Suspected Cancer Referral Pathways
Key points
- The threshold: NICE NG12 sets referral thresholds at a positive predictive value of around 3% - so most people referred will not have cancer, and that is by design.
- Urgent suspected cancer referral: still widely called a two week wait: the patient must be seen by a specialist within 14 days.
- Faster Diagnosis Standard: cancer must be diagnosed or ruled out within 28 days of an urgent referral, and treatment started within 62 days.
- Some pathways are faster: suspected childhood leukaemia and retinoblastoma need immediate or 48-hour assessment, not a two-week pathway.
- Colorectal referral now runs on FIT: a faecal immunochemical test at or above 10 micrograms of haemoglobin per gram of faeces triggers an urgent referral in a symptomatic patient.
- A normal test does not exclude cancer: around one in five lung cancers has a normal chest radiograph - refer anyway if clinical suspicion remains high.
- Safety netting: if you do not refer, you must arrange review, tell the patient what to come back for, and have a system that tracks the result.
- Non-specific symptoms: rapid diagnostic centres exist for patients with vague symptoms - weight loss, fatigue - who fit no site-specific pathway.
Introduction
UK cancer survival has historically lagged behind comparable European countries, and the largest single explanation is that patients are diagnosed at a later stage. Around a fifth of cancers in England are still diagnosed following an emergency presentation, and those patients do markedly worse than those diagnosed through a screening programme or a symptomatic referral.7
NICE NG12 is the guideline that addresses this. Its central decision, when it replaced the older guidance in 2015, was to lower the referral threshold from a positive predictive value of about 5% to about 3% - meaning that a symptom warrants urgent referral if roughly three in a hundred people with it turn out to have cancer.1 The consequence is deliberate: the great majority of people referred urgently do not have cancer, and referring them is the correct decision rather than a failure of discrimination.
The guideline is organised in two ways - by cancer site and by presenting symptom - which is what makes it usable in a ten-minute consultation. You can look up "dysphagia" as readily as "oesophageal cancer". For finals you are not expected to memorise every threshold, but the common ones recur constantly, and the structure of the decision matters more than the numbers.
The categories of referral
| Category | Timescale | Examples |
|---|---|---|
| Immediate referral | Within hours, usually by phone to the on-call team | A child with unexplained petechiae or hepatosplenomegaly (suspected leukaemia); suspected metastatic spinal cord compression; suspected retinoblastoma with an absent red reflex |
| Very urgent referral or investigation | Within 48 hours | Very urgent full blood count for suspected leukaemia in an adult; urgent X-ray in a child with a suspected bone sarcoma; very urgent protein electrophoresis for suspected myeloma |
| Urgent suspected cancer pathway referral | Seen by a specialist within 14 days - the "two week wait" | The great majority of NG12 recommendations |
| Urgent direct access investigation | Test performed and reported within 14 days | Chest radiograph for suspected lung cancer; upper GI endoscopy for dysphagia; CT abdomen for suspected pancreatic cancer; ultrasound for a soft tissue sarcoma |
| Non-urgent direct access investigation or referral | Within routine timescales, with safety netting | Breast lump in someone under 30; some basal cell carcinomas; lower-risk dyspepsia |
Site-specific criteria worth knowing
The following are the thresholds that appear most often in written papers and in practice. They are a summary rather than a substitute for the guideline, which should be consulted in real consultations.4
| Site | Trigger | Action |
|---|---|---|
| Lung | Chest radiograph suggestive of lung cancer, or aged 40 and over with unexplained haemoptysis | Refer |
| Lung | Aged 40 and over with two or more unexplained symptoms from cough, fatigue, breathlessness, chest pain, weight loss or appetite loss - or one or more if they have ever smoked. Also consider for persistent or recurrent chest infection, clubbing, supraclavicular or persistent cervical lymphadenopathy, thrombocytosis, or chest signs of lung cancer. | Urgent chest radiograph within 2 weeks |
| Breast | Aged 30 and over with an unexplained breast lump, with or without pain; or aged 50 and over with discharge, retraction or other concerning change in one nipple | Refer |
| Breast | Skin changes suggestive of breast cancer at any age; or aged 30 and over with an unexplained axillary lump | Consider referral |
