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'Referral advice' recommendation details

Referral for suspected cancer

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Guidance ID NICE 'referral advice' recommendation 'Referral advice' category
CG27 In patients with suspected cancer, discussion with a specialist should be considered if there is uncertainty about the interpretation of symptoms and signs, and whether a referral is needed. Urgent
CG27 General principles of mananging suspected cancer referrals: Cancer is uncommon in children, and its detection can present particular difficulties. Primary healthcare professionals should also be willing to reassess the initial diagnosis or to seek a second opinion from a colleague if a child fails to recover as expected. Discussion with a specialist should be considered if there is uncertainty about the interpretation of symptoms and signs, and whether a referral is needed. There should be local arrangements in place to ensure that letters about non-urgent referrals are assessed by the specialist, the patient being seen more urgently if necessary. The primary healthcare professional should include all appropriate information in referral correspondence, including whether the referral is urgent or non-urgent. The primary healthcare professional should use local referral proformas if these are in use. Once the decision to refer has been made, the primary healthcare professional should make sure that the referral is made within 1 working day. A patient who presents with symptoms suggestive of cancer should be referred by the primary healthcare professional to a team specialising in the management of the particular type of cancer, depending on local arrangements. In patients with features typical of cancer, investigations in primary care should not be allowed to delay referral. In patients with less typical symptoms and signs that might, nevertheless, be due to cancer, investigations may be necessary, but should be undertaken urgently to avoid delay. If specific investigations are not readily available locally, an urgent specialist referral should be made. Urgent
CG27 A patient who presents with symptoms suggestive of lung cancer should be referred to a team specialising in the management of lung cancer, depending on local arrangements. An urgent referral for a chest X-ray should be made when a patient presents with haemoptysis, or any of the following unexplained persistent (that is, lasting more than 3 weeks) symptoms and signs: chest and/or shoulder pain, dyspnoea, weight loss, chest signs, hoarseness, finger clubbing, cervical and/or supraclavicular lymphadenopathy, cough with or without any of the above, features suggestive of metastasis from a lung cancer (for example, in brain, bone, liver or skin). Urgent
CG27 Patients being referred urgently for endoscopy should ideally be free from acid suppression medication, including proton pump inhibitors or histamine H2 receptor antagonists, for a minimum of 2 weeks. Urgent
CG27 A patient who presents with symptoms suggestive of colorectal or anal cancer should be referred to a team specialising in the management of lower gastrointestinal cancer, depending on local arrangements. Urgent
CG27 Urgent referrals for suspected bowel cancer have been recommended in patients presenting with the following features: - Patients aged 40 years and older, reporting rectal bleeding with a change of bowel habit towards looser stools and/or increased stool frequency persisting for 6 weeks or more. - Patients aged 60 years and older with rectal bleeding persisting for 6 weeks or more without a change in bowel habit and without anal symptoms. - Patients presenting with a right lower abdominal mass consistent with involvement of the large bowel irrespective of age. - Patients presenting with a palpable rectal mass (intraluminal and not pelvic), irrespective of age. - A pelvic mass outside the bowel would warrant an urgent referral to a urologist or gynaecologist). - Men of any age with unexplained iron deficiency anaemia and a haemoglobin of 11 g/100 ml or below, or non-menstruating women with unexplained iron deficiency anaemia and a haemoglobin of 10 g/100 ml or below. Urgent
CG27 A patient who presents with symptoms suggestive of breast cancer should be referred to a team specialising in the management of breast cancer. Urgent
CG27 The features of a lump that should make the primary healthcare professional strongly suspect cancer are a discrete, hard lump with fixation, with or without skin tethering. In patients presenting in this way an urgent referral should be made, irrespective of age. In a woman aged 30 years and older with a discrete lump that persists after her next period, or presents after menopause, an urgent referral should be made. Suspected benign lumps (for example, fibroadenoma) in women under 30 years are common and non-urgent referral should be considered. However, in women aged younger than 30 years: with a lump that enlarges, or with a lump that has other features associated with cancer (fixed and hard), or in whom there are other reasons for concern such as family history an urgent referral should be made. The patient's history should always be taken into account. For example, it may be appropriate, in discussion with a specialist, to agree referral within a few days in patients reporting a lump or other symptom that has been present for several months. In a patient who has previously had histologically confirmed breast cancer, who presents with a further lump or suspicious symptoms, an urgent referral should be made, irrespective of age. In patients presenting with unilateral eczematous skin or nipple change that does not respond to topical treatment, or with nipple distortion of recent onset, an urgent referral should be made. In patients presenting with spontaneous unilateral bloody nipple discharge, an urgent referral should be made. In a man aged 50 years and older with a unilateral, firm subareolar mass with or without nipple distortion or associated skin changes, an urgent referral should be made. Urgent
CG27 In patients presenting with symptoms and/or signs suggestive of breast cancer, investigation prior to referral is not recommended. Time frame not specified
CG27 In patients found on examination of the cervix to have clinical features that raise the suspicion of cervical cancer, an urgent referral should be made. A cervical smear test is not required before referral, and a previous negative cervical smear result is not a reason to delay referral. Urgent

This page was last updated: 22 August 2012

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Accessibility | Cymraeg | Freedom of information | Vision Impaired | Contact Us | Glossary | Data protection | Copyright | Disclaimer | Terms and conditions

Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.