a dentist in people who have either:
a lump on the lip or in the oral cavity or
a red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia. 
Consider a suspected cancer pathway referral by the dentist (for an appointment within 2 weeks) for oral cancer in people when assessed by a dentist as having either:
a lump on the lip or in the oral cavity consistent with oral cancer or
a red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia. 

## Thyroid cancer
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for thyroid cancer in people with an unexplained thyroid lump. 

# Brain and central nervous system cancers

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

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

# Haematological cancers

## Leukaemia in adults
Consider a very urgent full blood count (within 48 hours) to assess for leukaemia in adults with any of the following:
pallor
persistent fatigue
unexplained fever
unexplained persistent or recurrent infection
generalised lymphadenopathy
unexplained bruising
unexplained bleeding
unexplained petechiae
hepatosplenomegaly. 

## Leukaemia in children and young people
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) to assess for leukaemia in children and young people with any of the following:
pallor
persistent fatigue
unexplained fever
unexplained persistent infection
generalised lymphadenopathy
persistent or unexplained bone pain
unexplained bruising
unexplained bleeding. 

## Myeloma
Offer a full blood count and blood tests for calcium and plasma viscosity or erythrocyte sedimentation rate to assess for myeloma in people aged 60 and over with persistent bone pain, particularly back pain, or unexplained fracture. 
Offer very urgent protein electrophoresis and a BenceJones protein urine test (within 48 hours) to assess for myeloma in people aged 60 and over with hypercalcaemia or leukopenia and a presentation that is consistent with possible myeloma. 
Consider very urgent protein electrophoresis and a BenceJones protein urine test (within 48 hours) to assess for myeloma if the plasma viscosity or erythrocyte sedimentation rate and presentation are consistent with possible myeloma. 
Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) if the results of protein electrophoresis or a BenceJones protein urine test suggest myeloma. 

## Non-Hodgkin's lymphoma
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.
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for nonHodgkin's lymphoma in adults presenting with unexplained lymphadenopathy or splenomegaly. When considering referral, take into account any associated symptoms, particularly fever, night sweats, shortness of breath, pruritus or weight loss. 
Consider a very urgent referral (for an appointment within 48 hours) for specialist assessment for nonHodgkin's lymphoma in children and young people presenting with unexplained lymphadenopathy or splenomegaly. When considering referral, take into account any associated symptoms, particularly fever, night sweats, shortness of breath, pruritus or weight loss. 

## Hodgkin's lymphoma
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.
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for Hodgkin's lymphoma in adults presenting with unexplained lymphadenopathy. When considering referral, take into account any associated symptoms, particularly fever, night sweats, shortness of breath, pruritus, weight loss or alcoholinduced lymph node pain. 
Consider a very urgent referral (for an appointment within 48 hours) for specialist assessment for Hodgkin's lymphoma in children and young people presenting with unexplained lymphadenopathy. When considering referral, take into account any associated symptoms, particularly fever, night sweats, shortness of breath, pruritus or weight loss. 

# Sarcomas
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.

## Bone sarcoma in adults
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for adults if an Xray suggests the possibility of bone sarcoma. 

## Bone sarcoma in children and young people
Consider a very urgent referral (for an appointment within 48 hours) for specialist assessment for children and young people if an Xray suggests the possibility of bone sarcoma. 
Consider a very urgent direct access Xray (to be done within 48 hours) to assess for bone sarcoma in children and young people with unexplained bone swelling or pain. 

## Soft tissue sarcoma in adults
Consider an urgent direct access ultrasound scan (to be done within 2 weeks) to assess for soft tissue sarcoma in adults with an unexplained lump that is increasing in size. 
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for adults if they have ultrasound scan findings that are suggestive of soft tissue sarcoma or if ultrasound findings are uncertain and clinical concern persists. 

## Soft tissue sarcoma in children and young people
Consider a very urgent direct access ultrasound scan (to be done within 48 hours) to assess for soft tissue sarcoma in children and young people with an unexplained lump that is increasing in size. 
Consider a very urgent referral (for an appointment within 48 hours) for children and young people if they have ultrasound scan findings that are suggestive of soft tissue sarcoma or if ultrasound findings are uncertain and clinical concern persists. 

# Childhood cancers
NICE has published a guideline on babies, children and young people's experience of healthcare.

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

## Retinoblastoma
Consider urgent referral (for an appointment within 2 weeks) for ophthalmological assessment for retinoblastoma in children with an absent red reflex. If there is new-onset squint that occurs together with an absent red reflex, see the recommendation on new-onset squint with loss of red reflex in NICE's guideline on suspected neurological conditions. 

## Wilms' tumour
Consider very urgent referral (for an appointment within 48 hours) for specialist assessment for Wilms' tumour in children with any of the following:
a palpable abdominal mass
an unexplained enlarged abdominal organ
unexplained visible haematuria. 

# Non-site-specific symptoms
Some symptoms or symptom combinations may be features of several different cancers. For some of these symptoms, the risk for each individual cancer may be low but the total risk of cancer of any type may be higher. This section includes recommendations for these symptoms.

