g logo ipb green

Introduction

The rapid referral guidance toolkit has been produced by Macmillan Cancer Support. It contains the NICE referral guidelines for suspected cancer, with accompanying notes from Macmillan GPs and GP advisers. It’s been produced by GPs for GPs with the aim of providing support, guidance and practical referral recommendations.

Macmillan’s Rapid Referral Guidelines are based on NICE guidance whose remit covers England and Wales. This toolkit supports all of the recommendations in the NICE guideline on suspected cancer: recognition and referral apart from those relating to specific childhood cancers. For more information on this endorsement, please see the 'into practice' section of the NICE website. GPs located in Scotland can access the Scottish Referral Guidelines for suspected cancer online.

Head and neck

Laryngeal cancer

Urgent referral

Consider urgent referral (appointment within two weeks) for people aged 45 or over with either:

  • persistent unexplained hoarseness or
  • an unexplained lump in the neck.

Oral cancer

Urgent referral

Consider urgent referral (appointment within two weeks) for people with:

  • an unexplained ulceration in the oral cavity that lasts for more than three weeks or
  • a persistent and unexplained lump in the neck.

Consider urgently referring (appointment within two weeks) people to a dentist for assessment if they have:

  • an unexplained lump on the lip or in the oral cavity or
  • a red or red and white patch in the oral cavity that's consistent with erythroplakia or erythroleukoplakia.

A dentist should consider urgent referral (appointment within two weeks) for people with either of the following, after a dental surgeon has assessed and concluded the symptom is consistent with oral cancer:

  • a lump on the lip or the oral cavity or
  • a red or red and white patch in the oral cavity that's consistent with erythroplakia or erythroleukoplakia.

Thyroid cancer

Urgent referral

Consider urgent referral (appointment within two weeks) for patients with an unexplained thyroid lump.

Skin

Malignant melanoma

Urgent referral

Urgently refer (appointment within two weeks) if:

  • a person presents with a suspicious pigmented skin lesion that has a weighted seven-point checklist score of three or more or
  • dermoscopy suggests malignant melanoma of the skin.

Consider urgent referral (appointment within two weeks) for melanoma in patients with a pigmented or non-pigmented skin lesion that suggests nodular melanoma.

Accompanying notes:

The seven-point weighted checklist:

Major features (scoring two points each)

  • change in size
  • irregular shape
  • irregular colour.

Minor features (scoring one point each)

  • largest diameter of 7 mm or more
  • inflammation
  • oozing
  • change in sensation.

Squamous cell carcinoma

Urgent referral

Consider urgently referring (appointment within two weeks) if a person has a skin lesion that raises the suspicion of squamous cell carcinoma.

Accompanying notes:

Squamous cell carcinomas are usually raised lesions. They’re often described as being ulcerated, keratinised or crusting lesions that typically grow on the head and neck, or the back of the hand. They occur commonly, and people who are immunocompromised or have had an organ transplant are more likely to develop them. If a person like this does develop a new skin lesion, urgently refer them.

Basal cell carcinoma

Urgent referral

Only consider urgent referral (appointment within two weeks) if a person has a skin lesion that raises the suspicion of a basal cell carcinoma and there's concern a delay may have an unfavourable impact, because of the location or size of the lesion.

Non-urgent referral

Consider routine referral for people with a skin lesion that raises the suspicion of a basal cell carcinoma.

Accompanying notes:

Features suggestive of a basal cell carcinoma include:

  • an ulcer with raised, rolled edge
  • prominent fine blood vessels around the lesion
  • nodules, often waxy or pearly in appearance.

Suspected basal cell carcinomas should only be excised in primary care in accordance with the NICE guidance on Improving outcomes for people with skin tumours including melanoma  (May 2010).

Specific sites of concern are sun-exposed areas such as the scalp, face, hands and arms, particularly with fair-haired people.

Urological

Prostate cancer

Urgent referral

Urgently refer men (appointment within two weeks) if either:

  • their prostate feels malignant on digital rectal examination (DRE) or
  • their prostate specific antigen (PSA) levels are above the age-specific reference range.

Non-urgent investigation

Consider a PSA test and DRE in men with any of the following:

  • any lower urinary tract symptoms, such as nocturia, urinary frequency, hesitancy, urgency or retention
  • erectile dysfunction
  • visible haematuria.

