Recommendations organised by symptom and findings of primary care investigations

The following guidance is based on the best available evidence. The full guideline gives details of the methods and the evidence used to develop the guidance.

The wording used in the recommendations in this guideline (for example, words such as 'offer' and 'consider') denotes the certainty with which the recommendation is made (the strength of the recommendation). See about this guideline for details.

The recommendations in this guideline have been organised into 3 separate sections to help healthcare professionals find the relevant information easily. This section includes the recommendations for investigation and referral organised by symptoms and investigation findings. The recommendations in this section have also been organised by site of suspected cancer in a separate section. There is also a section covering patient support, safety netting and the diagnostic process, which should be used in conjunction with this section.

The recommendations in this section are displayed alphabetically by symptom then in order of urgency of the action needed, to make sure that most urgent actions are not missed. Where there are several recommendations relating to the same cancer these have been grouped for ease of reference. Occasionally the same symptom may suggest more than one cancer site. In such instances the recommendations are displayed together and the GP should use their clinical judgement to decide on the most appropriate action.

Abdominal symptoms

See also bleeding for recommendations on rectal bleeding.

Abdominal distension

Symptom and specific features

Possible cancer

Recommendation

Abdominal distension (persistent or frequent – particularly more than 12 times per month) in women, especially if 50 and over.

Ovarian

Carry out tests in primary care1 [1.5.2]

Measure serum CA125 in primary care1 [1.5.6]

See primary care investigations for more information on tests for ovarian cancer

1The recommendations for ovarian cancer apply to women aged 18 and over.

Abdominal examination findings

Symptoms and signs

Possible cancer

Recommendation

Ascites and/or a pelvic or abdominal mass identified by physical examination (which is not obviously uterine fibroids) in women

Ovarian

Refer urgently1,2 [1.5.1]

1An urgent referral means that the woman is referred to a gynaecological cancer service within the national target in England and Wales for referral for suspected cancer, which is currently 2 weeks.

2The recommendations for ovarian cancer apply to women aged 18 and over.

Abdominal, pelvic or rectal mass or enlarged abdominal organ

Symptom and specific features

Possible cancer

Recommendation

Abdominal or pelvic mass identified by physical examination (which is not obviously uterine fibroids) in women

Ovarian

Refer urgently1,2 [1.5.1]

Abdominal or rectal mass

Colorectal

Consider a suspected cancer pathway referral (for an appointment within 2 weeks) [1.3.2]

Splenomegaly (unexplained) in adults3

Non‑Hodgkin's lymphoma

Consider a suspected cancer pathway referral (for an appointment within 2 weeks). When considering referral, take into account any associated symptoms, particularly fever, night sweats, shortness of breath, pruritus or weight loss. [1.10.8]

Upper abdominal mass consistent with stomach cancer

Stomach

Consider a suspected cancer pathway referral (for an appointment within 2 weeks) [1.2.6]

Upper abdominal mass consistent with an enlarged gall bladder

Gall bladder

Consider an urgent direct access ultrasound scan (to be performed within 2 weeks) [1.2.10]

Upper abdominal mass consistent with an enlarged liver

Liver

Consider an urgent direct access ultrasound scan (to be performed within 2 weeks) [1.2.11]

Hepatosplenomegaly

Leukaemia

Consider a very urgent full blood count (within 48 hours) [1.10.1]

1An urgent referral means that the woman is referred to a gynaecological cancer service within the national target in England and Wales for referral for suspected cancer, which is currently 2 weeks

2The recommendations for ovarian cancer apply to women aged 18 and over.

3Separate recommendations have been made for adults and for children and young people to reflect that there are different referral pathways. However, in practice young people (aged 16–24) may be referred using either an adult or children's pathway depending on their age and local arrangements.

Abdominal or pelvic pain

Symptom and specific features

Possible cancer

Recommendation

Abdominal pain with weight loss (unexplained), 40 and over

Colorectal

Refer adults using a suspected cancer pathway referral (for an appointment within 2 weeks) [1.3.1]

Abdominal pain (unexplained) with rectal bleeding in adults under 50

Colorectal

Consider a suspected cancer pathway referral (for an appointment within 2 weeks) [1.3.3]

Abdominal pain without rectal bleeding, 50 and over

Colorectal

Offer testing for occult blood in faeces [1.3.4]

See primary care investigations for more information on tests for occult blood in faeces

Upper abdominal pain with weight loss, 55 and over

Oesophageal or stomach

Offer urgent direct access upper gastrointestinal endoscopy (to be performed within 2 weeks) [1.2.1] [1.2.7]

Upper abdominal pain with low haemoglobin levels or raised platelet count or nausea or vomiting, 55 and over

Oesophageal or stomach

Consider non‑urgent direct access upper gastrointestinal endoscopy [1.2.3] [1.2.9]

Abdominal or pelvic pain (persistent or frequent – particularly more than 12 times per month) in women, especially if 50 and over

Ovarian

Carry out tests in primary care1 [1.5.2]

Measure serum CA125 in primary care1 [1.5.6]

See primary care investigations for more information on tests for ovarian cancer

Abdominal pain with weight loss, 60 and over

Pancreatic

Consider an urgent direct access CT scan (to be performed within 2 weeks), or an urgent ultrasound scan if CT is not available[1.2.5]

Irritable bowel syndrome symptoms 2 within the last 12 months in women 50 and over

Ovarian

Carry out appropriate tests for ovarian cancer, because irritable bowel syndrome rarely presents for the first time in women of this age1 [1.5.5]

Measure serum CA125 in primary care [1.5.6]

See primary care investigations for more information on tests for ovarian cancer

1The recommendations for ovarian cancer apply to women aged 18 and over.

2See the NICE guideline on irritable bowel syndrome in adults.

Change in bowel habit

Symptom and specific features

Possible cancer

Recommendation

Change in bowel habit (unexplained), 60 and over

Colorectal

Refer adults using a suspected cancer pathway referral (for an appointment within 2 weeks) [1.3.1]

Change in bowel habit (unexplained) with rectal bleeding, in adults under 50

Colorectal

Consider a suspected cancer pathway referral (for an appointment within 2 weeks) [1.3.3]

Change in bowel habit without rectal bleeding, under 60

Colorectal

Offer testing for occult blood in faeces [1.3.4]

See primary care investigations for more information on tests for occult blood in faeces

Change in bowel habit. (unexplained) in women

Ovarian

Consider carrying out tests in primary care1 [1.5.3]

Measure serum CA125 in primary care1 [1.5.6]

See primary care investigations for information on tests for ovarian cancer

Diarrhoea or constipation with weight loss, 60 and over

Pancreatic

Consider an urgent direct access CT scan (to be performed within 2 weeks), or an urgent ultrasound scan if CT is not available [1.2.5]

Irritable bowel syndrome symptoms within the last 12 months, in women 50 and over

Ovarian

Carry out appropriate tests for ovarian cancer), because irritable bowel syndrome rarely presents for the first time in women of this age1 [1.5.5]

Measure serum CA125 in primary care [1.5.6]

See primary care investigations for more information about tests for ovarian cancer

1The recommendations for ovarian cancer apply to women aged 18 and over.

