Suspected Cancer


external-link-blue Refer urgently if:

  1. an X-ray indicates possible bone cancer
  2. a patient presents with a palpable lump that is:
    • • greater than about 5 cm in diameter
    • • deep to fascia, fixed or immobile
    • • increasing in size
    • • painful
    • • a recurrence after previous excision
  3. If a patient has HIV, consider Kaposi’s sarcoma and make an urgent referral if suspected

  1. Refer for an immediate X-ray a patient with suspected spontaneous fracture.
    • If the X-ray suggests possible bone cancer, refer urgently as above.
    • If the X-ray is normal but symptoms persist, follow-up and / or request repeat X-ray, bone function tests or make a non-urgent referral.
  2. Urgently investigate increasing, unexplained or persistent bone pain or tenderness, particularly pain at rest (and especially if not in the joint), or an unexplained limp.
  3. In older people metastases, myeloma or lymphoma, as well as sarcoma, should be considered

Further reading and references

external-link-blue Refer urgently patients with:

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

Consider urgent referral (to an appropriate specialist) in patients with rapid progression of:

  • subacute focal neurological deficit
  • unexplained cognitive impairment, behavioural disturbance or slowness, or a combination of these
  • personality changes confirmed by a witness and for which there is no reasonable explanation even in the absence of the other symptoms and signs of a brain tumour.

Refer urgently patients previously diagnosed with any cancer who develop any of the following symptoms:

  • recent-onset seizure
  • progressive neurological deficit
  • persistent headaches
  • new mental or cognitive changes
  • • new neurological signs

Consider non-urgent referral or discussion with specialist for:

  • unexplained headaches of recent onset:
  • • present for at least 1 month
  • • not accompanied by features suggestive of raised intracranial pressure

Consider direct referral for a MRI scan in patients presenting with headaches and warning features pdf


Further reading and references

QCancer®-score for women

external-link-blue Refer urgently patients:

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

Consider non-urgent referral in:

  1. women aged younger than 30 years with a lump
  2. patients with breast pain and no palpable abnormality, when initial treatment fails and/or with unexplained persistent symptoms.

Further reading and references

Investigations and urgent referral should be considered in the following situations:

  1. Persistent back pain
  2. Persistent parental anxiety
  3. If a child presents several times (e.g. 3 or more times) with the same unexplained symptom

Leukaemia external-link-16

Refer immediately children or young people with either:

  • • Unexplained petechiae or hepatosplenomegaly

If one or more of the following symptoms are present a blood test should be carried out:

  • • pallor
  • • fatigue
  • • unexplained irritability
  • • unexplained fever
  • • persistent or recurrent upper respiratory tract infections
  • • generalised lymphadenopathy
  • • persistent or unexplained bone pain
  • • unexplained bruising.

If the results of the tests indicate leukaemia then an urgent referral should be made.

Lymphomas external-link-16

Refer immediately children or young people with either:

  • Hepatosplenomegaly or
  • • Mediastinal or hilar mass on chest X-ray
  • • With shortness of breath and unexplained petechiae or hepatosplenomegaly (particularly if not responding to bronchodilators).

Refer urgently children or young people with one or more of the following (particularly if there is no evidence of local infection):

  • • Non-tender, firm or hard lymph nodes
  • • Lymph nodes greater than 2cm in size
  • • Lymph nodes progressively enlarging
  • • Other features of general ill-health, fever or weight loss
  • • Axillary node involvement (in the absence of local infection or dermatitis)
  • Supraclavicular node involvement

Brain and CNS tumours external-link-16

Refer immediately children or young people with:

  • • A reduced level of consciousness

Children aged over 2 years and young people with:

  • • Headache and vomiting that cause early morning waking or occur on waking – signs of raised intracranial pressure

Children younger than 2 years with:

  • • New-onset seizures
  • • Bulging fontanelle
  • Extensor attacks
  • • Persistent vomiting

Refer urgently children and young people of any age with:

  • • Abnormal increase in head size
  • • Arrest or regression of motor development
  • • Altered behaviour
  • • Abnormal eye movements
  • • Lack of visual following
  • • Poor feeding/failure to thrive
  • • Squint, urgency dependent on other factors

A neurological examination should be carried out in children and young people over 2 years who have a persistent headache

Neuroblastoma external-link-16

Refer immediately children younger than 6 months with:

  • • Lump in the abdomen
  • • Small lumps on the skin

Refer urgently all children and young people with:

  • Proptosis
  • • Unexplained back pain
  • • Leg weakness
  • • Unexplained urinary retention

Wilm’s tumour external-link-16

Soft tissue sarcoma external-link-16

Bone sarcomas external-link-16

Retinoblastoma external-link-16


Further reading and references

QCancer®-score for men QCancer®-score for women

Primary care cancer Risk Assessment Tool pdf

external-link-16 Refer urgently patients:

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

external-link-16 Risk factors

external-link-16 Investigations

pdf GP referral for flexible sigmoidoscopy


Further reading and references

QCancer®-score for men QCancer®-score for women

external-link-16 Refer urgently patients presenting with:

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

Consider urgent referral for patients presenting with:

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

external-link-16 Refer urgently for endoscopy, or to a specialist, patients of any age with dyspepsia and any of the following:

  • • chronic gastrointestinal bleeding
  • dysphagia
  • progressive unintentional weight loss
  • persistent vomiting
  • iron deficiency anaemia
  • epigastric mass
  • suspicious barium meal result

Refer urgently for endoscopy patients

  • aged 55 years and older with unexplained and persistent recent-onset dyspepsia alone

  1. Helicobacter pylori status should not affect the decision to refer for suspected cancer
  2. Note that for patients under 55 years, referral for endoscopy is not necessary in the absence of alarm symptoms
  3. Patients being referred urgently for endoscopy should ideally be free from acid suppression medication, including proton pump inhibitors or H2 receptor agonists, for a minimum of 2 weeks

Further reading and references

QCancer®-score for women

external-link-16 Refer urgently patients:

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

Consider urgent referral for patients

  • • with persistent intermenstrual bleeding and negative pelvic examination


Refer urgently for an ultrasound scan patients:

  • • with a palpable abdominal or pelvic mass on examination that is not obviously uterine fibroids or not of gastrointestinal or urological origin.

If the scan is suggestive of cancer, an urgent referral should be made. If urgent ultrasound is not available, an urgent referral should be made

external-link-16 Ovarian cancer

Carry out tests in primary care if a woman (especially if 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 (‘bloating’)
  • feeling full (early satiety) and/or loss of appetite
  • pelvic or abdominal pain
  • increased urinary urgency and/or frequency

external-link-16 Carry out appropriate tests for ovarian cancer in any woman of 50 or over who has experienced symptoms within the last 12 months that suggest irritable bowel syndrome (IBS), as IBS rarely presents for the first time in women of this age.

A full pelvic examination, including speculum examination of the cervix, is recommended for patients presenting with any of the following:

  • • alterations in the menstrual cycle
  • • intermenstrual bleeding
  • • postcoital bleeding
  • • postmenopausal bleeding
  • • vaginal discharge.

In patients with vulval pruritus or pain, a period of ‘treat, watch and wait’ is reasonable. Active follow-up is recommended until symptoms resolve or a diagnosis is confirmed. If symptoms persist, the referral may be urgent or non-urgent, depending on the symptoms and the degree of concern about cancer.


Further reading and references

QCancer®-score for men QCancer®-score for women

external-link-16 Refer immediately patients:

  • • With blood count/film reported as acute leukaemia
  • • With spinal cord compression or renal failure suspected of being caused by myeloma

Refer urgently patients:

  • • With persistent unexplained splenomegaly

Haematological cancers can present with a variety of symptoms that may have a number of different clinical explanations. Combinations of the following symptoms warrant full examination, further investigation (including a blood count and film) and possible referral:

  • • Fatigue
  • • Drenching night sweats
  • • Fever
  • • Weight loss
  • • Generalised itching
  • • Breathlessness
  • • Bruising
  • • Bleeding
  • • Recurrent infections
  • • Bone pain
  • • Alcohol-induced pain
  • • Lymphadenopathy
  • • Splenomegaly

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

external-link-16 In patients with:

  • • persistent unexplained fatigue carry out a FBC, blood film and ESR, plasma viscosity or C-reactive protein (according to local policy). Repeat at least once if the patient’s condition remains unexplained and does not improve
  • • unexplained lymphadenopathy carry out a FBC, blood film and ESR, plasma viscosity or C-reactive protein. Consider glandular fever test if age <30 and consider a course of antibiotics if lymphadenopathy localized.
  • • any of the following additional features of lymphadenopathy:
    • • persistence for 6 weeks or more
    • • lymph nodes increasing in size
    • • lymph nodes greater than 2 cm in size
    • • widespread nature
    • • associated splenomegaly, night sweats or weight loss