## Symptoms of concern in children and young people
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. 

## Symptoms of concern in adults
For people with unexplained weight loss, which is a symptom of several cancers including colorectal, gastrooesophageal, lung, prostate, pancreatic and urological cancer:
carry out an assessment for additional symptoms, signs or findings that may help to clarify which cancer is most likely and
-ffer urgent investigation or a suspected cancer pathway referral (for an appointment within 2 weeks). 
For people with unexplained appetite loss, which is a symptom of several cancers including lung, oesophageal, stomach, colorectal, pancreatic, bladder and renal cancer:
carry out an assessment for additional symptoms, signs or findings that may help to clarify which cancer is most likely and
-ffer urgent investigation or a suspected cancer pathway referral (for an appointment within 2 weeks). 
For people with deep vein thrombosis, which is associated with several cancers including urogenital, breast, colorectal and lung cancer:
carry out an assessment for additional symptoms, signs or findings that may help to clarify which cancer is most likely and
consider urgent investigation or a suspected cancer pathway referral (for an appointment within 2 weeks). # Recommendations on patient support, safety netting and the diagnostic process
Use this guideline to guide referrals. If still uncertain about whether a referral is needed, consider contacting a specialist (see the recommendations on the diagnostic process). Consider a review for people with any symptom associated with increased cancer risk who do not meet the criteria for referral or investigative action (see the recommendations on safety netting).

# Patient information and support
Discuss with people with suspected cancer (and their carers as appropriate, taking account of the need for confidentiality) their preferences for being involved in decisionmaking about referral options and further investigations including their potential risks and benefits. 
When cancer is suspected in a child, discuss the referral decision and information to be given to the child with the parents or carers (and the child if appropriate). 
Explain to people who are being referred with suspected cancer that they are being referred to a cancer service. Reassure them, as appropriate, that most people referred will not have a diagnosis of cancer, and discuss alternative diagnoses with them. 
Give the person information on the possible diagnosis (both benign and malignant) in accordance with their wishes for information (see also NICE's guideline on patient experience in adult NHS services). 
The information given to people with suspected cancer and their families and/or carers should cover, among other issues:
where the person is being referred to
how long they will have to wait for the appointment
how to obtain further information about the type of cancer suspected or help before the specialist appointment
what to expect from the service the person will be attending
what type of tests may be carried out, and what will happen during diagnostic procedures
how long it will take to get a diagnosis or test results
whether they can take someone with them to the appointment
who to contact if they do not receive confirmation of an appointment
-ther sources of support. 
Provide information that is appropriate for the person in terms of language, ability and culture, recognising the potential for different cultural meanings associated with the possibility of cancer. 
Have information available in a variety of formats on both local and national sources of information and support for people who are being referred with suspected cancer. For more information on information sharing, see the section on enabling patients to actively participate in their care in NICE's guideline on patient experience in adult NHS services. 
Reassure people in the safety netting group (see recommendation 1.15.2) who are concerned that they may have cancer that with their current symptoms their risk of having cancer is low. 
Explain to people who are being offered safety netting (see recommendation 1.15.2) which symptoms to look out for and when they should return for reevaluation. It may be appropriate to provide written information. 
When referring a person with suspected cancer to a specialist service, assess their need for continuing support while waiting for their referral appointment. This should include inviting the person to contact their healthcare professional again if they have more concerns or questions before they see a specialist. 
If the person has additional support needs because of their personal circumstances, inform the specialist (with the person's agreement). 

# Safety netting
Ensure that the results of investigations are reviewed and acted upon appropriately, with the healthcare professional who ordered the investigation taking or explicitly passing on responsibility for this. Be aware of the possibility of falsenegative results for chest Xrays and tests for occult blood in faeces. 
Consider a review for people with any symptom that is associated with an increased risk of cancer, but who do not meet the criteria for referral or other investigative action. The review may be:
planned within a time frame agreed with the person or
patientinitiated if new symptoms develop, the person continues to be concerned, or their symptoms recur, persist or worsen. 

# The diagnostic process
Take part in continuing education, peer review and other activities to improve and maintain clinical consulting, reasoning and diagnostic skills, in order to identify at an early stage people who may have cancer, and to communicate the possibility of cancer to the person. 
Discussion with a specialist (for example, by telephone or email) should be considered if there is uncertainty about the interpretation of symptoms and signs, and whether a referral is needed. This may also enable the primary healthcare professional to communicate their concerns and a sense of urgency to secondary healthcare professionals when symptoms are not classical. 
Put in place local arrangements to ensure that letters about non-urgent referrals are assessed by the specialist, so that the person can be seen more urgently if necessary. 
Put in place local arrangements to ensure that there is a maximum waiting period for nonurgent referrals, in accordance with national targets and local arrangements. 
Ensure local arrangements are in place to identify people who miss their appointments so that they can be followed up. 
Include all appropriate information in referral correspondence, including whether the referral is urgent or nonurgent. 
Use local referral proformas if these are in use. 
Once the decision to refer has been made, make sure that the referral is made within 1 working day. # Recommendations organised by symptom and findings of primary care investigations
The recommendations in this section are displayed alphabetically by symptom then in order of urgency of the action needed, to make sure that the most urgent actions are not missed. Where there are several recommendations relating to the same cancer these have been grouped for ease of reference. Occasionally the same symptom may suggest more than one cancer site. In such instances the recommendations are displayed together and the GP should use their clinical judgement to decide on the most appropriate action.
Use this guideline to guide referrals. If still uncertain about whether a referral is needed, consider contacting a specialist (see the recommendations on the diagnostic process). Consider a review for people with any symptom associated with increased cancer risk who do not meet the criteria for referral or investigative action (see the recommendations on safety netting).