2See the NICE guideline on irritable bowel syndrome in adults.

Dyspepsia

Symptom and specific features

Possible cancer

Recommendation

Dyspepsia (treatment‑resistant), 55 and over

Oesophageal or stomach

Consider non‑urgent direct access upper gastrointestinal endoscopy [1.2.3] [1.2.9]

Dyspepsia

Dyspepsia with weight loss, 55 and over

Oesophageal or stomach

Offer urgent direct access upper gastrointestinal endoscopy (to be performed within 2 weeks) [1.2.1] [1.2.7]

Dyspepsia with raised platelet count or nausea or vomiting, 55 and over

Oesophageal or stomach

Consider non‑urgent direct access upper gastrointestinal endoscopy [1.2.3] [1.2.9]

Dysphagia

Symptom and specific features

Possible cancer

Recommendation

Dysphagia

Oesophageal or stomach

Offer urgent direct access upper gastrointestinal endoscopy (to be performed within 2 weeks) [1.2.1, 1.2.7]

Nausea or vomiting

Symptom and specific features

Possible cancer

Recommendation

Nausea or vomiting with weight loss, 60 and over

Pancreatic

Consider an urgent direct access CT scan (to be performed within 2 weeks), or an urgent ultrasound scan if CT is not available [1.2.5]

Nausea or vomiting with raised platelet count or weight loss or reflux or dyspepsia or upper abdominal pain, 55 and over

Oesophageal or stomach

Consider non‑urgent direct access upper gastrointestinal endoscopy [1.2.3][1.2.9]

Rectal examination findings

Symptom and signs

Possible cancer

Recommendation

Prostate feels malignant on digital rectal examination, in men

Prostate

Refer men using a suspected cancer pathway referral (for an appointment within 2 weeks) [1.6.1]

Anal mass or anal ulceration (unexplained)

Anal

Consider a suspected cancer pathway referral (for an appointment within 2 weeks) [1.3.5]

Rectal mass

Colorectal

Consider a suspected cancer pathway referral (for an appointment within 2 weeks) [1.3.2]

Reflux

Symptom and specific features

Possible cancer

Recommendation

Reflux with weight loss, 55 and over

Oesophageal or stomach

Offer urgent direct access upper gastrointestinal endoscopy (to be performed within 2 weeks) [1.2.1] [1.2.7]

Reflux with raised platelet count or nausea or vomiting, 55 and over

Oesophageal or stomach

Consider non‑urgent direct access upper gastrointestinal endoscopy [1.2.3] [1.2.9]

Bleeding

See also:

Bleeding, bruising or petechiae

Symptom and specific features

Possible cancer

Recommendation

Bruising, bleeding or petechiae (unexplained)

Leukaemia

Consider a very urgent full blood count (within 48 hours) [1.10.1]

Haematemesis

Symptom and specific features

Possible cancer

Recommendation

Haematemesis

Oesophageal or stomach

Consider non-urgent direct access upper gastrointestinal endoscopy [1.2.2] [1.2.8]

Haemoptysis

Symptom and specific features

Possible cancer

Recommendation

Haemoptysis (unexplained), 40 and over

Lung

Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) [1.1.1]

Post‑menopausal bleeding

Symptom and specific features

Possible cancer

Recommendation

Post‑menopausal bleeding 1 in women 55 and over

Endometrial

Refer women using a suspected cancer pathway referral (for an appointment within 2 weeks) [1.5.10]

Post‑menopausal bleeding 1 in women under 55

Endometrial

Consider a suspected cancer pathway referral (for an appointment within 2 weeks) [1.5.11]

1Unexplained vaginal bleeding more than 12 months after menstruation has stopped because of the menopause.

Rectal bleeding

Symptom and specific features

Possible cancer

Recommendation

Rectal bleeding (unexplained), 50 and over

Colorectal

Refer adults using a suspected cancer pathway referral (for an appointment within 2 weeks) [1.3.1]

Rectal bleeding with abdominal pain or change in bowel habit or weight loss or iron‑deficiency anaemia in adults under 50

Colorectal

Consider a suspected cancer pathway referral (for an appointment within 2 weeks) [1.3.3]

Vulval bleeding

Symptom and specific features

Possible cancer

Recommendation

Vulval bleeding (unexplained) in women

Vulval

Consider a suspected cancer pathway referral (for an appointment within 2 weeks) [1.5.14]

Gynaecological symptoms

See also bleeding for post‑menopausal (vaginal) bleeding

Gynaecological examination findings

Symptom and signs

Possible cancer

Recommendation

Appearance of cervix consistent with cervical cancer

Cervical

Consider a suspected cancer pathway referral (for an appointment within 2 weeks) [1.5.13]

Vaginal symptoms

Symptom and specific features

Possible cancer

Recommendation

Vaginal discharge (unexplained) either at first presentation or with thrombocytosis or with haematuria, in women 55 and over

Endometrial

Consider a direct access ultrasound scan [1.5.12]

Vaginal mass (unexplained and palpable) in or at the entrance to the vagina

Vaginal

Consider a suspected cancer pathway referral (for an appointment within 2 weeks) [1.5.15]

Vulval symptoms

Symptom and specific features

Possible cancer

Recommendation

Vulval bleeding (unexplained)

Vulval

Consider a suspected cancer pathway referral (for an appointment within 2 weeks) [1.5.14]

Vulval lump or ulceration (unexplained)

Vulval

Consider a suspected cancer pathway referral (for an appointment within 2 weeks) [1.5.14]

Lumps or masses

See also abdominal symptoms for abdominal, anal, pelvic and rectal lumps or masses.