| Colorectal | A symptomatic patient meeting the FIT criteria, with faecal haemoglobin at or above 10 micrograms per gram; or a rectal or abdominal mass, or an anal ulcer or mass on examination | Refer. FIT has become the gateway test for most symptomatic presentations.2 |
| Oesophageal and gastric | Dysphagia at any age, or aged 55 and over with weight loss and upper abdominal pain, reflux or dyspepsia | Urgent direct access upper GI endoscopy within 2 weeks |
| Pancreatic | Aged 40 and over with jaundice | Refer |
| Pancreatic | Aged 60 and over with weight loss plus any of diarrhoea, back pain, abdominal pain, nausea, vomiting, constipation or new-onset diabetes | Urgent direct access CT (or ultrasound) within 2 weeks |
| Bladder and renal | Aged 45 and over with unexplained visible haematuria without urinary infection, or visible haematuria persisting after successful treatment of infection; or aged 60 and over with unexplained non-visible haematuria plus dysuria or a raised white cell count | Refer |
| Prostate | The prostate feels malignant on digital rectal examination, or the PSA is above the age-specific reference range | Refer |
| Ovarian | Ascites, or a pelvic or abdominal mass not clearly explained by fibroids | Refer. Otherwise measure CA 125 in women aged 50 and over with new IBS-like symptoms, persistent bloating, early satiety, pelvic or abdominal pain, or urinary urgency or frequency; if CA 125 is 35 IU/mL or above, arrange an ultrasound. |
| Endometrial | Aged 55 and over with post-menopausal bleeding | Refer. Consider direct access ultrasound in women under 55 with post-menopausal bleeding. |
| Cervical | Appearances on examination consistent with cervical cancer | Refer - and do not wait for a cervical screening result |
| Testicular | Non-painful enlargement or change in shape or texture of the testis | Consider referral; consider direct access ultrasound |
| Melanoma | Weighted 7-point checklist score of 3 or more, dermoscopic suspicion of melanoma, or a new pigmented line in a nail with associated destruction of the nail | Refer |
| Squamous cell carcinoma of skin | A skin lesion raising suspicion of squamous cell carcinoma | Refer |
| Head and neck | Unexplained ulceration in the oral cavity lasting more than 3 weeks; a persistent unexplained lump in the neck; unexplained persistent hoarseness in someone aged 45 or over (also arrange an urgent chest radiograph); an unexplained thyroid lump | Refer |
| Brain and CNS | Progressive, sub-acute loss of central neurological function | Consider urgent direct access MRI (or CT if MRI contraindicated) within 2 weeks |
| Sarcoma | An unexplained lump that is increasing in size | Urgent ultrasound within 2 weeks. For suspected bone sarcoma, urgent X-ray within 2 weeks in adults, or within 48 hours in children and young people. |
| Myeloma | Aged 60 and over with persistent bone pain, particularly back pain, or an unexplained fracture | FBC, calcium, and plasma viscosity or ESR. If suggestive, very urgent protein electrophoresis and Bence Jones protein within 48 hours. |
| Leukaemia | Suspected leukaemia in an adult | Very urgent full blood count within 48 hours. In a child or young person with unexplained petechiae or hepatosplenomegaly, immediate specialist assessment. |
Symptoms that cross sites
Several presentations do not point to one organ and are worth recognising as a group, because they are the ones most often dismissed.
- Unexplained weight loss - prompts consideration of colorectal, gastro-oesophageal, lung, pancreatic, prostate and urological cancer, and myeloma. Combined with any other symptom it usually crosses a referral threshold.
- Unexplained iron deficiency anaemia - in a man of any age or a post-menopausal woman, this means gastrointestinal investigation until proven otherwise
- Unexplained lymphadenopathy or splenomegaly - consider haematological malignancy and arrange a full blood count
- Thrombocytosis - an unexplained raised platelet count is now recognised as a marker for lung, oesophageal, gastric, colorectal, uterine and renal cancer, and should prompt review rather than being ignored
- An unprovoked venous thromboembolism - warrants clinical review for cancer, though routine extensive screening is no longer recommended
- New-onset diabetes with weight loss in an older adult - specifically flagged in the pancreatic pathway
- A GP's clinical concern that does not fit a pathway - which is exactly what non-specific symptom pathways exist for
Safety netting
Most patients with the symptoms in NG12 do not meet a referral threshold, and most who do will not have cancer. Safety netting is what makes it safe to not refer, and its absence is a recurring theme in serious incident reports and in exam questions.