# Abdominal symptoms
See also the section on bleeding for recommendations on rectal bleeding.
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 
Measure serum CA125 in primary care 
See the section on primary care investigations for more information on tests for ovarian cancer
These recommendations apply to women aged 18 and over
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
Urgent referral 
These recommendations apply to women aged 18 and over
Symptom and specific features
Possible cancer
Recommendation
Abdominal or pelvic mass identified by physical examination (which is not obviously uterine fibroids) in women
Ovarian
Urgent referral 
These recommendations apply to women aged 18 and over
Abdominal or rectal mass
Colorectal
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) 
Splenomegaly (unexplained) in adults
NonHodgkin's lymphoma
Consider a suspected cancer pathway referral (for an appointment within 2 weeks). When considering referral, take into account any associated symptoms, particularly fever, night sweats, shortness of breath, pruritus or weight loss 
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 (for an appointment within 2 weeks) 
Upper abdominal mass consistent with an enlarged gall bladder
Gall bladder
Consider an urgent direct access ultrasound scan (to be done within 2 weeks) 
Upper abdominal mass consistent with an enlarged liver
Liver
Consider an urgent direct access ultrasound scan (to be done within 2 weeks) 
Hepatosplenomegaly
Leukaemia
Consider a very urgent full blood count (within 48 hours) 
Symptom and specific features
Possible cancer
Recommendation
Abdominal pain with weight loss (unexplained), 40 and over
Colorectal
Refer adults using a suspected cancer pathway referral (for an appointment within 2 weeks) 
Abdominal pain (unexplained) with rectal bleeding in adults under 50
Colorectal
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) 
Abdominal pain (unexplained) without rectal bleeding, 50 and over
Colorectal
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) 
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)  
Upper abdominal pain with low haemoglobin levels or raised platelet count or nausea or vomiting, 55 and over
Oesophageal or stomach
Consider nonurgent direct access upper gastrointestinal endoscopy  
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 
Measure serum CA125 in primary care 
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 
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 
Measure serum CA125 in primary care 
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.
Symptom and specific features
Possible cancer
Recommendation
Change in bowel habit (unexplained), 60 and over
Colorectal
Refer adults using a suspected cancer pathway referral (for an appointment within 2 weeks) 
Change in bowel habit (unexplained) with rectal bleeding, in adults under 50
Colorectal
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) 
Change in bowel habit without rectal bleeding, adults under 60
Colorectal
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) 
Change in bowel habit (unexplained) in women
Ovarian
Consider carrying out tests in primary care 
Measure serum CA125 in primary care 
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 
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 
Measure serum CA125 in primary care 
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
Symptom and specific features
Possible cancer
Recommendation
Dyspepsia (treatmentresistant), 55 and over
Oesophageal or stomach
Consider nonurgent direct access upper gastrointestinal endoscopy  
Dyspepsia
Dyspepsia with weight loss, 55 and over
Oesophageal or stomach
Offer urgent direct access upper gastrointestinal endoscopy (to be done within 2 weeks)  
Dyspepsia with raised platelet count or nausea or vomiting, 55 and over
Oesophageal or stomach
Consider nonurgent direct access upper gastrointestinal endoscopy  
Symptom and specific features
Possible cancer
Recommendation
Dysphagia
Oesophageal or stomach
Offer urgent direct access upper gastrointestinal endoscopy (to be done within 2 weeks) 
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 
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 nonurgent direct access upper gastrointestinal endoscopy  
Symptom and signs
Possible cancer
Recommendation
Prostate feels malignant on digital rectal examination, in men
Prostate
Refer men using a suspected cancer pathway referral (for an appointment within 2 weeks) 
Anal mass or anal ulceration (unexplained)
Anal
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) 
Rectal
                mass
Colorectal
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) 
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)  
Reflux with raised platelet count or nausea or vomiting, 55 and over
Oesophageal or stomach
Consider nonurgent direct access upper gastrointestinal endoscopy  

# Bleeding
See also:
the section on urological symptoms for haematuria
the section on primary care investigations for faecal occult blood.
Symptom and specific features
Possible cancer
Recommendation
Bleeding, bruising or petechiae (unexplained)
Leukaemia
Consider a very urgent full blood count (within 48 hours) 
Symptom and specific features
Possible cancer
Recommendation
Haematemesis
Oesophageal or stomach
Consider non-urgent, direct access upper gastrointestinal endoscopy  
Symptom and specific features
Possible cancer
Recommendation
Haemoptysis (unexplained), 40 and over
Lung
Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) 
Symptom and specific features
Possible cancer
Recommendation
Postmenopausal bleeding in women 55 and over
Endometrial
Refer women using a suspected cancer pathway referral (for an appointment within 2 weeks) 
Postmenopausal bleeding in women under 55
Endometrial
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) 
Postmenopausal bleeding is unexplained vaginal bleeding more than 12 months after menstruation has stopped because of the menopause.
Symptom and specific features
Possible cancer
Recommendation
Rectal bleeding (unexplained), 50 and over
Colorectal
Refer adults using a suspected cancer pathway referral (for an appointment within 2 weeks) 
Rectal bleeding with abdominal pain or change in bowel habit or weight loss or irondeficiency anaemia in adults under 50
Colorectal
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) 
Symptom and specific features
Possible cancer
Recommendation
Vulval bleeding (unexplained) in women
Vulval
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) 

# Gynaecological symptoms
See also the section on bleeding for postmenopausal (vaginal) bleeding
Symptom and signs
Possible cancer
Recommendation
Appearance of cervix
                consistent with cervical cancer
Cervical
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) 
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 
Vaginal mass (unexplained and palpable) in or at the entrance to the vagina
Vaginal
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) 
Symptom and specific features
Possible cancer
Recommendation
Vulval bleeding (unexplained)
Vulval
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) 
Vulval lump or ulceration (unexplained)
Vulval
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) 