Accompanying notes:

Prostate-specific antigen ranges:

  • 40–49 years 0–2.5 ng/l
  • 50–59 years 0–3.5 ng/l
  • 60–69 years 0–4.5 ng/l
  • 70–79 years 0–6.5 ng/l.

Consider alternative contributing factors that may influence an individual’s PSA ranges.

Bladder cancer

Urgent referral

Urgently refer people (appointment within two weeks) if they are:

  • aged 45 and over with either:
    • unexplained visible haematuria without urinary tract infection or
    • visible haematuria that persists or recurs after successful treatment of urinary tract infection
  • aged 60 and over with unexplained non-visible haematuria and either:
    • dysuria or
    • a raised white cell count on a blood test.

Non-urgent referral

Consider referring people aged 60 and over with recurrent or persistent urinary tract infection that is unexplained.

Renal cancer

Urgent referral

Urgently refer people (appointment within two weeks) if they are aged 45 years and over with either:

  • unexplained visible haematuria without urinary tract infection or

  • visible haematuria that persists or recurs after successful treatment of urinary tract infection.

Testicular cancer

Urgent referral

Consider urgent referral (appointment within two weeks) in men with any of the following changes in the testis:

  • non-painful enlargement

  • change in shape

  • change in texture.

Direct access ultrasound

Consider a direct access ultrasound scan in men with unexplained or persistent testicular symptoms.

Penile cancer

Urgent referral

Consider urgent referral (appointment within two weeks) for men with any of the following (after a sexually transmitted infection [STI] has been ruled out as a cause, or they have completed treatment for an STI)

  • a penile mass

  • an ulcerated lesion

  • unexplained or persistent symptoms affecting the foreskin or glans.

Lung

Lung and pleural cancers

Urgent referral

Urgently refer people (appointment within two weeks) if:

  • chest X-ray findings suggest lung cancer or mesothelioma or

  • they're aged 40 or over and have unexplained haemoptysis.

Urgent investigations

Consider an urgent chest X-ray (to be performed within two weeks) for lung cancer or mesothelioma in people aged 40 or over with any of the following:

  • persistent or recurrent chest infection

  • finger clubbing

  • supraclavicular lymphadenopathy or persistent cervical lymphadenopathy

  • chest signs consistent with lung cancer or pleural disease

  • thrombocytosis.

Offer an urgent chest X-ray (to be performed within two weeks) to the following people to assess for lung cancer or mesothelioma:

  • aged 40 or over who have never smoked and display two or more of the unexplained signs or symptoms listed, or

  • aged 40 or over and have previously smoked and display one or more of the signs or symptoms listed, or

  • of any age who have been exposed to asbestos and display one or more of the signs or symptoms listed:

    • cough

    • fatigue

    • shortness of breath

    • chest pain

    • weight loss

    • appetite loss.

Accompanying notes:

A normal chest X-ray does not exclude the possibility of a lung cancer diagnosis. This was shown in a large British Journal of General Practice study conducted in 2006. It revealed that 23% of chest X-rays done in a primary care setting for people with lung cancer were negative when performed within a year of diagnosis.

Brain and CNS

Brain and CNS cancer

Very urgent referral

Consider very urgent referral (appointment within 48 hours) in children and young people with newly abnormal central neurological or cerebellar function.

Urgent direct access

Consider urgent direct access MRI brain scan (appointment within two weeks) in adults with progressive, sub-acute loss of central neurological function.

Accompanying notes:

A ‘normal’ scan

  • A normal investigation does not preclude the need for ongoing follow up, monitoring and further investigation. In addition, a seemingly ‘normal’ MRI scan may provide false reassurance in people who have neurological pathology that MRI scanning is unable to detect
  • Approximately 10% of people may be unsuitable for, or unable to tolerate an MRI brain scan, e.g. people with pacemakers or those with severe claustrophobia. A CT scan may be more appropriate for these people, but potential radiation exposure should be considered.