Lumps and masses

Symptom and specific features

Possible cancer

Recommendation

Anal mass (unexplained)

Anal

Consider a suspected cancer pathway referral (for an appointment within 2 weeks) [1.3.5]

Axillary lump (unexplained), 30 and over

Breast

Consider a suspected cancer pathway referral (for an appointment within 2 weeks) [1.4.2]

Breast lump (unexplained) with or without pain, 30 and over

Breast

Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) [1.4.1]

Breast lump (unexplained) with or without pain, under 30

Breast

Consider non-urgent referral

See also recommendations 1.16.2 and 1.16.3 for information about seeking specialist advice [1.4.3]

Lip or oral cavity lump

Oral

Consider an urgent referral (for an appointment within 2 weeks) for assessment by a dentist [1.8.3]

Consider a suspected cancer pathway referral by the dentist (for an appointment within 2 weeks) in people when assessed by a dentist as having a lump on the lip or in the oral cavity consistent with oral cancer [1.8.4]

Lump (unexplained) that is increasing in size in adults

Soft tissue sarcoma

Consider an urgent direct access ultrasound scan (to be performed within 2 weeks) [1.11.4]

Neck lump (unexplained), 45 and over

Laryngeal

Consider a suspected cancer pathway referral (for an appointment within 2 weeks) [1.8.1]

Neck lump (persistent and unexplained)

Oral

Consider a suspected cancer pathway referral (for an appointment within 2 weeks) [1.8.2]

Penile mass (and sexually transmitted infection has been excluded as a cause) in men

Penile

Consider a suspected cancer pathway referral (for an appointment within 2 weeks) [1.6.9]

Thyroid lump (unexplained)

Thyroid

Consider a suspected cancer pathway referral (for an appointment within 2 weeks) [1.8.5]

Vaginal mass (unexplained and palpable) in or at the entrance to the vagina in women

Vaginal

Consider a suspected cancer pathway referral (for an appointment within 2 weeks) [1.5.15]

Vulval lump (unexplained) in women

Vulval

Consider a suspected cancer pathway referral (for an appointment within 2 weeks) [1.5.14]

1Separate recommendations have been made for adults and for children and young people to reflect that there are different referral pathways. However, in practice young people (aged 16–24) may be referred using either an adult or children's pathway depending on their age and local arrangements.

Lymphadenopathy

Symptom and specific features

Possible cancer

Recommendation

Lymphadenopathy (unexplained) in adults

Non‑Hodgkin's lymphoma or Hodgkin's lymphoma

Consider a suspected cancer pathway referral (for an appointment within 2 weeks)

When considering referral for Hodgkin's lymphoma, take into account any associated symptoms, particularly fever, night sweats, shortness of breath, pruritus, weight loss or alcohol‑induced lymph node pain [1.10.10]

When considering referral for non‑Hodgkin's lymphoma, take into account any associated symptoms, particularly fever, night sweats, shortness of breath, pruritus or weight loss [1.10.8]

Lymphadenopathy (supraclavicular or persistent cervical), 40 and over

Lung

Consider an urgent chest X‑ray (to be performed within 2 weeks) [1.1.3]

Lymphadenopathy (generalised) in adults

Leukaemia

Consider a very urgent full blood count (within 48 hours) [1.10.1]

1Separate recommendations have been made for adults and for children and young people to reflect that there are different referral pathways. However, in practice young people (aged 16–24) may be referred using either an adult or children's pathway depending on their age and local arrangements.

Oral lesions

Symptom and specific features

Possible cancer

Recommendation

Ulceration in the oral cavity (unexplained and lasting for more than 3 weeks)

Oral

Consider a suspected cancer pathway referral (for an appointment within 2 weeks) [1.8.2]

Lip or oral cavity lump

Oral

Consider an urgent referral (for an appointment within 2 weeks) for assessment by a dentist [1.8.3]

Consider a suspected cancer pathway referral by the dentist (for an appointment within 2 weeks) in people when assessed by a dentist as having a lump on the lip or in the oral cavity consistent with oral cancer [1.8.4]

Neurological symptoms in adults

Symptom and specific features

Possible cancer

Recommendation

Loss of central neurological function (progressive, sub‑acute) in adults

Brain or central nervous system

Consider an urgent direct access MRI scan of the brain (or CT scan if MRI is contraindicated) (to be performed within 2 weeks) [1.9.1]

Pain

See also abdominal symptoms for abdominal or pelvic pain.

Symptom and specific features

Possible cancer

Recommendation

Alcohol‑induced lymph node pain with unexplained lymphadenopathy in adults1

Hodgkin's lymphoma

Consider a suspected cancer pathway referral (for an appointment within 2 weeks). When considering referral, take into account any associated symptoms [1.10.10]

Back pain with weight loss, 60 and over

Pancreatic

Consider an urgent direct access CT scan (to be performed within 2 weeks), or an urgent ultrasound scan if CT is not available[1.2.5]

Back pain (persistent), 60 and over

Myeloma

Offer a full blood count, blood tests for calcium and plasma viscosity or erythrocyte sedimentation rate [1.10.4]

See primary care investigations for more information on tests for myeloma

Bone pain (persistent), 60 and over

Myeloma

Offer a full blood count, blood tests for calcium and plasma viscosity or erythrocyte sedimentation rate to assess for myeloma [1.10.4]

See primary care investigations for more information on tests for myeloma

Chest pain (unexplained), 40 and over, ever smoked

Lung or mesothelioma

Offer an urgent chest X‑ray (to be performed within 2 weeks) [1.1.2] [1.1.5]

Chest pain (unexplained), 40 and over, exposed to asbestos

Mesothelioma

Offer an urgent chest X‑ray (to be performed within 2 weeks) [1.1.5]

Chest pain (unexplained) with cough or fatigue or shortness of breath or weight loss or appetite loss (unexplained), 40 and over

Lung or mesothelioma

Offer an urgent chest X‑ray (to be performed within 2 weeks) [1.1.2] [1.1.5]

1Separate recommendations have been made for adults and for children and young people to reflect that there are different referral pathways. However, in practice young people (aged 16–24) may be referred using either an adult or children's pathway depending on their age and local arrangements.

Respiratory symptoms

Chest infection

Symptom and specific features

Possible cancer

Recommendation

Chest infection (persistent or recurrent), 40 and over

Lung

Consider an urgent chest X‑ray (to be performed within 2 weeks) [1.1.3]

Chest pain

Symptom and specific features

Possible cancer

Recommendation

Chest pain (unexplained), 40 and over, ever smoked

Lung or mesothelioma

Offer an urgent chest X‑ray (to be performed within 2 weeks) [1.1.2] [1.1.5]

Chest pain (unexplained), 40 and over, exposed to asbestos

Mesothelioma

Offer an urgent chest X‑ray (to be performed within 2 weeks) [1.1.5]

Chest pain (unexplained) with cough or fatigue or shortness of breath or weight loss or appetite loss (unexplained), 40 and over

Lung or mesothelioma

Offer an urgent chest X‑ray (to be performed within 2 weeks) [1.1.2] [1.1.5]