# Lumps or masses
Symptom and specific features
Possible cancer
Recommendation
Anal mass (unexplained)
Anal
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) 
Axillary lump (unexplained), 30 and over
Breast
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) 
Breast lump (unexplained) with or without pain, 30 and over
Breast
Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) 
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 
Lip or oral cavity
                lump
Oral
Consider an urgent referral (for an appointment within 2 weeks) for assessment by a dentist 
Consider a suspected cancer pathway referral by the dentist (for an appointment within 2 weeks) in people when assessed by a dentist as having a lump on the lip or in the oral cavity consistent with oral cancer 
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) 
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 (for an appointment within 2 weeks) 
Neck lump (persistent and unexplained)
Oral
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) 
Penile mass (and sexually transmitted infection has been excluded as a cause) in men
Penile
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) 
Thyroid lump (unexplained)
Thyroid
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) 
Vaginal mass (unexplained and palpable) in or at the entrance to the vagina in women
Vaginal
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) 
Vulval lump (unexplained) in women
Vulval
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) 
See also the section on abdominal symptoms for abdominal, anal, pelvic and rectal lumps or masses.
Symptom and specific features
Possible cancer
Recommendation
Lymphadenopathy (unexplained) in adults
NonHodgkin's lymphoma or Hodgkin's lymphoma
Consider a suspected cancer pathway referral (for an appointment within 2 weeks)
When considering referral for Hodgkin's lymphoma, take into account any associated symptoms, particularly fever, night sweats, shortness of breath, pruritus, weight loss or alcoholinduced lymph node pain 
When considering referral for nonHodgkin's lymphoma, take into account any associated symptoms, particularly fever, night sweats, shortness of breath, pruritus or weight loss 
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 Xray (to be done within 2 weeks) 
Lymphadenopathy (generalised) in adults
Leukaemia
Consider a very urgent full blood count (within 48 hours) 
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 (for an appointment within 2 weeks) 
Lip or oral cavity lump
Oral
Consider an urgent referral (for an appointment within 2 weeks) for assessment by a dentist 
Consider a suspected cancer pathway referral by the dentist (for an appointment within 2 weeks) in people when assessed by a dentist as having a lump on the lip or in the oral cavity consistent with oral cancer 

# Neurological symptoms in adults
Symptom and specific features
Possible cancer
Recommendation
Loss of central neurological function (progressive, subacute) 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) 

# Pain
See also the section on abdominal symptoms for abdominal or pelvic pain.
Symptom and specific features
Possible cancer
Recommendation
Alcoholinduced lymph node pain with unexplained lymphadenopathy in adults
Hodgkin's lymphoma
Consider a suspected cancer pathway referral (for an appointment within 2 weeks). When considering referral, take into account any associated symptoms 
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 
Back pain (persistent), 60 and over
Myeloma
Offer a full blood count and blood tests for calcium and plasma viscosity or erythrocyte sedimentation rate 
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 
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 Xray (to be done within 2 weeks)  
Chest pain (unexplained), 40 and over, exposed to asbestos
Mesothelioma
Offer an urgent chest Xray (to be done within 2 weeks) 
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 Xray (to be done within 2 weeks)  

# Respiratory symptoms
Symptom and specific features
Possible cancer
Recommendation
Chest infection (persistent or recurrent), 40 and over
Lung
Consider an urgent chest Xray (to be done within 2 weeks) 
Symptom and specific features
Possible cancer
Recommendation
Chest pain (unexplained), 40 and over, ever smoked
Lung or mesothelioma
Offer an urgent chest Xray (to be done within 2 weeks)  
Chest pain (unexplained), 40 and over, exposed to asbestos
Mesothelioma
Offer an urgent chest Xray (to be done within 2 weeks) 
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 Xray (to be done within 2 weeks)  
Symptom and specific features
Possible cancer
Recommendation
Cough (unexplained), 40 and over, ever smoked
Lung or mesothelioma
Offer an urgent chest Xray (to be done within 2 weeks)  
Cough (unexplained), 40 and over, exposed to asbestos
Mesothelioma
Offer an urgent chest Xray (to be done within 2 weeks) 
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 Xray (to be done within 2 weeks)  
Symptom and specific features
Possible cancer
Recommendation
Hoarseness (persistent and unexplained), 45 and over
Laryngeal
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) 
Symptom and signs
Possible cancer
Recommendation
Chest signs
                consistent with lung cancer, 40 and over
Lung
Consider an urgent chest Xray (to be done within 2 weeks) 
Chest signs compatible with pleural disease, 40 and over
Mesothelioma
Consider an urgent chest Xray (to be done within 2 weeks) 
Finger clubbing, 40 and over
Lung or mesothelioma
Consider an urgent chest Xray (to be done within 2 weeks)  
Symptom and specific features
Possible cancer
Recommendation
Shortness of breath (unexplained), 40 and over, ever smoked
Lung or mesothelioma
Offer an urgent chest Xray (to be done within 2 weeks)  
Shortness of breath (unexplained), 40 and over, and exposed to asbestos
Mesothelioma
Offer an urgent chest Xray (to be done within 2 weeks) 
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 Xray (to be done within 2 weeks)  
Shortness of breath with unexplained lymphadenopathy in adults
NonHodgkin's lymphoma or Hodgkin's lymphoma
Consider a suspected cancer pathway referral (for an appointment within 2 weeks). When considering referral, take into account any associated symptoms 
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
NonHodgkin's lymphoma
Consider a suspected cancer pathway referral (for an appointment within 2 weeks). When considering referral, take into account any associated symptoms 
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
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 
Back pain (persistent), 60 and over
Myeloma
Offer a full blood count and blood tests for calcium and plasma viscosity or erythrocyte sedimentation rate 
See the section on primary care investigations for more information on tests for myeloma
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 
See the section on primary care investigations for more information on tests for myeloma
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 
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.
Symptoms and signs
Possible cancer
Recommendation
Anal ulceration (unexplained)
Anal
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) 
Bruising (unexplained) in adults
Leukaemia
Consider a very urgent full blood count (within 48 hours) 
Nipple changes of concern (in one nipple only) including discharge and retraction, 50 and over
Breast
Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) 
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 
Consider a suspected cancer pathway referral by the dentist (for an appointment within 2 weeks) 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 
Pallor
Leukaemia
Consider a very urgent full blood count (within 48 hours) 
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 (for an appointment within 2 weeks) 
Penile mass (and sexually transmitted infection has been excluded as a cause) in men
Penile
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) 
Penile symptoms
                affecting the foreskin or glans (unexplained or persistent) in men
Penile
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) 
Petechiae (unexplained) in adults
Leukaemia
Consider a very urgent full blood count (within 48 hours) 
Pruritus with unexplained splenomegaly in adults
NonHodgkin's lymphoma
Consider a suspected cancer pathway referral (for an appointment within 2 weeks). When considering referral, take into account any associated symptoms 
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 nonHodgkin's lymphoma
Consider a suspected cancer pathway referral (for an appointment within 2 weeks). When considering referral, take into account any associated symptoms 
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 (for an appointment within 2 weeks) 
Skin lesion (pigmented and suspicious) with a weighted 7point checklist score of 3 or more
Melanoma
Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) 
Skin lesion (pigmented or nonpigmented) that suggests nodular melanoma
Melanoma
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) 
Skin lesion that raises the suspicion of a squamous cell carcinoma
Squamous cell carcinoma
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) 
Skin lesion that raises the suspicion of a basal cell carcinoma
Basal cell carcinoma
Consider routine referral 
Only consider a suspected cancer pathway referral (for an appointment within 2 weeks) if there is particular concern that a delay may have a significant impact, because of factors such as lesion site or size 
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 (for an appointment within 2 weeks) 