Incidental findings

  • A small percentage of MRI scans may yield abnormalities in otherwise healthy individuals. This may impact on these people in a number of ways including the need for further investigation and their health insurance premiums being potentially affected. As incidental findings are not an infrequent result of MRI scanning, people should be offered counselling and information tbefore a scan to make them aware that such findings are possible
  • No definition of ‘progressive sub-acute loss of central neurological function’ has been provided for this update, but the 2005 NICE guidance for suspected cancer states signs or symptoms that may cause concern, include:
    • progressive neurological deficit
    • new-onset seizures
    • headaches
    • mental changes
    • cranial nerve palsy
    • recent headaches accompanied by features suggestive of raised intracranial pressure, e.g. vomiting, drowsiness, posture-related headache, pulse-synchronous tinnitus, or other focal or non-focal neurological symptoms, such as blackout or change in personality or memory
  • Consider urgent referral for people with rapid progression of sub-acute focal neurological deficit; unexplained cognitive impairment, behavioural disturbance or slowness, or a combination of these; personality changes there's no reasonable explanation for and which have been confirmed by a witness, even in the absence of the other symptoms or signs of a brain tumour.

Upper gastrointestinal

Oesophageal and gastric cancer

O=oesophageal; G=gastric

Urgent referral for endoscopy within two weeks

Urgently refer people:

  • of any age presenting with dysphagia (OG) or
  • aged 55 and over with weight loss and
  • upper abdominal pain or
  • reflux or
  • dyspepsia (OG).

Consider urgent referral (appointment within two weeks) for people with an upper abdominal mass consistent with stomach cancer (G).

Non-urgent direct access endoscopy

Consider non-urgent direct access endoscopy for people:

  • at any age presenting with haematemesis (OG) or
  • aged 55 and over with:
    • treatment resistant dyspepsia (OG) or
    • upper abdominal pain and low haemoglobin (OG) or
    • raised platelet count with any of the following:
      • nausea
      • vomiting
      • reflux
      • weight loss
      • dyspepsia
      • upper abdominal pain (OG) or
    • nausea or vomiting with any of the following
      • weight loss
      • reflux
      • dyspepsia
      • upper abdominal pain (OG).

Pancreatic cancer

Urgent referral

Urgently refer (appointment within two weeks) people aged 40 or over with jaundice.

Urgent direct access CT scan or an urgent ultrasound scan if CT scan is not available

Consider urgent direct access CT scan (within two weeks)—or ultrasound scan if CT scan is not available—for people aged 60 or over displaying weight loss and any of the following:

  • diarrhoea
  • back pain
  • abdominal pain
  • nausea/vomiting
  • constipation
  • new-onset diabetes.

Gall bladder

Urgent direct access

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

Liver cancer

Urgent direct access

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

Accompanying notes:

Consider that 10% of pancreatic cancers are missed by abdomen ultrasounds, whilst tumours smaller than 3 cm will not be visible using an ultrasound. An additional benefit of CT scan is that it can determine what stage a cancer is at.

Bone and sarcoma

Bone sarcoma

Very urgent direct access

Consider a very urgent direct access X-ray (appointment within 48 hours) for any child or young person with unexplained:

  • bone swelling or
  • bone pain.

Very urgent referral

Consider very urgent referral in children and young people (appointment within 48 hours) with an X-ray that suggests the possibility of bone sarcoma.

Urgent referral

Consider urgent referral (appointment within two weeks) in adults with an X-ray that suggests the possibility of bone sarcoma.

Soft tissue sarcoma

Very urgent direct access

Consider very urgent direct access ultrasound scan (performed within 48 hours) for children and young people with an unexplained lump that is increasing in size.

Urgent direct access

Consider urgent direct access ultrasound scan (performed within two weeks) for adults with an unexplained lump that is increasing in size.

Very urgent referral

Consider very urgent referral (within 48 hours) in children or young people with:

  • ultrasound scan findings that are suggestive of soft-tissue sarcoma or
  • ultrasound scan findings that are uncertain and clinical concern persists.

Urgent referral

Consider urgent referral (within two weeks) for adults with:

  • ultrasound scan findings that are suggestive of soft-tissue sarcoma or
  • ultrasound scan findings that are uncertain and clinical concern persists.

Breast

Breast cancer

Urgent referral

Urgently refer people (appointment within two weeks) if they are:

  • aged 30 and over with an unexplained breast lump (with or without pain) or
  • aged 50 and over with any unilateral nipple changes of concern including discharge or retraction.

Consider urgent referral (appointment within two weeks) for people:

  • of any age with skin changes suggestive of breast cancer or
  • aged 30 and over with an unexplained lump in the axilla.