Cough

Symptom and specific features

Possible cancer

Recommendation

Cough (unexplained), 40 and over, ever smoked

Lung or mesothelioma

Offer an urgent chest X‑ray (to be performed within 2 weeks) [1.1.2] [1.1.5]

Cough (unexplained), 40 and over, exposed to asbestos

Mesothelioma

Offer an urgent chest X‑ray (to be performed within 2 weeks) [1.1.5]

Cough (unexplained) with fatigue or shortness of breath or chest pain or weight loss or appetite loss (unexplained), 40 and over

Lung or mesothelioma

Offer an urgent chest X‑ray (to be performed within 2 weeks) [1.1.2] [1.1.5]

Hoarseness

Symptom and specific features

Possible cancer

Recommendation

Hoarseness (persistent and unexplained), 45 and over

Laryngeal

Consider a suspected cancer pathway referral (for an appointment within 2 weeks) [1.8.1]

Respiratory examination findings

Symptom and signs

Possible cancer

Recommendation

Chest signs consistent with lung cancer, 40 and over

Lung

Consider an urgent chest X‑ray (to be performed within 2 weeks) [1.1.3]

Chest signs compatible with pleural disease, 40 and over

Mesothelioma

Consider an urgent chest X‑ray (to be performed within 2 weeks) [1.1.6]

Finger clubbing, 40 and over

Lung or mesothelioma

Consider an urgent chest X‑ray (to be performed within 2 weeks) [1.1.3] [1.1.6]

Shortness of breath

Symptom and specific features

Possible cancer

Recommendation

Shortness of breath (unexplained), 40 and over, ever smoked

Lung or mesothelioma

Offer an urgent chest X‑ray (to be performed within 2 weeks) [1.1.2] [1.1.5]

Shortness of breath (unexplained), 40 and over, and exposed to asbestos

Mesothelioma

Offer an urgent chest X‑ray (to be performed within 2 weeks) [1.1.5]

Shortness of breath with cough or fatigue or chest pain or weight loss or appetite loss (unexplained), 40 and over

Lung or mesothelioma

Offer an urgent chest X‑ray (to be performed within 2 weeks) [1.1.2] [1.1.5]

Shortness of breath with unexplained lymphadenopathy in adults

Non‑Hodgkin's lymphoma or Hodgkin's lymphoma

Consider a suspected cancer pathway referral (for an appointment within 2 weeks). When considering referral, take into account any associated symptoms [1.10.8]

Shortness of breath with unexplained splenomegaly in adults1

Non‑Hodgkin's lymphoma

Consider a suspected cancer pathway referral (for an appointment within 2 weeks). When considering referral, take into account any associated symptoms [1.10.8]

1Separate recommendations have been made for adults and for children and young people to reflect that there are different referral pathways. However, in practice young people (aged 16–24) may be referred using either an adult or children's pathway depending on their age and local arrangements.

Skeletal symptoms

Back pain

Symptom and specific features

Possible cancer

Recommendation

Back pain with weight loss, 60 and over

Pancreatic

Consider an urgent direct access CT scan (to be performed within 2 weeks), or an urgent ultrasound scan if CT is not available[1.2.5]

Back pain (persistent), 60 and over

Myeloma

Offer a full blood count, blood tests for calcium and plasma viscosity or erythrocyte sedimentation rate [1.10.4]

See primary care investigations for more information on tests for myeloma

Bone pain

Symptom and specific features

Possible cancer

Recommendation

Bone pain (persistent), 60 and over

Myeloma

Offer a full blood count, blood tests for calcium and plasma viscosity or erythrocyte sedimentation rate to assess for myeloma [1.10.4]

See primary care investigations for more information on tests for myeloma

Fracture

Symptom and specific features

Possible cancer

Recommendation

Fracture (unexplained), 60 and over

Myeloma

Offer a full blood count, blood tests for calcium and plasma viscosity or erythrocyte sedimentation rate [1.10.4]

See primary care investigations for more information on tests for myeloma

Skin or surface symptoms

See also lumps or masses for oral lesions.

Symptoms and signs

Possible cancer

Recommendation

Anal ulceration (unexplained)

Anal

Consider a suspected cancer pathway referral (for an appointment within 2 weeks) [1.3.5]

Bruising (unexplained) in adults

Leukaemia

Consider a very urgent full blood count (within 48 hours) [1.10.1]

Nipple changes of concern (in one nipple only) including discharge and retraction, 50 and over

Breast

Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) [1.4.1]

Oral cavity red or red and white patch erythroplakia or erythroleukoplakia consistent with

Oral

Consider urgent referral (for an appointment within 2 weeks) for assessment by a dentist [1.8.3]

Consider a suspected cancer pathway referral by the dentist (for an appointment within 2 weeks) for people when assessed by a dentist as having a red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia. [1.8.4]

Pallor

Leukaemia

Consider a very urgent full blood count (within 48 hours) [1.10.1]

Penile lesion (ulcerated and sexually transmitted infection has been excluded or persistent after treatment for a sexually transmitted infection has been completed) in men

Penile

Consider a suspected cancer pathway referral (for an appointment within 2 weeks) [1.6.9]

Penile mass (and sexually transmitted infection has been excluded as a cause) in men

Penile

Consider a suspected cancer pathway referral (for an appointment within 2 weeks) [1.6.9]

Penile symptoms affecting the foreskin or glans (unexplained or persistent) in men

Penile

Consider a suspected cancer pathway referral (for an appointment within 2 weeks) [1.6.10]

Petechiae (unexplained) in adults

Leukaemia

Consider a very urgent full blood count (within 48 hours) [1.10.1]

Pruritus with unexplained splenomegaly in adults

Non‑Hodgkin's lymphoma

Consider a suspected cancer pathway referral (for an appointment within 2 weeks). When considering referral, take into account any associated symptoms[1.10.8]

Pruritus with unexplained lymphadenopathy in adults

Hodgkin's lymphoma or non‑Hodgkin's lymphoma

Consider a suspected cancer pathway referral (for an appointment within 2 weeks). When considering referral, take into account any associated symptoms [1.10.10]

Skin changes that suggest breast cancer

Breast

Consider a suspected cancer pathway referral (for an appointment within 2 weeks) [1.4.2]

Skin lesion (pigmented and suspicious) with a weighted 7‑point checklist score of 3 or more

Melanoma

Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) [1.7.1]

Skin lesion (pigmented or non‑pigmented) that suggests nodular melanoma

Melanoma

Consider a suspected cancer pathway referral (for an appointment within 2 weeks) [1.7.3]

Skin lesion that raises the suspicion of a squamous cell carcinoma

Squamous cell carcinoma

Consider a suspected cancer pathway referral (for an appointment within 2 weeks) [1.7.4]

Skin lesion that raises the suspicion of a basal cell carcinoma2

Basal cell carcinoma

Consider routine referral [1.7.5]

Only consider a suspected cancer pathway referral (for an appointment within 2 weeks) if there is particular concern that a delay may have a significant impact, because of factors such as lesion site or size [1.7.6]

Vulval lump or ulceration (unexplained) in women

Vulval

Consider a suspected cancer pathway referral (for an appointment within 2 weeks) [1.5.14]

1Separate recommendations have been made for adults and for children and young people to reflect that there are different referral pathways. However, in practice young people (aged 16–24) may be referred using either an adult or children's pathway depending on their age and local arrangements.