- Tell the patient what you are thinking, in proportionate terms, and what specifically should bring them back - a symptom that persists beyond a stated interval, or a new symptom
- Set a definite review interval rather than "come back if it doesn't settle", and document it
- Have a system for tracking results, so a report that comes back abnormal after the consultation is acted on and not filed
- Repeat the test where appropriate - a normal FIT in a patient with persisting symptoms and a strong clinical suspicion does not close the matter, and NICE is explicit that FIT does not override clinical judgement
- Document your reasoning for not referring, including the negative findings
- Follow up non-attenders. A patient who does not attend a suspected cancer appointment needs active follow-up, not discharge - the group who do not attend have a higher cancer incidence, not lower.
- Use risk assessment tools such as QCancer where they help, particularly in patients with multiple low-level symptoms
What happens after referral
| Standard | What it measures |
|---|---|
| 14 days | From urgent suspected cancer referral to first being seen by a specialist |
| 28 days - Faster Diagnosis Standard | From urgent referral (or an urgent screening referral) to the point at which cancer is diagnosed or ruled out and the patient is told3 |
| 31 days | From the decision to treat to the start of first definitive treatment |
| 62 days | From urgent referral to the start of first definitive treatment |
The Faster Diagnosis Standard is why so many pathways now run tests in parallel rather than in sequence - straight-to-test endoscopy, a CT booked at the point of referral, one-stop breast clinics combining examination, imaging and core biopsy in a single visit. It also means that a patient in whom cancer is excluded should be told promptly, rather than left waiting for a clinic appointment to hear good news.
Explaining the referral to the patient
Patients recognise the words "two week wait", and being referred on one is frightening. It is neither honest nor kind to conceal why - "I'm referring you to make sure this isn't anything serious" leaves the patient to fill in the gap themselves, usually with something worse. A workable form of words is: "There's a specific pathway for getting people seen quickly when there's a symptom we need to explain. Most people referred this way turn out not to have cancer, but I want to be sure, and this is the fastest way to find out." Then check what they have understood, tell them to expect contact within two weeks, and explain what to do if they hear nothing.
Pitfalls
Outcomes
Since NG12 lowered the referral threshold, urgent referral volumes have risen substantially while the conversion rate - the proportion of referrals that turn out to be cancer - has fallen. That is the intended trade-off: more people investigated unnecessarily, in exchange for finding more cancers at an earlier and more treatable stage. The detection rate, meaning the proportion of all cancers diagnosed through an urgent pathway, has risen, and emergency presentations have fallen.5,7
Stage at diagnosis is the outcome that matters, because it determines whether treatment is given with curative or palliative intent. Earlier diagnosis in colorectal, lung, breast and ovarian cancer translates directly into better survival, which is the reasoning behind both the referral thresholds and the Faster Diagnosis Standard.
For the individual clinician, the practical conclusion is straightforward. The system is designed on the assumption that most urgent referrals will be negative, so a low conversion rate is not evidence of poor practice. The failure mode to avoid is the opposite one: the patient seen three times, given three courses of antibiotics, and referred at the fourth visit - by which time the stage has changed.
References
- NICE NG12. Suspected cancer: recognition and referral. 2015, updated 2023. Available here
- NICE DG56. Quantitative faecal immunochemical testing to guide colorectal cancer pathway referral in primary care. 2023. Available here
- NHS England. Faster Diagnosis Standard and cancer waiting times standards. Available here
- NICE Clinical Knowledge Summaries. Suspected cancer - recognition and referral. Available here
- Hamilton W. The CAPER studies: clinical features of cancer in primary care. British Journal of Cancer. 2009. Available here
- NHS England. Rapid diagnostic centres: vision and 2019/20 implementation specification. Available here
- Cancer Research UK. Early diagnosis and routes to diagnosis statistics. Available here
This article is written for revision and education. It is not clinical guidance and must not be used to make decisions about the care of a patient. Always check current NICE guidance and local protocols.