# Urological symptoms
Symptom and specific features
Possible cancer
Recommendation
Dysuria with unexplained nonvisible haematuria, 60 and over
Bladder
Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) 
Symptom and specific features
Possible cancer
Recommendation
Erectile dysfunction in men
Prostate
Consider a prostatespecific antigen (PSA) test and digital rectal examination 
See the section on primary care investigations for more information on PSA tests and digital rectal examination
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 (for an appointment within 2 weeks)  
Haematuria (nonvisible 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 (for an appointment within 2 weeks) 
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 
Haematuria (visible) in men
Prostate
Consider a prostatespecific antigen (PSA) test and digital rectal examination 
See the section on primary care investigations for more information on PSA tests and digital rectal examination
Symptom and specific features
Possible cancer
Recommendation
Testis enlargement or change in shape or texture (nonpainful) in men
Testicular
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) 
Testicular symptoms (unexplained or persistent) in men
Testicular
Consider a direct access ultrasound scan 
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 
Lower urinary tract symptoms, such as nocturia, urinary frequency, hesitancy, urgency or retention in men
Prostate
Consider a prostatespecific antigen (PSA) test and digital rectal examination 
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 
Measure serum CA125 in primary care 
See the section on primary care investigations for information on tests for ovarian cancer
These recommendations apply to women aged 18 and over

