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Referral
Non site-specific 2 WW
Adults with high GP suspicion of cancer but no site-specific symptoms
Key Message
It is common for General Practitioners to suspect cancer in patients with weight loss and malaise, and without any other focal symptoms. The presence of a 'GP hunch' for cancer is known to have a positive predictive value of greater than 10%, and possibly in excess of 30% - far higher than the 3% threshold designed in to the NG12 guidelines. The reliability of this GP hunch is greater both with increasing patient age and increasing GP experience.
At present, none of our suspected cancer pathways serves these patients well. Some patients with these symptoms are sent through multiple referrals and can take an unnecessarily long time to reach the cancer diagnosis which was suspected. Some patients deteriorate clinically to the point where they are no longer able to tolerate palliative chemo- or radiotherapy, or even such that they require admission. Multiple clinic attendances and unplanned admissions are costly, but above all this is a poor and anxiety provoking experience for patients and their relatives.
Pathway
This guidance aims to formalise a way of assessing and referring these patients. It provides a structured approach to investigating the patient for possible suitability for a site-specific referral pathway, and if no such pathway is suitable directs the GP to request non site-specific investigation, usually in the form of CT of the Chest, Abdomen and Pelvis. If malignancy is found, the patient will be directed to the most appropriate MDT without a requirement for further referral from the GP.
The majority of patients referred on this pathway will not have cancer. For those patients in whom cross sectional imaging does not reveal a diagnosis, further investigation may be undertaken to try to establish a cause for the patient’s symptoms. In many cases, the GP may prefer to direct further management themselves and if this is so, it would be very helpful the GP ticks the appropriate box on the referral form.
Scope
Patients over the age of 18 in whom the GP suspects cancer but who do not fit any of the existing 2WW referral pathways.
These patients would usually have a combination of malaise and weight loss, but the pathway is not restricted by these criteria: we require only that the GP suspects cancer and that the patient does not fit any of the existing suspected cancer (2WW) pathways.
Out of scope
- Patients with symptoms, signs or test results indicating referral on a site-specific pathway.
- Patients who are unable to attend hospital and lie flat in a CT scanner. Please consider seeking advice regarding management or investigation of such a patient from your local medical or Care-of-the-Elderly team.
- Patients with rapidly deteriorating symptoms where a wait for outpatient assessment could adversely affect outcome. Under these circumstances consider contacting your local acute medical team for advice. Some teams have urgent ambulatory care services which may offer a more suitable assessment for your patient.
- Patients with chronic symptoms more consistent with MUS or functional syndromes in whom the index of suspicion for cancer is low.
PLEASE REFER TO THE NICE GUIDELINE ON THE RECOGNITION AND REFERRAL OF SUSPECTED CANCER TO CHECK WHETHER PATIENT FITS ANY OF THE EXISTING SUSPECTED CANCER REFERRAL CRITERIA.
Pre-referral criteria apply to this pathway. The referral may be returned to the GP requesting more information if these criteria are not evidenced.
A physical examination is required prior to referral.
This is to ensure that a single speciality referral is not more appropriate
This should include the following:
Examination of
- Chest
- Abdomen including rectal examination and genital examination
- Full cutaneous examination for evidence of cutaneous malignancy
- Breast examination
- Examination for lymphadenopathy including neck, axillae and inguinal region
The following blood tests are required prior to referral:
- FBC
- Renal function
- Bone/calcium
- HbA1c
- CRP
- Plasma Viscosity
- LFT
- CA125 (female only)
- PSA (male only)
- TFT
The following urine tests are required prior to referral
Urine analysis for the presence of blood
The following special tests are required prior to referral:
Faecal Immunochemical Testing (FIT)
Explanatory note:
The GP may feel that the finding of a minor abnormality such as a borderline PSA, or trace microscopic haematuria, does not explain the patient's symptoms. Under these circumstances we would recommend clinical discretion as to the direction of referral. With an appropriate explanatory comment in the referral letter, such patients may be accepted onto this pathway.
Please complete the 'Non-specific but concerning symptoms' 2WW referral form (see below) and submit via eRS.
It is essential that the patient be informed that they are being referred for a test to investigate the possibility of cancer, and that following the test they may hear directly from a hospital administrator asking them to attend a clinic for further assessment.
Referral Forms
Your referral will be checked by the clinical or administrative staff at your local trust. If the referral is incomplete you may be contacted and asked to perform further testing or provide additional information. The patient will be contacted and offered an appointment for a diagnostic test which will usually be CT of the Thorax, Abdomen and Pelvis depending on the information you have provided.
If this test shows evidence of cancer, the patient will be allocated to the appropriate MDT.
If the test does not show evidence of cancer, you will be informed of the outcome and in most cases, it will remain your responsibility to arrange suitable follow up for your patient. For some non-cancer conditions, the team at the trust will arrange onward referral to the appropriate speciality.
This guideline has been signed off on behalf of the NHS Devon.
Publication date: April 2022
Updated: March 2023