Non-urgent referral

Consider non-urgent referral in people under the age of 30 with an unexplained breast lump (with or without pain).

Haematological

Leukaemia

Very urgent investigation

Refer children and young people for immediate specialist assessment for leukaemia if they have:

  • unexplained petechiae or
  • hepatosplenomegaly.

Offer a very urgent full blood count (within 48 hours) in children and young people with any of the following unexplained signs or symptoms:

  • pallor
  • persistent fatigue
  • fever
  • persistent infection
  • generalised lymphadenopathy
  • persistent or unexplained bone pain
  • bruising
  • bleeding.

Consider a very urgent full blood count (within 48 hours) in adults with any of the following unexplained signs or symptoms:

  • pallor
  • persistent fatigue
  • fever
  • persistent or recurrent infection
  • generalised lymphadenopathy
  • bruising
  • bleeding
  • petechiae
  • hepatosplenomegaly.

Accompanying notes:

Immediately refer adults, children and young people with a blood count or blood film reported as acute leukaemia.

Myeloma


Urgent investigation

Offer a full blood count, blood tests for calcium and plasma viscosity or erythrocyte sedimentation rate (ESR) to people aged 60 and over with:

  • persistent bone pain (particularly back pain) or
  • unexplained fracture.

Offer a very urgent protein electrophoresis and a Bence-Jones protein urine test (within 48 hours) to people aged 60 and over with:

  • hypercalcaemia or leukopenia and
  • a presentation that is consistent with possible myeloma.

Consider a very urgent protein electrophoresis and Bence-Jones protein urine test (within 48 hours) for people with:

  • raised plasma viscosity or ESR at levels consistent with possible myeloma and
  • presentation consistent with possible myeloma.

Urgent referral

Urgently refer people (appointment within two weeks) if the results of protein electrophoresis or Bence-Jones protein urine test suggest myeloma.

Lymphoma

Immediate specialist assessment

Consider very urgent referral (appointment within 48 hours) in children and young people with:

  • unexplained lymphadenopathy or
  • splenomegaly.

Take into account associated symptoms, particularly:

  • fever
  • night sweats
  • shortness of breath
  • pruritus
  • weight loss.

Urgent referral

Consider urgent referral (appointment within two weeks) for adults presenting with:

  • unexplained lymphadenopathy or
  • splenomegaly.

Take into account associated symptoms, particularly:

  • fever
  • night sweats
  • shortness of breath
  • pruritus
  • weight loss
  • alcohol-induced lymph node pain.

Gynaecological

Ovarian cancer

Urgent referral

Urgently refer (appointment within two weeks) if physical examination identifies any of the following:

  • ascites
  • pelvic or abdominal mass (which is not obviously uterine fibroids).

Urgent investigation

Arrange CA125 and/or ultrasound tests in women (especially if 50 or over) who persistently or frequently (particularly more than 12 times per month) experience the following:

  • persistent abdominal distension (bloating)
  • early satiety and/or loss of appetite
  • pelvic or abdominal pain
  • increased urinary urgency and/or frequency
  • new onset symptoms suggestive of IBS (as IBS rarely presents for the first time in women of this age).

Consider CA125 and/or ultrasound tests if a woman reports any of the following:

  • unexplained weight loss
  • fatigue
  • changes in bowel habit (though colorectal cancer is a more common malignant cause).

Algorithm 1: Referral pathway for suspected ovarian cancer

Ovarian cancer algorithm

Endometrial cancer

Urgent referral

Urgently refer women (appointment within two weeks) if they are aged 55 and over with post-menopausal bleeding (unexplained vaginal bleeding more than 12 months after menstruation has stopped due to the menopause).

Consider urgently referring (appointment within two weeks) women aged under 55 with post-menopausal bleeding.

Direct access ultrasound

Consider direct access ultrasound 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.

Consider direct access ultrasound in women aged 55 and over presenting with visible haematuria and any of the following:

  • low haemoglobin
  • thrombocytosis
  • high blood glucose level.

Cervical cancer

Urgent referral

Consider urgent referral (appointment within two weeks) if the appearance of the woman’s cervix is consistent with cervical cancer.

Accompanying notes:

A smear test is not required before referral, and a previous negative result should not delay referral.