2Typical 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).

Urological symptoms

Dysuria

Symptom and specific features

Possible cancer

Recommendation

Dysuria with unexplained non‑visible haematuria, 60 and over

Bladder

Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) [1.6.4]

Erectile dysfunction

Symptom and specific features

Possible cancer

Recommendation

Erectile dysfunction in men

Prostate

Consider a prostate‑specific antigen (PSA) test and digital rectal examination [1.6.2]

See primary care investigations for more information on PSA tests and digital rectal examination

Haematuria

Symptom and specific features

Possible cancer

Recommendation

Haematuria (visible and unexplained) either without urinary tract infection or that persists or recurs after successful treatment of urinary tract infection, 45 and over

Bladder or renal

Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) [1.6.4] [1.6.6]

Haematuria (non‑visible and unexplained) with dysuria or raised white cell count on a blood test, 60 and over

Bladder

Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) [1.6.4]

Haematuria (visible) with low haemoglobin levels or thrombocytosis or high blood glucose levels or unexplained vaginal discharge in women 55 and over

Endometrial

Consider a direct access ultrasound scan [1.5.12]

Haematuria (visible) in men

Prostate

Consider a prostate‑specific antigen (PSA) test and digital rectal examination [1.6.2]

See primary care investigations for more information on PSA tests and digital rectal examination

Testicular symptoms

Symptom and specific features

Possible cancer

Recommendation

Testis enlargement or change in shape or texture (non‑painful) in men

Testicular

Consider a suspected cancer pathway referral (for an appointment within 2 weeks) [1.6.7]

Testicular symptoms (unexplained or persistent), men

Testicular

Consider a direct access ultrasound scan [1.6.8]

Other urinary tract symptoms

Symptom and specific features

Possible cancer

Recommendation

Urinary tract infection (unexplained and recurrent or persistent), 60 and over

Bladder

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

Lower urinary tract symptoms, such as nocturia, urinary frequency, hesitancy, urgency or retention in men

Prostate

Consider a prostate‑specific antigen (PSA) test and digital rectal examination [1.6.2]

See primary care investigations for more information on PSA tests and digital rectal examination

Urinary urgency and/or frequency (increased and persistent or frequent – particularly more than 12 times per month) in women, especially if 50 and over

Ovarian

Carry out tests in primary care1 [1.5.2]

Measure serum CA125 in primary care1 [1.5.6]

See primary care investigations for information on tests for ovarian cancer

1The recommendations for ovarian cancer apply to women aged 18 and over.

Non‑specific features of cancer

Appetite loss or early satiety

Symptom and specific features

Possible cancer

Recommendation

Appetite loss (unexplained)

Several, including lung, oesophageal, stomach, colorectal, pancreatic, bladder or renal

Carry out an assessment for additional symptoms, signs or findings that may help to clarify which cancer is most likely

Offer urgent investigation or a suspected cancer pathway referral (for an appointment within 2 weeks) [1.13.3]

Appetite loss (unexplained), 40 and over, ever smoked

Lung or mesothelioma

Offer an urgent chest X‑ray (to be performed within 2 weeks) [1.1.2] [1.1.5]

Appetite loss (unexplained), 40 and over, exposed to asbestos

Mesothelioma

Offer an urgent chest X‑ray (to be performed within 2 weeks) [1.1.5]

Appetite loss (unexplained) with cough or fatigue or shortness of breath or chest pain or weight loss (unexplained), 40 and over

Lung or mesothelioma

Offer an urgent chest X‑ray (to be performed within 2 weeks) [1.1.2] [1.1.5]

Appetite loss or early satiety (persistent or frequent – particularly more than 12 times per month) in women, especially if 50 and over

Ovarian

Carry out tests in primary care1 [1.5.2]

Measure serum CA125 in primary care1 [1.5.6]

See primary care investigations for information on tests for ovarian cancer

1The recommendations for ovarian cancer apply to women aged 18 and over.

Deep vein thrombosis

Symptom and specific features

Possible cancer

Recommendation

Deep vein thrombosis

Several, including urogenital, breast, colorectal or lung

Carry out an assessment for additional symptoms, signs or findings that may help to clarify which cancer is most likely

Consider urgent investigation or a suspected cancer pathway referral (for an appointment within 2 weeks) [1.13.4]

Diabetes

Symptom and specific features

Possible cancer

Recommendation

Diabetes (new onset) with weight loss, 60 and over

Pancreatic

Consider an urgent direct access CT scan (to be performed within 2 weeks), or urgent ultrasound scan if CT is not available[1.2.5]

Fatigue

Symptom and specific features

Possible cancer

Recommendation

Fatigue (unexplained), 40 and over, ever smoked

Lung or mesothelioma

Offer an urgent chest X‑ray (to be performed within 2 weeks) [1.1.2] [1.1.5]

Fatigue (unexplained), 40 and over, exposed to asbestos

Mesothelioma

Offer an urgent chest X‑ray (to be performed within 2 weeks) [1.1.5]

Fatigue with cough or shortness of breath or chest pain or weight loss or appetite loss (unexplained), 40 and over

Lung or mesothelioma

Offer an urgent chest X‑ray (to be performed within 2 weeks) [1.1.2] [1.1.5]

Fatigue (persistent) in adults

Leukaemia

Consider a very urgent full blood count (within 48 hours) [1.10.1]

Fatigue (unexplained) in women

Ovarian

Carry out tests in primary care1 [1.5.2]

Measure serum CA125 in primary care1 [1.5.6]

See primary care investigations for information on tests for ovarian cancer

1The recommendations for ovarian cancer apply to women aged 18 and over.

Fever

See also respiratory symptoms for chest infection.

