1 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).

1.1 Lung and pleural cancers

Lung cancer

1.1.1 Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for lung cancer if they:

  • have chest X‑ray findings that suggest lung cancer or

  • are aged 40 and over with unexplained haemoptysis. [2015]

1.1.2 Offer an urgent chest X‑ray (to be performed 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. [2015]

1.1.3 Consider an urgent chest X‑ray (to be performed 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. [2015]

Mesothelioma

1.1.4 Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for mesothelioma if they have chest X‑ray findings that suggest mesothelioma. [2015]

1.1.5 Offer an urgent chest X‑ray (to be performed 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. [2015]

1.1.6 Consider an urgent chest X‑ray (to be performed within 2 weeks) to assess for mesothelioma in people aged 40 and over with either:

  • finger clubbing or

  • chest signs compatible with pleural disease. [2015]

1.2 Upper gastrointestinal tract cancers

Oesophageal cancer

1.2.1 Offer urgent, direct access upper gastrointestinal endoscopy (to be performed 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. [2015]

1.2.2 Consider non-urgent direct access upper gastrointestinal endoscopy to assess for oesophageal cancer in people with haematemesis. [2015]

1.2.3 Consider non‑urgent direct access upper gastrointestinal endoscopy to assess for oesophageal cancer in people aged 55 or over with:

  • treatment‑resistant 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. [2015]

Pancreatic cancer

1.2.4 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. [2015]

1.2.5 Consider an urgent direct access CT scan (to be performed 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

  • new‑onset diabetes. [2015]

Stomach cancer

1.2.6 Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for people with an upper abdominal mass consistent with stomach cancer. [2015]

1.2.7 Offer urgent direct access upper gastrointestinal endoscopy (to be performed 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. [2015]

1.2.8 Consider non‑urgent direct access upper gastrointestinal endoscopy to assess for stomach cancer in people with haematemesis. [2015]

1.2.9 Consider non‑urgent direct access upper gastrointestinal endoscopy to assess for stomach cancer in people aged 55 or over with:

  • treatment‑resistant 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. [2015]

Gall bladder cancer

1.2.10 Consider an urgent direct access ultrasound scan (to be performed within 2 weeks) to assess for gall bladder cancer in people with an upper abdominal mass consistent with an enlarged gall bladder. [2015]

Liver cancer

1.2.11 Consider an urgent direct access ultrasound scan (to be performed within 2 weeks) to assess for liver cancer in people with an upper abdominal mass consistent with an enlarged liver. [2015]

1.3 Lower gastrointestinal tract cancers

Colorectal cancer

1.3.1 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:

    • iron‑deficiency anaemia or

    • changes in their bowel habit, or

  • tests show occult blood in their faeces. [2015]

1.3.2 Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for colorectal cancer in adults with a rectal or abdominal mass. [2015]

1.3.3 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

  • iron‑deficiency anaemia. [2015]

1.3.4 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. [2021]

Anal cancer

1.3.5 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. [2015]

1.4 Breast cancer

1.4.1 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

    • other changes of concern. [2015]

1.4.2 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. [2015]

1.4.3 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. [2015]

1.5 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.

1.5.1 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). [2011, amended 2020]

1.5.2 Carry out tests in primary care (see recommendations 1.5.6 to 1.5.9) 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 (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. [2011]

1.5.3 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. [2011]

1.5.4 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. [2011]

1.5.5 Carry out appropriate tests for ovarian cancer (see recommendations 1.5.6 to 1.5.9) in any woman of 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). [2011]

1.5.6 Measure serum CA125 in primary care in women with symptoms that suggest ovarian cancer (see recommendations 1.5.1 to 1.5.5). [2011]

1.5.7 If serum CA125 is 35 IU/ml or greater, arrange an ultrasound scan of the abdomen and pelvis. [2011]

1.5.8 If the ultrasound suggests ovarian cancer, make an urgent referral to a gynaecological cancer service. [2011, amended 2020]

1.5.9 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. [2011]

Endometrial cancer

1.5.10 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 post‑menopausal bleeding (unexplained vaginal bleeding more than 12 months after menstruation has stopped because of the menopause). [2015]

1.5.11 Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for endometrial cancer in women aged under 55 with post‑menopausal bleeding. [2015]

1.5.12 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. [2015]

Cervical cancer

1.5.13 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. [2015]

Vulval cancer

1.5.14 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. [2015]

Vaginal cancer

1.5.15 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. [2015]

1.6 Urological cancers

Prostate cancer

1.6.1 Refer men using a suspected cancer pathway referral (for an appointment within 2 weeks) for prostate cancer if their prostate feels malignant on digital rectal examination. [2015]

1.6.2 Consider a prostate‑specific antigen (PSA) test and digital rectal examination to assess for prostate cancer in men with:

  • any lower urinary tract symptoms, such as nocturia, urinary frequency, hesitancy, urgency or retention or

  • erectile dysfunction or

  • visible haematuria. [2015]

1.6.3 Refer men using a suspected cancer pathway referral (for an appointment within 2 weeks) for prostate cancer if their PSA levels are above the age‑specific reference range. [2015]