Investigate further and/or refer

  • unexplained bruising, bleeding and purpura or symptoms suggesting anaemia, carry out FBC, blood film, clotting screen and ESR, plasma viscosity or C-reactive protein (according to local policy)
  • persistent and unexplained bone pain, carry out FBC and X-ray, urea and electrolytes, liver and bone profile, PSA test (in males) and ESR, plasma viscosity or C-reactive protein (according to local policy).

Further reading and references

external-link-16 Head and neck cancer

Refer urgently patients with:

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

Refer for an urgent chest x-ray patients with hoarseness persisting for more than 3 weeks, particularly smokers aged over 50 years and heavy drinkers. Patients with positive findings should be referred urgently to a team specialising in the management of lung cancer. Patients with a negative finding should be urgently referred to a team specialising in head and neck cancer

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


external-link-16 Thyroid cancer

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

Refer urgently patients with a thyroid swelling associated with any of the following:

  • • A solitary nodule increasing in size
  • • A history of neck irradiation
  • • A family history of an endocrine tumour
  • • Unexplained hoarseness or voice changes
  • • Cervical lymphadenopathy
  • • Very young (pre-pubertal) patient
  • • Patient aged 65 years & older

Request thyroid function tests in patients with a thyroid swelling without stridor or any of the features listed above.

Refer patients with hyper or hypothyroidism & an associated goiter, non urgently to an endocrinologist. Patients with goiter & normal thyroid function tests without any of the features above should be referred non urgently.

Further reading and references

QCancer®-score for men QCancer®-score for women

Primary care cancer Risk Assessment Tool

Immediately refer patients with:

  1. signs of superior vena caval obstruction (swelling of the face/neck with fixed elevation of jugular venous pressure)
  2. stridor
  3. massive haemoptysis

external-link-16 Refer urgently patients with:

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


external-link-16 Refer urgently for chest X-ray (the report should be returned within 5 days) for patients with any of the following:

  1. haemoptysis
  2. unexplained or persistent (longer than 3 weeks):
    • • cough
    • • chest and/or shoulder pain
    • • dyspnoea
    • • weight loss
    • • chest signs
    • • hoarseness
    • • finger clubbing
    • • cervical or supraclavicular lymphadenopathy
    • • features suggestive of metastasis from a lung cancer (for example, secondaries in the brain, bone, liver, skin)
  3. underlying chronic respiratory problems with unexplained changes in existing symptoms
  4. worsening spirometry

Patients in the following categories have a higher risk of developing lung cancer:

  1. are current or ex-smokers
  2. have smoking-related chronic obstructive pulmonary disease (COPD)
  3. have been exposed to asbestos
  4. have had a previous history of cancer (especially head and neck).

Further reading and references

external-link-16 Melanoma

  • • A lesion suspected to be melanoma. (Excision in primary care should be avoided.)

external-link-16 Squamous cell carcinomas

  • • Non-healing keratinised or crusted tumours larger than 1cm with significant induration on palpation. They are commonly found on the face, scalp or back of the hand with a documented expansion over 8 weeks
  • • New or growing cutaneous lesions in patients who have had an organ transplant and/or are on immunosuppressive therapy.
  • • Histological diagnosis of squamous cell carcinoma

Non-urgent referral

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

Further reading and references

QCancer®-score for men

Refer urgently patients:

external-link-16 Prostate

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

external-link-16 Bladder and renal

  • • Of any age with painless macroscopic haematuria
  • • Aged 40 years and older who present with recurrent or persistent urinary tract infection associated with macroscopic haematuria
  • • With an abdominal mass identified clinically or on imaging that is thought to arise from the urinary tract
  • • Aged 50 years and older who present with unexplained microscopic haematuria on urine microscopy without infection

external-link-16 Testicular

  • • With a swelling or mass in the body of the testis

external-link-16 Penile

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


Non-urgent referral

  • • Refer patients under 50 years of age with microscopic haematuria.
  • • Patients under 50 years of age with microscopic haematuria with proteinuria or raised serum creatinine should be referred to a renal physician.

Further reading and references