Symptom and specific features

Possible cancer

Recommendation

Fever (unexplained)

Leukaemia

Consider a very urgent full blood count (within 48 hours) [1.10.1]

Fever with unexplained splenomegaly in adults

Non‑Hodgkin's lymphoma

Consider a suspected cancer pathway referral (for an appointment within 2 weeks). When considering referral, take into account any associated symptoms [1.10.8]

Fever with unexplained lymphadenopathy in adults

Hodgkin's lymphoma or non‑Hodgkin's lymphoma

Consider a suspected cancer pathway referral (for an appointment within 2 weeks). When considering referral, take into account any associated symptoms [1.10.10]

1Separate recommendations have been made for adults and for children and young people to reflect that there are different referral pathways. However, in practice young people (aged 16–24) may be referred using either an adult or children's pathway depending on their age and local arrangements.

Infection

Symptom and specific features

Possible cancer

Recommendation

Infection (unexplained and persistent or recurrent) in adults

Leukaemia

Consider a very urgent full blood count (within 48 hours) [1.10.1]

Night sweats

Symptom and specific features

Possible cancer

Recommendation

Night sweats with unexplained splenomegaly in adults

Non‑Hodgkin's lymphoma

Consider a suspected cancer pathway referral (for an appointment within 2 weeks). When considering referral, take into account any associated symptoms[1.10.8]

Night sweats with unexplained lymphadenopathy in adults

Hodgkin's lymphoma or Non‑Hodgkin's lymphoma

Consider a suspected cancer pathway referral (for an appointment within 2 weeks). When considering referral, take into account any associated symptoms [1.10.10]

1Separate recommendations have been made for adults and for children and young people to reflect that there are different referral pathways. However, in practice young people (aged 16–24) may be referred using either an adult or children's pathway depending on their age and local arrangements.

Pallor

Symptom and specific features

Possible cancer

Recommendation

Pallor

Leukaemia

Consider a very urgent full blood count (within 48 hours) [1.10.1]

Pruritus

Symptom and specific features

Possible cancer

Recommendation

Pruritus with unexplained splenomegaly in adults

Non‑Hodgkin's lymphoma

Consider a suspected cancer pathway referral (for an appointment within 2 weeks). When considering referral, take into account any associated symptoms[1.10.8]

Pruritus with unexplained lymphadenopathy in adults

Hodgkin's lymphoma or non‑Hodgkin's lymphoma

Consider a suspected cancer pathway referral (for an appointment within 2 weeks). When considering referral, take into account any associated symptoms [1.10.10]

1Separate recommendations have been made for adults and for children and young people to reflect that there are different referral pathways. However, in practice young people (aged 16–24) may be referred using either an adult or children's pathway depending on their age and local arrangements.

Weight loss

Symptom and specific features

Possible cancer

Recommendation

Weight loss (unexplained)

Several, including colorectal, gastro‑oesophageal, lung, prostate, pancreatic or urological cancer

Carry out an assessment for additional symptoms, signs or findings that may help to clarify which cancer is most likely

Offer urgent investigation or a suspected cancer pathway referral (for an appointment within 2 weeks) [1.13.2]

Weight loss (unexplained) with abdominal pain, 40 and over

Colorectal

Refer adults using a suspected cancer pathway referral (for an appointment within 2 weeks) [1.3.1]

Weight loss (unexplained) with rectal bleeding in adults under 50

Colorectal

Consider a suspected cancer pathway referral (for an appointment within 2 weeks) [1.3.3]

Weight loss (unexplained) without rectal bleeding, 50 and over

Colorectal

Offer testing for occult blood in faeces [1.3.4]

See primary care investigations for more information on tests for occult blood in faeces

Weight loss (unexplained), 40 and over, ever smoked

Lung or mesothelioma

Offer an urgent chest X‑ray (to be performed within 2 weeks) [1.1.2] [1.1.5]

Weight loss (unexplained), 40 and over, exposed to asbestos

Mesothelioma

Offer an urgent chest X‑ray (to be performed within 2 weeks) [1.1.5]

Weight loss with cough or fatigue or shortness of breath or chest pain or appetite loss (unexplained), 40 and over, never smoked

Lung or mesothelioma

Offer an urgent chest X‑ray (to be performed within 2 weeks) [1.1.2] [1.1.5]

Weight loss with unexplained splenomegaly in adults1

Non‑Hodgkin's lymphoma

Consider a suspected cancer pathway referral (for an appointment within 2 weeks). When considering referral, take into account any associated symptoms [1.10.8]

Weight loss with unexplained lymphadenopathy in adults

Hodgkin's lymphoma or non‑Hodgkin's lymphoma

Consider a suspected cancer pathway referral (for an appointment within 2 weeks). When considering referral, take into account any associated symptoms [1.10.8] [1.10.10]

Weight loss with upper abdominal pain or reflux or dyspepsia, 55 and over

Oesophageal or stomach

Offer urgent direct access upper gastrointestinal endoscopy (to be performed within 2 weeks) [1.2.1] [1.2.7]

Weight loss (unexplained) in women

Ovarian

Consider carrying out tests in primary care [1.5.3]

Measure serum CA125 in primary care [1.5.6]

See primary care investigations for information on tests for ovarian cancer

Weight loss with diarrhoea or back pain or abdominal pain or nausea or vomiting or constipation or new‑onset diabetes, 60 and over

Pancreatic

Consider an urgent direct access CT scan (to be performed within 2 weeks), or an urgent ultrasound scan if CT is not available[1.2.5]

Weight loss with raised platelet count or nausea or vomiting, 55 and over

Oesophageal or stomach

Consider non-urgent direct access upper gastrointestinal endoscopy [1.2.3] [1.2.9]

1Separate recommendations have been made for adults and for children and young people to reflect that there are different referral pathways. However, in practice young people (aged 16–24) may be referred using either an adult or children's pathway depending on their age and local arrangements.

2The recommendations for ovarian cancer apply to women aged 18 and over.

Primary care investigations

Blood test findings

Investigation findings and specific features

Possible cancer

Recommendation

Anaemia (iron‑deficiency), 60 and over

Colorectal

Refer adults using a suspected cancer pathway referral (for an appointment within 2 weeks) [1.3.1]

Anaemia (iron‑deficiency, unexplained) with rectal bleeding in adults under 50

Colorectal

Consider a suspected cancer pathway referral (for an appointment within 2 weeks) [1.3.3]

Anaemia (iron‑deficiency) without rectal bleeding in adults under 60

Colorectal

Offer testing for occult blood in faeces [1.3.4]

Anaemia (even in the absence of iron‑deficiency) without rectal bleeding, 60 and over

Colorectal

Offer testing for occult blood in faeces [1.3.4]

Blood glucose levels high with visible haematuria in women 55 and over

Endometrial

Consider a direct access ultrasound scan [1.5.12]

Diabetes (new‑onset) with weight loss, 60 and over

Pancreatic

Consider an urgent direct access CT scan (to be performed within 2 weeks), or an urgent ultrasound scan if CT is not available[1.2.5]