Bladder cancer

1.6.4 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 non‑visible haematuria and either dysuria or a raised white cell count on a blood test. [2015]

1.6.5 Consider non-urgent referral for bladder cancer in people aged 60 and over with recurrent or persistent unexplained urinary tract infection. [2015]

Renal cancer

1.6.6 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. [2015]

Testicular cancer

1.6.7 Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for testicular cancer in men if they have a non‑painful enlargement or change in shape or texture of the testis. [2015]

1.6.8 Consider a direct access ultrasound scan for testicular cancer in men with unexplained or persistent testicular symptoms. [2015]

Penile cancer

1.6.9 Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for penile cancer in men if they have either:

  • a penile mass or ulcerated lesion, where 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. [2015]

1.6.10 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. [2015]

1.7 Skin cancers

Malignant melanoma of the skin

1.7.1 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 7‑point checklist score of 3 or more. [2015]

Weighted 7‑point checklist

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

  • oozing

  • change in sensation.

1.7.2 Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) if dermoscopy suggests melanoma of the skin. [2015]

1.7.3 Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for melanoma in people with a pigmented or non‑pigmented skin lesion that suggests nodular melanoma. [2015]

Squamous cell carcinoma

1.7.4 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. [2015]

Basal cell carcinoma

1.7.5 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 (particularly pearly or waxy nodules).) [2015]

1.7.6 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. [2015]

1.7.7 Follow NICE's guidance on improving outcomes for people with skin tumours including melanoma for advice on who should excise suspected basal cell carcinomas. [2015]

1.8 Head and neck cancers

Laryngeal cancer

1.8.1 Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for laryngeal cancer in people aged 45 and over with:

Oral cancer

1.8.2 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. [2015]

1.8.3 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. [2015]

1.8.4 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. [2015]

Thyroid cancer

1.8.5 Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for thyroid cancer in people with an unexplained thyroid lump. [2015]

1.9 Brain and central nervous system cancers

Adults

1.9.1 Consider an urgent direct access MRI scan of the brain (or CT scan if MRI is contraindicated) (to be performed within 2 weeks) to assess for brain or central nervous system cancer in adults with progressive, sub‑acute loss of central neurological function. [2015]

Children and young people

1.9.2 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. [2015]

1.10 Haematological cancers

Leukaemia in adults

1.10.1 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. [2015]

Leukaemia in children and young people

1.10.2 Refer children and young people for immediate specialist assessment for leukaemia if they have unexplained petechiae or hepatosplenomegaly. [2015]

1.10.3 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. [2015]

Myeloma

1.10.4 Offer a full blood count, 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. [2015]

1.10.5 Offer very urgent protein electrophoresis and a Bence‑Jones 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. [2015]

1.10.6 Consider very urgent protein electrophoresis and a Bence‑Jones 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. [2015]

1.10.7 Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) if the results of protein electrophoresis or a Bence‑Jones protein urine test suggest myeloma. [2015]

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.

Adults

1.10.8 Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for non‑Hodgkin'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. [2015]

Children and young people

1.10.9 Consider a very urgent referral (for an appointment within 48 hours) for specialist assessment for non‑Hodgkin'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. [2015]

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.

Adults

1.10.10 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 alcohol‑induced lymph node pain. [2015]

Children and young people

1.10.11 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. [2015]

1.11 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

1.11.1 Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for adults if an X‑ray suggests the possibility of bone sarcoma. [2015]

Bone sarcoma in children and young people

1.11.2 Consider a very urgent referral (for an appointment within 48 hours) for specialist assessment for children and young people if an X‑ray suggests the possibility of bone sarcoma. [2015]

1.11.3 Consider a very urgent direct access X‑ray (to be performed within 48 hours) to assess for bone sarcoma in children and young people with unexplained bone swelling or pain. [2015]

Soft tissue sarcoma in adults

1.11.4 Consider an urgent direct access ultrasound scan (to be performed within 2 weeks) to assess for soft tissue sarcoma in adults with an unexplained lump that is increasing in size. [2015]

1.11.5 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. [2015]

Soft tissue sarcoma in children and young people

1.11.6 Consider a very urgent direct access ultrasound scan (to be performed within 48 hours) to assess for soft tissue sarcoma in children and young people with an unexplained lump that is increasing in size. [2015]

1.11.7 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. [2015]

1.12 Childhood cancers

Neuroblastoma

1.12.1 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. [2015]

Retinoblastoma

1.12.2 Consider urgent referral (for an appointment within 2 weeks) for ophthalmological assessment for retinoblastoma in children with an absent red reflex. [2015]

Wilms' tumour

1.12.3 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. [2015]

1.13 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

1.13.1 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. [2015]

Symptoms of concern in adults

1.13.2 For people with unexplained weight loss, which is a symptom of several cancers including colorectal, gastro‑oesophageal, 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

  • offer urgent investigation or a suspected cancer pathway referral (for an appointment within 2 weeks). [2015]

1.13.3 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

  • offer urgent investigation or a suspected cancer pathway referral (for an appointment within 2 weeks). [2015]

1.13.4 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). [2015]

  • National Institute for Health and Care Excellence (NICE)