Imaging pathway for Primary Care direct access to CT chest/abdomen/pelvis for suspected malignancy (Guidelines)

Clinical assessment of patient by GP leads to very strong suspicion of suspected underlying malignancy with, for example:

• New unexplained significant weight loss (either documented 5% or more body weight lost or a strong clinical suspicion if no documentation available)
• New unexplained loss of appetite, fatigue, nausea, malaise or bloating of 4 weeks or more (less if strong clinical suspicion)
• New unexplained, unexpected, or progressive pain, including bone pain, of 4 weeks or more.

There is no indication of localising signs, symptoms or laboratory tests to suggest malignancy in a specific system. If there is any indication of localising signs, symptoms or laboratory tests to suggest malignancy in a specific system then direct referral to secondary care should be made using the appropriate established pathway without requesting a CT scan

This pathway is for patients who are 40 years of age or over, except where metastatic disease has been reported on chest x-ray (CXR) or ultrasound.

A GP should have completed the following elements:      

1. Full systems examination including depression screening.
2. Relevant biochemical and haematological testing, if not done within the last 3 months:
   • FBC, PV, CRP, Renal function including eGFR, HbA1c, LFTs, TFTs, myeloma screen, bone profile, ferritin, B12 and folate
3. Consider Ca-125 (see gynaecology cancer guidelines for who to test and thresholds for referral), PSA (see urological cancer guidelines for who to test and thresholds for referral), blood borne viruses.
4. Urinalysis
5. CXR
6. Consider the principles of realistic medicine

1. No CT of chest / abdomen / pelvis in last 12 months
2. Patient is 40 years of age or over.
   An Ultrasound of abdomen and pelvis can be requested if the patient meets referral criteria but is under 40.
3. If a CXR has been reported as showing metastatic disease with no known primary do not request CT.  Please refer to respiratory as USC.  
4. If a CXR has been reported as showing metastatic disease and the patient has had an invasive malignancy in the previous 5 years please discuss with that team.
5. If the patient is under active follow up then discuss with parent team. If the patient had an in situ malignancy or cancer >5 years ago and is no longer under active follow up then this pathway is appropriate.
6. This pathway is NOT for patients where there is evidence of primary intrapulmonary malignancy on CXR. If a CXR has been reported as a likely primary lung malignancy please refer to respiratory as USC.
7. If an ultrasound has been reported as showing likely liver metastases then this CT pathway can also be used for all age groups
8. Do NOT request a CT scan to speed up care if you have a primary site in mind. See standard USC pathways for GP referrals to secondary care. See: Scottish referral guidelines for suspected cancer | Right Decisions

Notes: 

• DNA: referring practice will be notified. New referral required if still wanted, after discussion with the patient to ensure adherence.
• Target will be to book CTs (and USs) within 2 weeks, and for CT, report within 1 to 2 weeks.
• Any unexpected urgent findings will be notified to the practice within 1 working day by email or telephone. Life threatening findings will be communicated more urgently.

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• CT: Computerised tomography
• CRP: C-reactive protein
• CXR: Chest X-ray
• DNA: Did not attend
• eGFR: Estimated glomerular filtration rate
• HbA1c: Haemoglobin A1c
• FBC: Full blood count
• LFT: Liver function test
• TFT: Thyroid function test
• PSA: Prostate specific antigen
• PV: Polycythaemia vera
• USC: Urgent Suspected Cancer
• US: Ultrasound scan