This guideline updates and replaces NICE guideline CG27. The recommendations are labelled according to when the evidence was last reviewed (see update information for details).
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 one‑third 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 the large majority of 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 prostate‑specific antigen and imaging such as chest X‑ray), primary care tests that could be used in place of specialist referral, non‑urgent 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.
This guideline covers the recognition and selection for referral or investigation in primary care of people of all ages, including children and young people, who may have cancer. Although we have used the terms 'men' and 'women' for recommendations on gender‑related cancers, these recommendations also extend to people who have changed or are in the process of changing gender, and who retain the relevant organs.
The guideline aims to help people understand what to expect if they have symptoms that may suggest cancer. It should also help those in secondary care to understand which services should be provided for people with suspected cancer. Finally, these recommendations are recommendations, not requirements, and they are not intended to override clinical judgement.
The recommendations in this guideline have been organised into 3 separate sections to help clinicians find the relevant information easily. In the first, the recommendations are organised by cancer site. There is a section covering patient support, safety netting and the diagnostic process. Then, for those wanting to find recommendations on specific symptoms and primary care investigations, the recommendations are in a section organised by symptoms and investigation findings.
Remember that child maltreatment:
can present anywhere
may co‑exist 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 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.
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.
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.