Haemoglobin levels low with visible haematuria in women 55 and over

Endometrial

Consider a direct access ultrasound scan [1.5.12]

Haemoglobin levels low with upper abdominal pain, 55 and over

Oesophageal or stomach

Consider non-urgent direct access upper gastrointestinal endoscopy [1.2.3] [1.2.9]

Hypercalcaemia or leukopenia and presentation consistent with possible myeloma, 60 and over

Myeloma

Offer very urgent protein electrophoresis and a Bence‑Jones protein urine test (within 48 hours) [1.10.5]

Plasma viscosity or erythrocyte sedimentation rate and presentation consistent with possible myeloma

Myeloma

Consider very urgent protein electrophoresis and a Bence‑Jones protein urine test (within 48 hours) [1.10.6]

Platelet count raised with nausea or vomiting or weight loss or reflux or dyspepsia or upper abdominal pain, 55 and over

Oesophageal or stomach

Consider non‑urgent direct access upper gastrointestinal endoscopy [1.2.3] [1.2.9]

Prostate‑specific antigen levels above the age‑specific reference range

Prostate

Refer men using a suspected cancer pathway referral (for an appointment within 2 weeks) [1.6.3]

Protein electrophoresis suggests myeloma

Myeloma

Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) [1.10.7]

Serum CA125 results

Ovarian

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

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. [1.5.9]

Thrombocytosis, 40 and over

Lung

Consider an urgent chest X‑ray (to be performed within 2 weeks) [1.1.3]

Thrombocytosis with visible haematuria or vaginal discharge (unexplained) in women 55 and over

Endometrial

Consider a direct access ultrasound scan [1.5.12]

White cell count raised on a blood test with unexplained non‑visible haematuria, 60 and over

Bladder

Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) [1.6.4]

1The recommendations for ovarian cancer apply to women aged 18 and over.

Dermoscopy findings

Investigation findings and specific features

Possible cancer

Recommendation

Dermoscopy suggests melanoma of the skin

Melanoma

Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) [1.7.2]

Digital rectal examination findings

Examination findings and specific features

Possible cancer

Recommendation

Prostate feels malignant on digital rectal examination

Prostate

Refer men using a suspected cancer pathway referral (for an appointment within 2 weeks) [1.6.1]

Faecal tests

Investigation findings and specific features

Possible cancer

Recommendation

Occult blood in faeces

Colorectal

Refer adults using a suspected cancer pathway referral (for an appointment within 2 weeks) [1.3.1]

Imaging tests

Investigation findings and specific features

Possible cancer

Recommendation

Chest X‑ray suggests lung cancer

Lung

Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) [1.1.1]

Chest X‑ray suggests mesothelioma

Mesothelioma

Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) [1.1.4]

Ultrasound suggests ovarian cancer

Ovarian

Refer urgently for further investigation [1.5.8]

Ultrasound normal with CA125 of 35 IU/ml or greater

Ovarian

Assess 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 [1.5.9]

Ultrasound suggests soft tissue sarcoma or is uncertain and clinical concern persists in adults3

Soft tissue sarcoma

Consider a suspected cancer pathway referral (for an appointment within 2 weeks) [1.11.5]

X‑ray suggests the possibility of bone sarcoma in adults3

Bone sarcoma

Consider a suspected cancer pathway referral (for an appointment within 2 weeks) [1.11.1]

1An urgent referral means that the woman is referred to a gynaecological cancer service within the national target in England and Wales for referral for suspected cancer, which is currently 2 weeks.

2The recommendations for ovarian cancer apply to women aged 18 and over.

3Separate recommendations have been made for adults and for children and young people to reflect that there are different referral pathways. However, in practice young people (aged 16–24) may be referred using either an adult or children's pathway depending on their age and local arrangements.

Jaundice

Investigation findings and specific features

Possible cancer

Recommendation

Jaundice, 40 and over

Pancreatic

Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) [1.2.4]

Urine test findings

Investigation findings and specific features

Possible cancer

Recommendation

Bence‑Jones protein urine results suggest myeloma

Myeloma

Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) [1.10.7]

Symptoms in children and young people

Abdominal symptoms

Symptom and specific features

Possible cancer

Recommendation

Hepatosplenomegaly (unexplained) in children and young people

Leukaemia

Refer for immediate specialist assessment [1.10.2]

Abdominal mass (palpable) orenlarged abdominalorgan (unexplained) in children

Neuroblastoma or Wilms' tumour

Consider very urgent referral (for an appointment within 48 hours) for specialist assessment [1.12.1] [1.12.3]

Splenomegaly (unexplained) in children and young people1

Non‑Hodgkin's lymphoma

Consider a very urgent referral (for an appointment within 48 hours) for specialist assessment. When considering referral, take into account any associated symptoms, particularly fever, night sweats, shortness of breath, pruritus or weight loss [1.10.9]

1Separate recommendations have been made for adults and for children and young people to reflect that there are different referral pathways. However, in practice young people (aged 16–24) may be referred using either an adult or children's pathway depending on their age and local arrangements.

Bleeding, bruising or rashes

Symptom and specific features

Possible cancer

Recommendation

Petechiae (unexplained) in children and young people

Leukaemia

Refer for immediate specialist assessment [1.10.2]

Bleeding or bruising (unexplained) in children and young people

Leukaemia

Offer a very urgent full blood count (within 48 hours) [1.10.3]

Lumps or masses

See also abdominal symptoms for abdominal mass or unexplained enlarged abdominal organ, splenomegaly and hepatosplenomegaly.

Symptom and specific features

Possible cancer

Recommendation

Lymphadenopathy (unexplained) in children and young people1

Non‑Hodgkin's lymphoma or Hodgkin's lymphoma

Consider a very urgent referral (for an appointment within 48 hours) for specialist assessment. When considering referral, take into account any associated symptoms, particularly fever, night sweats, shortness of breath, pruritus or weight loss [1.10.9] [1.10.11]

Lymphadenopathy (generalised) in children and young people

Leukaemia

Offer a very urgent full blood count (within 48 hours) [1.10.3]

Lump (unexplained) that is increasing in size in children and young people1

Soft tissue sarcoma

Consider a very urgent direct access ultrasound scan (to be performed within 48 hours) [1.11.6]

See primary care investigations for more information on ultrasound scans

1Separate recommendations have been made for adults and for children and young people to reflect that there are different referral pathways. However, in practice young people (aged 16–24) may be referred using either an adult or children's pathway depending on their age and local arrangements.