# Nonspecific features of cancer
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 (for an appointment within 2 weeks) 
Appetite loss (unexplained), 40 and over, ever smoked
Lung or mesothelioma
Offer an urgent chest Xray (to be done within 2 weeks)  
Appetite loss (unexplained), 40 and over, exposed to asbestos
Mesothelioma
Offer an urgent chest Xray (to be done within 2 weeks) 
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 Xray (to be done within 2 weeks)  
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 
Measure serum CA125 in primary care 
See the section on primary care investigations for information on tests for ovarian cancer
These recommendations apply to women aged 18 and over
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 (for an appointment within 2 weeks) 
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 
Symptom and specific features
Possible cancer
Recommendation
Fatigue (unexplained), 40 and over, ever smoked
Lung or mesothelioma
Offer an urgent chest Xray (to be done within 2 weeks)  
Fatigue (unexplained), 40 and over, exposed to asbestos
Mesothelioma
Offer an urgent chest Xray (to be done within 2 weeks) 
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 Xray (to be done within 2 weeks)  
Fatigue (persistent) in adults
Leukaemia
Consider a very urgent full blood count (within 48 hours) 
Fatigue (unexplained) in women
Ovarian
Carry out tests in primary care 
Measure serum CA125 in primary care 
See the section on primary care investigations for information on tests for ovarian cancer
These recommendations apply to women aged 18 and over
Symptom and specific features
Possible cancer
Recommendation
Fever (unexplained)
Leukaemia
Consider a very urgent full blood count (within 48 hours) 
Fever with unexplained splenomegaly in adults
NonHodgkin's lymphoma
Consider a suspected cancer pathway referral (for an appointment within 2 weeks). When considering referral, take into account any associated symptoms 
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 nonHodgkin's lymphoma
Consider a suspected cancer pathway referral (for an appointment within 2 weeks). When considering referral, take into account any associated symptoms 
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.
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) 
Symptom and specific features
Possible cancer
Recommendation
Night sweats with unexplained splenomegaly in adults
NonHodgkin's lymphoma
Consider a suspected cancer pathway referral (for an appointment within 2 weeks). When considering referral, take into account any associated symptoms 
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 NonHodgkin's lymphoma
Consider a suspected cancer pathway referral (for an appointment within 2 weeks). When considering referral, take into account any associated symptoms 
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
Symptom and specific features
Possible cancer
Recommendation
Pallor
Leukaemia
Consider a very urgent full blood count (within 48 hours) 
Symptom and specific features
Possible cancer
Recommendation
Pruritus with unexplained splenomegaly in adults
NonHodgkin's lymphoma
Consider a suspected cancer pathway referral (for an appointment within 2 weeks). When considering referral, take into account any associated symptoms 
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 nonHodgkin's lymphoma
Consider a suspected cancer pathway referral (for an appointment within 2 weeks). When considering referral, take into account any associated symptoms 
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
Symptom and specific features
Possible cancer
Recommendation
Weight loss (unexplained)
Several, including colorectal, gastrooesophageal, 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 (for an appointment within 2 weeks) 
Weight loss (unexplained) with abdominal pain, 40 and over
Colorectal
Refer adults using a suspected cancer pathway referral (for an appointment within 2 weeks) 
Weight loss (unexplained) with rectal bleeding in adults under 50
Colorectal
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) 
Weight loss (unexplained) without rectal bleeding, 50 and over
Colorectal
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) 
Weight loss (unexplained), 40 and over, ever smoked
Lung or mesothelioma
Offer an urgent chest Xray (to be done within 2 weeks)  
Weight loss (unexplained), 40 and over, exposed to asbestos
Mesothelioma
Offer an urgent chest Xray (to be done within 2 weeks) 
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 Xray (to be done within 2 weeks)  
Weight loss with unexplained splenomegaly in adults
NonHodgkin's lymphoma
Consider a suspected cancer pathway referral (for an appointment within 2 weeks). When considering referral, take into account any associated symptoms 
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 nonHodgkin's lymphoma
Consider a suspected cancer pathway referral (for an appointment within 2 weeks). When considering referral, take into account any associated symptoms  
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)  
Weight loss (unexplained) in women
Ovarian
Consider carrying out tests in primary care 
Measure serum CA125 in primary care 
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 newonset 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 
Weight loss with raised platelet count or nausea or vomiting, 55 and over
Oesophageal or stomach
Consider non-urgent direct access upper gastrointestinal endoscopy  

# Primary care investigations
Investigation findings and specific features
Possible cancer
Recommendation
Anaemia (irondeficiency), 60 and over
Colorectal
Refer adults using a suspected cancer pathway referral (for an appointment within 2 weeks) 
Anaemia (irondeficiency, unexplained) with rectal bleeding in adults under 50
Colorectal
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) 
Anaemia (iron deficiency) without rectal bleeding, adults under 60
Colorectal
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) 
Anaemia (non-iron-deficiency), without rectal bleeding, 60 and over
Colorectal
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) 
Blood glucose levels high with visible haematuria in women 55 and over
Endometrial
Consider a direct access ultrasound scan 
Diabetes (newonset) 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 
Haemoglobin levels low with visible haematuria in women 55 and over
Endometrial
Consider a direct access ultrasound scan 
Haemoglobin levels low with upper abdominal pain, 55 and over
Oesophageal or stomach
Consider non-urgent direct access upper gastrointestinal endoscopy  
Hypercalcaemia or leukopenia and presentation consistent with possible myeloma, 60 and over
Myeloma
Offer very urgent protein electrophoresis and a BenceJones protein urine test (within 48 hours) 
Plasma viscosity or erythrocyte sedimentation rate and presentation consistent with possible myeloma
Myeloma
Consider very urgent protein electrophoresis and a BenceJones protein urine test (within 48 hours) 
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 nonurgent direct access upper gastrointestinal endoscopy  
Prostatespecific antigen
                levels above the agespecific 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 (for an appointment within 2 weeks) 
Protein electrophoresis suggests myeloma
Myeloma
Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) 
Serum CA125 results
Ovarian
If serum CA125 is 35 IU/ml or greater, arrange an ultrasound scan of the abdomen and pelvis 
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. 
These recommendations apply to women aged 18 and over
Thrombocytosis, 40 and over
Lung
Consider an urgent chest Xray (to be done within 2 weeks) 
Thrombocytosis with visible haematuria or vaginal discharge (unexplained) in women 55 and over
Endometrial
Consider a direct access ultrasound scan 
White cell count raised on a blood test with unexplained nonvisible haematuria, 60 and over
Bladder
Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) 
Investigation findings and specific features
Possible cancer
Recommendation
Dermoscopy suggests melanoma of the skin
Melanoma
Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) 
Examination findings and specific features
Possible cancer
Recommendation
Prostate feels malignant on digital rectal examination
Prostate
Refer men using a suspected cancer pathway referral (for an appointment within 2 weeks) 
Investigation findings and specific features
Possible cancer
Recommendation
Occult blood in faeces
Colorectal
Refer adults using a suspected cancer pathway referral (for an appointment within 2 weeks) 
Investigation findings and specific features
Possible cancer
Recommendation
Chest Xray suggests lung cancer
Lung
Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) 
Chest Xray suggests mesothelioma
Mesothelioma
Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) 
Ultrasound suggests ovarian cancer
Ovarian
Make an urgent referral for further investigation 
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 
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 (for an appointment within 2 weeks) 
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
Xray suggests the possibility of bone sarcoma in adults
Bone sarcoma
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) 
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
Investigation findings and specific features
Possible cancer
Recommendation
Jaundice, 40 and over
Pancreatic
Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) 
Investigation findings and specific features
Possible cancer
Recommendation
BenceJones protein urine results suggest myeloma
Myeloma
Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) 

