Suspected cancer with non-specific symptoms

Update to Pathway from Primary Care for Direct Access to CT of Chest/Abdomen/Pelvis for NHS Greater Glasgow & Clyde. December 2024

Direct Access to CT Chest/Abdomen/Pelvis (CT CAP) in NHS GG&C was implemented in 2022. The pathway document was based on the Scottish Clinical Imaging Network pathway from October 2015. A review of the pathway was undertaken following an audit of the current pathway, the introduction of a “non-specific symptoms” section in the Scottish Referral Guidelines for Suspected Cancer 2025 and discussion with primary care clinical advisory group and radiology services within NHS Greater Glasgow & Clyde.

The main amendment to this pathway is the removal of the requirement for Chest X-Ray prior to referral for CT CAP.

Referral Pathway

1. Clinical assessment of patient by General Practitioner leading to very strong suspicion of suspected underlying malignancy with no localising features.

This may include person with any of the following features:

• New unexplained weight loss (either documented ≥5% in three months or with strong clinical suspicion)
• New unexplained loss of appetite, fatigue, nausea, malaise, or bloating of four weeks or more (less if strong clinical suspicion)
• New unexplained, unexpected or progressive pain, including bone pain, of four weeks or more
• GP ‘gut feeling’ of cancer diagnosis

2. Consider the following investigations where appropriate to clinical presentation. These will help identify if a patient needs to be referred to a speciality or through non-specific symptoms pathway:

• Urinalysis (for haematuria: see national guideline and *Urological cancer)
• Haematology: Full blood count, ESR, haematinics
• Biochemistry: U&Es, LFTs, Bone profile, TFTs, HbA1C, CRP
• Blood borne virus screen
• CA-125 (see *Gynaecological cancer guidelines)
• PSA (see *Urological cancer guidelines)
• Plain film x-ray (for example Chest X-ray or bone X-ray)

3. If there is any indication of localising clinical features or results from investigations to suggest malignancy in a specific system, direct USC referral to secondary care should be made to ensure cancer tracking and waiting times monitoring is activated.

4. Prior to requesting a CT scan of chest/abdomen/pelvis the requester must ensure the following has been completed.

• Appropriate history & examination and investigations as indicated
• Psychosocial history to exclude mental health as possible cause
• eGFR within the last 3 months to allow for contrast
• Consideration of principles of realistic medicine

5. Pathway is intended for patients 40+ years of age. For patients under 40 use of existing referral pathways and/or discussion with consultant colleagues initially is recommended.

6. Exclude pregnancy. If patients are known to be pregnant CT CAP is not an appropriate investigation. If significant concern discuss with obstetrician. If possibility of pregnancy cannot be excluded discuss with radiologist prior to referral.

Further Information

Useful guidance on assessment of unintentional weight loss can be found in BMJ Best Practice and a BMJ clinical review for older adults

For the full Scottish Referral Guidelines for Suspected Cancer go to: https://www.cancerreferral.scot.nhs.uk or download the app.

There is a “non-specific symptoms” cancer module on the Gateway C platform. This is free for anyone working in NHS Scotland supported by NHS Education for Scotland. Access the module here: https://www.gatewayc.org.uk/courses/non-specific-symptoms/