Neurological symptoms

Symptom and specific features

Possible cancer

Recommendation

Newly abnormal cerebellar or other central neurological function in children and young people

Brain or central nervous system cancer

Consider a very urgent referral (for an appointment within 48 hours) [1.9.2]

Respiratory symptoms

Symptom and specific features

Possible cancer

Recommendation

Shortness of breath with lymphadenopathy in children and young people1

Non‑Hodgkin's lymphoma or Hodgkin's lymphoma

Consider a very urgent referral (for an appointment within 48 hours) for specialist assessment. When considering referral, take into account any associated symptoms [1.10.9] [1.10.11]

Shortness of breath with splenomegaly (unexplained) in children and young people1

Non‑Hodgkin's lymphoma

Consider a very urgent referral (for an appointment within 48 hours) for specialist assessment. When considering referral, take into account any associated symptoms [1.10.9]

1Separate recommendations have been made for adults and for children and young people to reflect that there are different referral pathways. However, in practice young people (aged 16–24) may be referred using either an adult or children's pathway depending on their age and local arrangements.

Skeletal symptoms

Symptom and specific features

Possible cancer

Recommendation

Bone pain (persistent or unexplained) in children and young people

Leukaemia

Offer a very urgent full blood count (within 48 hours) [1.10.3]

Bone pain (unexplained) in children and young people

Bone sarcoma

Consider a very urgent direct access X‑ray (to be performed within 48 hours) [1.11.3]

See primary care investigations for more information on X‑rays

Bone swelling (unexplained) in children and young people

Bone sarcoma

Consider a very urgent direct access X‑ray (to be performed within 48 hours) [1.11.3]

See primary care investigations for more information on X‑rays

Skin or surface symptoms

Symptom and specific features

Possible cancer

Recommendation

Petechiae (unexplained) in children and young people

Leukaemia

Refer for immediate specialist assessment [1.10.2]

Bruising (unexplained) in children and young people

Leukaemia

Offer a very urgent full blood count (within 48 hours) [1.10.3]

Pallor in children and young people

Leukaemia

Offer a very urgent full blood count (within 48 hours) [1.10.3]

Urological symptoms

Symptom and specific features

Possible cancer

Recommendation

Haematuria (visible and unexplained) in children

Wilms' tumour

Consider very urgent referral (for an appointment within 48 hours) for specialist assessment [1.12.3]

Non‑specific features of cancer

Symptom and specific features

Possible cancer

Recommendation

Fatigue (persistent) in children and young people

Leukaemia

Offer a very urgent full blood count (within 48 hours) [1.10.3]

Fever with lymphadenopathy (unexplained) in children and young people1

Non‑Hodgkin's lymphoma or Hodgkin's lymphoma

Consider a very urgent referral (for an appointment within 48 hours) for specialist assessment. When considering referral, take into account any associated symptoms [1.10.9] [1.10.11]

Fever with splenomegaly (unexplained) in children and young people1

Non‑Hodgkin's lymphoma

Consider a very urgent referral (for an appointment within 48 hours) for specialist assessment. When considering referral, take into account any associated symptoms [1.10.9]

Fever (unexplained) in children and young people

Leukaemia

Offer a very urgent full blood count (within 48 hours) [1.10.3]

Infection (unexplained and persistent) in children and young people

Leukaemia

Offer a very urgent full blood count (within 48 hours) [1.10.3]

Lymphadenopathy (unexplained) in children and young people1

Non‑Hodgkin's lymphoma or Hodgkin's lymphoma

Consider a very urgent referral (for an appointment within 48 hours) for specialist assessment. When considering referral, take into account any associated symptoms, particularly fever, night sweats, shortness of breath, pruritus or weight loss[1.10.9] [1.10.11]

Lymphadenopathy (generalised) in children and young people

Leukaemia

Offer a very urgent full blood count (within 48 hours) [1.10.3]

Night sweats with lymphadenopathy (unexplained) in children and young people1

Non‑Hodgkin's lymphoma or Hodgkin's lymphoma

Consider a very urgent referral (for an appointment within 48 hours) for specialist assessment. When considering referral, take into account any associated symptoms [1.10.9] [1.10.11]

Night sweats with splenomegaly (unexplained) in children and young people

Non‑Hodgkin's lymphoma

Consider a very urgent referral (for an appointment within 48 hours) for specialist assessment. When considering referral, take into account any associated symptoms [1.10.9]

Pruritus with lymphadenopathy (unexplained) in children and young people1

Non‑Hodgkin's lymphoma or Hodgkin's lymphoma

Consider a very urgent referral (for an appointment within 48 hours) for specialist assessment. When considering referral, take into account any associated symptoms [1.10.9] [1.10.11]

Pruritus with splenomegaly(unexplained) in children and young people1

Non‑Hodgkin's lymphoma

Consider a very urgent referral (for an appointment within 48 hours) for specialist assessment. When considering referral, take into account any associated symptoms[1.10.9]

Weight loss with lymphadenopathy (unexplained) in children and young people1

Non‑Hodgkin's lymphoma or Hodgkin's lymphoma

Consider a very urgent referral (for an appointment within 48 hours) for specialist assessment in children and young people. When considering referral, take into account any associated symptoms [1.10.9] [1.10.11]

Weight loss with splenomegaly (unexplained) in children and young people1

Non‑Hodgkin's lymphoma

Consider a very urgent referral (for an appointment within 48 hours) for specialist assessment. When considering referral, take into account any associated symptoms[1.10.9]

1Separate recommendations have been made for adults and for children and young people to reflect that there are different referral pathways. However, in practice young people (aged 16–24) may be referred using either an adult or children's pathway depending on their age and local arrangements.

Parental concern

Symptom and specific features

Possible cancer

Recommendation

Parental or carer insight, concern or anxiety about the child's or young person's symptoms (persistent)

Childhood cancer

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 [1.13.1]

Primary care investigations

Symptom and specific features

Possible cancer

Recommendation

Ultrasound scan suggests soft tissue sarcoma or is uncertain and clinical concern persists in children and young people1

Soft tissue sarcoma

Consider a very urgent referral (for an appointment within 48 hours) for specialist assessment [1.11.7]

X‑ray suggests the possibility of bone sarcoma in children and young people1

Bone sarcoma

Consider a very urgent referral (for an appointment within 48 hours) for specialist assessment [1.11.2]

1Separate recommendations have been made for adults and for children and young people to reflect that there are different referral pathways. However, in practice young people (aged 16–24) may be referred using either an adult or children's pathway depending on their age and local arrangements.

Ocular examination

Examination findings and specific features

Possible cancer

Recommendation

Absent red reflex in children

Retinoblastoma

Consider urgent referral (for an appointment within 2 weeks) for ophthalmological assessment [1.12.2]

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