# Symptoms in children and young people
Symptom and specific features
Possible cancer
Recommendation
Hepatosplenomegaly (unexplained) in children and young people
Leukaemia
Refer for immediate specialist assessment 
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  
Splenomegaly (unexplained) in children and young people
NonHodgkin'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 
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
Symptom and specific features
Possible cancer
Recommendation
Petechiae (unexplained) in children and young people
Leukaemia
Refer for immediate specialist assessment 
Bleeding or bruising (unexplained) in children and young people
Leukaemia
Offer a very urgent full blood count (within 48 hours) 
Symptom and specific features
Possible cancer
Recommendation
Lymphadenopathy (unexplained) in children and young people
NonHodgkin'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  
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) 
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) 
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.
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) 
Symptom and specific features
Possible cancer
Recommendation
Shortness of breath with lymphadenopathy in children and young people
NonHodgkin'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  
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
NonHodgkin'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 
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
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) 
Bone pain (unexplained) in children and young people
Bone sarcoma
Consider a very urgent direct access Xray (to be done within 48 hours) 
See the section on primary care investigations for more information on Xrays
Bone swelling (unexplained) in children and young people
Bone sarcoma
Consider a very urgent direct access Xray (to be done within 48 hours) 
See the section on primary care investigations for more information on Xrays
Symptom and specific features
Possible cancer
Recommendation
Petechiae (unexplained) in children and young people
Leukaemia
Refer for immediate specialist assessment 
Bruising (unexplained) in children and young people
Leukaemia
Offer a very urgent full blood count (within 48 hours) 
Pallor in children and young people
Leukaemia
Offer a very urgent full blood count (within 48 hours) 
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 
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) 
Fever with lymphadenopathy (unexplained) in children and young people
NonHodgkin'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  
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
NonHodgkin'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 
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) 
Infection (unexplained and persistent) in children and young people
Leukaemia
Offer a very urgent full blood count (within 48 hours) 
Lymphadenopathy (unexplained) in children and young people
NonHodgkin'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  
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) 
Night sweats with lymphadenopathy (unexplained) in children and young people
NonHodgkin'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  
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
NonHodgkin'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 
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
NonHodgkin'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  
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
NonHodgkin'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 
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
NonHodgkin'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  
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
NonHodgkin'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 
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
Examination findings and specific features
Possible cancer
Recommendation
Absent red reflex in children
Retinoblastoma
Consider urgent referral (for an appointment within 2 weeks) for ophthalmological assessment 
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 
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 
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
Xray 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 
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# Terms used in this guideline

# Children
From birth to 15 years.

# Children and young people
From birth to 24 years.

# Consistent with
The finding has characteristics that could be caused by many things, including cancer.

# Direct access
When a test is done 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.

# Nonurgent
The timescale generally used for a referral or investigation that is not considered very urgent or urgent.

# Persistent
The continuation of specified symptoms and/or signs beyond a period that would normally be associated with selflimiting problems. The precise period will vary depending on the severity of symptoms and associated features, as assessed by the health professional.

# Raises the suspicion of
A mass or lesion that has an appearance or a feel that makes the healthcare professional believe cancer is a significant possibility.

# Safety netting
The active monitoring in primary care of people who have presented with symptoms. It has 2 separate aspects:
timely review and action after investigations
active monitoring of symptoms in people at low risk (but not no risk) of having cancer to see if their risk of cancer changes.

# Suspected cancer pathway referral
The patient is seen within the national target for cancer referrals (2 weeks at the time of publication of this guideline).

# Unexplained
Symptoms or signs that have not led to a diagnosis being made by the healthcare professional in primary care after initial assessment (including history, examination and any primary care investigations).

# Urgent
To happen or be done before 2 weeks. An urgent referral means that the woman is referred to a gynaecological cancer service within the national target in England and Wales for referral for suspected cancer, which is currently 2 weeks.

# Very urgent
To happen within 48 hours.

# Young people
Aged 16 to 24 years.# Recommendations for research
The guideline committee has made the following recommendations for research.

# Key recommendations for research

## Age thresholds in cancer
Longitudinal studies should be carried out to identify and quantify factors in adults that are associated with development of specific cancers at a younger age than the norm. They should be designed to inform age thresholds in clinical guidance. The primary outcome should be likelihood ratios and positive predictive values for cancer occurring in younger age groups.

## Primary care testing
Diagnostic accuracy studies of tests accessible to primary care should be carried out for a given cancer in symptomatic people. Priority areas for research should include tests for people with cough, non-visible haematuria, suspected prostate cancer, suspected pancreatic cancer, suspected cancer in childhood and young people and other suspected rare cancers. Outcomes of interest are the performance characteristics of the test, particularly sensitivity, specificity and positive and negative predictive values.

## Cancers insufficiently researched in primary care
Observational studies of symptomatic primary care patients should be used to estimate the positive predictive value of different symptoms for specific cancers. Priority areas for research are those where the evidence base is currently insufficient and should include prostate cancer, pancreatic cancer, cancer in childhood and young people and other rare cancers. Outcomes of interest are positive predictive values and likelihood ratios for cancer.

## Patient experience
Qualitative studies are needed to assess the key issues in patient experience and patient information needs in the cancer diagnostic pathway, particularly in the interval between first presentation to primary care and first appointment in secondary care. Outcomes of interest are patient satisfaction, quality of life and patient perception of the quality of care and information.