Vulval cancer

Urgent referral

Consider urgently referring (appointment within two weeks) women with any of the following unexplained vulval signs or symptoms:

  • a vulval lump
  • ulceration
  • bleeding.

Vaginal cancer

Urgent referral

Consider urgently referring (appointment within two weeks) women with an unexplained palpable mass in or at the entrance to the vagina.

Lower gastrointestinal

Colorectal cancer

Urgent referral

Urgently refer (appointment within two weeks) people:

  • aged 40 and over with unexplained weight loss and abdominal pain
  • aged 50 and over with unexplained rectal bleeding
  • aged 60 and over with either
    • iron deficiency anaemia or
    • alteration in bowel habit
  • who have positively tested for occult blood in their faeces.

Consider urgent referral (appointment within 2 weeks) for people:

  • of any age with a rectal or abdominal mass
  • aged under 50 with rectal bleeding and any of the following unexplained signs or symptoms:
    • abdominal pain
    • altered bowel habit
    • weight loss
    • iron deficiency anaemia.

Faecal immunochemical testing

Faecal immunochemical testing (FIT) should be considered for any person who is suspected of having possible colorectal cancer and does not meet the criteria for urgent referral. 

Accompanying notes:

People who fall into the above category may include those:

  • aged 50 or over with unexplained:
    • abdominal pain or
    • weight loss
  • aged under 60 with either:
    • changes in bowel habit or
    • iron-deficiency anaemia
  • aged 60 or over with anaemia, even in the absence of iron deficiency.

Anal cancer

Urgent referral

Consider urgent referral (appointment within two weeks) for people with either:

  • an unexplained anal mass or
  • unexplained anal ulceration.

Patient support, safety netting and diagnostic access guidance

The following guidance is taken from the NICE 2015 guidance for suspected cancer referral. It includes recommendations on support for people with suspected cancer, safety netting and the diagnostic process:

  • 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 potential alternative diagnoses with them
  • when you refer a person with suspected cancer to a specialist service, assess what support they may need need while they wait for their referral appointment. If the person needs support because of their personal circumstances, inform the specialist who is seeing them (with the person's agreement)
  • advise people who may not meet the referral criteria to contact you again if their symptoms persist or progress
  • if direct access for some tests is unavailable in your area, seek an alternative urgent referral pathway
  • you will note that some symptoms from the 2005 NICE guidance for suspected cancer referral have been removed from the guidance update; although there may be no explicit recommendations, refer appropriately if clinical concern persists
  • give people information on their possible diagnosis (both benign and malignant) in accordance with their wishes for information (see also the NICE guideline on patient experiences in adult NHS services). You can order over 500 free information booklets and much more from be.macmillan.org.uk. These cover different types of cancer, treatments and side effects, as well as provide guidance on day-to-day issues that people living with cancer often face
  • the information you give to people with suspected cancer and their families and/or carers should include:
    • how to obtain further information about the cancer they're suspected of having
    • how to access any help they may need before their specialist appointment
    • what type of tests may be carried out and what will happen during these procedures
  • provide peole with information that is culturally and linguistically appropriate for them, and take into account their literacy level. You can download Macmillan’s most commonly requested cancer information in a selection of different languages
  • tell people about Macmillan’s Online Community. It gives people affected by cancer the opportunity to share experiences, ask questions, and vent their emotions.

Glossary

These descriptions are consistent with and taken from the 2015 NICE guidance for suspected cancer

  • Children: from birth to 15 years
  • Direct access: when a test is performed and primary care retain clinical responsibility throughout, including acting on the result
  • Immediate: an acute admission or referral occurring within a few hours, or even more quickly if necessary
  • Suspected cancer pathway referral: the patient is seen within the national target for cancer referrals (2 weeks at the time of publication of the NICE guidance)
  • Young people: aged 16–24 years of age

Key

  • Non-urgent: the timescale generally used for a referral or investigation that is not considered very urgent or urgent
  • Urgent: to happen/be performed within two weeks
  • Very urgent: to happen within 48 hours

Full guideline:

Macmillan Cancer Support. Rapid referral guidelines. Macmillan, 2019. Available at: macmillan.org.uk/_images/rapid-referral-toolkit-desktop-2019_tcm9-354239.pdf

First published: 2012.

Last updated: January 2019.