## Prostate-specific antigen testing
What is the diagnostic accuracy of using age-adjusted and fixed prostate-specific antigen thresholds for people with symptoms of prostate cancer, including those at high risk of developing prostate cancer (such as those with an African family background or a family history of prostate cancer)?
For a short explanation of why the committee made the recommendation for research see the rationale section on prostate-specific antigen testing for prostate cancer .
Full details of the evidence and the committee's discussion are in evidence review A: PSA testing for prostate cancer.
Loading. Please wait.# Rationale and impact
This section briefly explains why the committee made the recommendation and how it might affect practice.

# Prostate-specific antigen testing for prostate cancer
Recommendation 1.6.3

## Why the committee made the recommendation
The evidence on the diagnostic accuracy of fixed and age-specific prostate-specific antigen (PSA) thresholds was very uncertain because all of the studies were based on a population that had already been referred to secondary care. The 2019 guideline recommended referral if PSA levels were above the age-specific reference range. The committee agreed that referral should be considered based on PSA thresholds, but did not make a stronger recommendation because of the uncertainty in the evidence and the likely low positive predictive value of the PSA test for prevalence estimates based on UK population data. The committee noted that many prostate cancers are slow growing and might never impact a person's life expectancy. Some people might choose not to be referred to secondary care to avoid invasive investigations and treatment that might not benefit them. Therefore, the committee agreed that a patient-centred approach to referral is important, and recommended that the person's preferences and any comorbidities should be taken into account.
The committee agreed that more research is needed in this area to better understand the most appropriate thresholds that should prompt referral to secondary care for each age group. The committee noted that ethnicity and family history are important factors that affect the risk of prostate cancer. Therefore, they recommended that the data from research be stratified by these factors to determine whether different PSA levels should prompt referral in these groups. Research in this area may also help to address health inequalities in prostate cancer diagnosis and outcomes in the UK.
There was no strong evidence to differentiate between using age-specific or fixed PSA thresholds. The committee also noted that no cost-effectiveness evidence comparing age-specific thresholds with fixed thresholds was identified. However, because PSA levels increase naturally with age, the committee agreed a lower fixed PSA threshold would detect more cases of prostate cancer but also lead to unnecessary biopsies and overtreatment in some age groups. This would also be likely to result in more referrals to secondary care and have a significant impact on NHS resources. The committee therefore recommended the use of age-specific thresholds, which are already established in current practice and were recommended in the previous version of the guideline. Because of regional variations in practice (particularly in the 50 to 69 age range), the committee decided to define the age-specific PSA thresholds. The committee agreed that the thresholds used in the reviewed studies on people with symptoms of possible prostate cancer should be used in the absence of evidence to support alternative values, because these studies were most applicable to the population that the recommendation applies to. No evidence was available specifically for people under 40 or over 79, and so the committee recommended that clinical judgement is used when deciding whether to refer people in these groups to secondary care.

## How the recommendation might affect practice
Referral based on age-specific PSA thresholds is already recommended, so practice should not change significantly. Also, clarifying the age-specific thresholds will help standardise care. Taking into account patient preferences and comorbidities should also lead to a more patient-centred approach to referral.
Return to recommendation# Context
Cancer has an enormous impact, both in terms of the number of people affected by it and the individual impact it has on people with cancer and those close to them. More than 300,000 new cancers (excluding skin cancers) are diagnosed annually in the UK, across over 200 different cancer types. Each of these cancer types has different presenting features, though they sometimes overlap. Approximately onethird of the population will develop a cancer in their lifetime. There is considerable variation in referral and testing for possible cancer, which cannot be fully explained by variation in the population.
The identification of people with possible cancer usually happens in primary care, because most people first present to a primary care clinician. Therefore, evidence from primary care should inform the identification process and was used as the basis for this guideline.
The recommendations were developed using a 'risk threshold', whereby if the risk of symptoms being caused by cancer is above a certain level, then action (investigation or referral) is warranted. The positive predictive value (PPV) was used to determine the threshold. In the previous guideline, a disparate range of percentage risks of cancer was used to form the recommendations. Few corresponded with a PPV of lower than 5%. The guideline development group (GDG) felt that, in order to improve diagnosis of cancer, a PPV threshold lower than 5% was preferable. Taking into account the financial and clinical costs of broadening the recommendations, the GDG agreed to use a 3% PPV threshold value to underpin the recommendations for suspected cancer pathway referrals and urgent direct access investigations, such as brain scanning or endoscopy. Certain exceptions to a 3% PPV threshold were agreed. Recommendations were made for children and young people at below the 3% PPV threshold, although no explicit threshold value was set. The threshold was not applied to recommendations relating to tests routinely available in primary care (including blood tests such as prostatespecific antigen and imaging such as chest Xray), primary care tests that could be used in place of specialist referral, nonurgent direct access tests and routine referrals for specialist opinion. Further information about the methods used to underpin the recommendations can be found in the full guideline.
It is well recognised that some risk factors increase the chance of a person developing cancer in the future, for example, increasing age and a family history of cancer. However, risk factors do not affect the way in which cancer presents. Of the risk factors that were reported in the evidence, only smoking (in lung cancer) and age were found to significantly influence the chance of symptoms being predictive of cancer. Therefore, these are included in the recommendations where relevant. For all other risk factors, the recommendations would be the same for people with possible symptoms of cancer, irrespective of whether they had a risk factor. However, an exception was made to include asbestos exposure in the recommendations because of the high relative risk of mesothelioma in people who have been exposed to asbestos.