CANCER REFERRAL PATHWAY FOLLOWING NICE GUIDANCE FOR

PRIMARY CARE PHYSICIANS

The following document shall give guidance on each of the following types of 2WW Cancer
Referral Pathways and accompanying with it, I have produced a poster as a form of quality
improvement activity; which should raise an awareness of the pre-requisite criteria required
for producing a prompt and appropriate patient referral.

In short, a referral via the 2WW cancer referral pathway is dependent on three main
attributes. These involve (a) identification of key red flag/s in the clinical history (b) worrying
examination findings e.g. painless jaundice, hepatosplenomegaly, abdominal mass,
persistent macroscopic or microscopic haematuria. These may be isolated findings or may
supplement a concerning clinical history that would prompt referral (c) abnormal
investigations, e.g. positive FIT test or a persistently raised PSA test on 2 or more occasions.

According to the audit performed looking at 2WW cancer referral data at Farnham Rd
Surgery from April 2019 – September 2019 vs April 2020 – September 2020, it was clear that
the most popular top 5 specialties for 2WW referrals were Breast, Lower GI, Dermatology,
Upper GI and Gynaecology. Page 2 gives a breakdown as to specific pre-requisite criteria
required to ensure there is minimal delay in getting patients to be seen urgently in
secondary care. Below the following criteria may change depending on local policy and any
changes in NICE guidance. Usually DXS referral forms may be subsequently updated.

Page 3-4 show flowcharts which I feel would be useful to implement whenever anybody is
unsure of particular red flags either in clinical history or examination. These would serve as
useful reminders and may also be used to highlight the importance of cancer recognition to
patients who are being examined face-to-face in GP during COVID-19 times. However, these
flowcharts are to be used as guides and where there is clinical doubt the correct avenues
should be taken i.e. consulting another primary care colleague, picking up the phone to
speak to a secondary care colleague or by putting an Advice & Guidance/communication via
any platforms like local WhatsApp groups; the latter can be used where the concern isn’t
imminently likely to cause patient deterioration in the next 1-2 weeks whilst awaiting a reply
from a secondary care colleague. Sources used include NICE guidance, DXS forms in local
area and useful breakdown of 2WW criteria as found on NHS Devon CCG page.

In terms of improving the audit for future purposes, there was a suggestion raised at one of
the Monday meetings to evaluate those patients diagnosed with cancer in secondary care
mainly upon hospital admission; without prior 2WW referral by the primary care physician.
These may have been incidental findings but would thus generate a retrospective form of
learning. For this perhaps a search function on DocMan would need to be initiated to search
for terms such as “tumour” or “cancer”. However, the logistics of doing this may be difficult
alongside a regular EMIS search function for extrapolating data for referrals that have
actually been put through via primary care colleagues.

Yours Sincerely,

Dr Mohammed Omer Anwar, GPST2 Doctor at Farnham Road Surgery.

 PRE-REQUISITE CRITERIA FOR CANCER REFERRALS

Haematology 2WW Referral Criteria (Attach blood results <8 weeks old).

 Suspected Myeloma = FBC, U&Es, Calcium, ESR or CRP, Serum Protein

Electrophoresis, urinary Bence - Jones protein.
 Suspected Lymphoma = FBC, U&Es, LFTs, LDH.

Colorectal 2WW Referral Criteria (Attach blood results <6 weeks old).

 Suspected lower GI cancer requires blood tests including FBC, U&Es, LFTs, CRP or
ESR, Ferritin and Faecal Immunochemical Test (FIT). Ca-125 or PSA test may be
added depending on the clinical circumstances in which they are performed.

Gynaecology 2WW Referral Criteria (Attach blood results <6 weeks old)

 Suspected Ovarian Cancer = Please attach FBC and Ca-125 result.

 Suspected Endometrial Cancer = Stop HRT in order to evaluate if improvement in
PV bleeding when considering referral. Provide BMI, height and weight, PMH, BP,
allergies, current medications and routine blood screen.

ENT 2WW Referral Criteria

 Preferably a thyroid function test result <8 weeks old would be useful.

Lung 2WW Referral Criteria (Attach blood results <8 weeks old)

 If abnormal findings are noted on CXR suggestive of lung cancer or mesothelioma,

then CXR should be <3 weeks old.
 If patient is aged 40+ with unexplained haemoptysis, consider urgent CXR <48hrs.
 When referring, it is important that the following bloods are performed (<8 weeks
old) = FBC, U&Es, LFTs, bone profile, clotting.

Upper GI 2WW Referral Criteria (Attach blood results <8 weeks old).

 Suspected upper GI Cancers = FBC, U&Es, LFTs, ferritin, iron studies, bilirubin.

Urology 2WW Referral Criteria (Attach blood results <8 weeks old and up-to-date MSU)

 Ensure that an up-to-date urine MSU is attached alongside FBC, U&Es (less than 8
weeks old). Attach PSA blood test where necessary when suspicious for prostate
cancer. Ensure a reliable PSA test is attached prior to referral following suspicious
DRE.
 KNOW YOUR CANCER PATHWAYS (adapted from NICE)!!
Part 1
The following flowchart represents the Top 5 MOST COMMON Referrals that are done at
Farnham Road Surgery. Please check pre-requisite criteria on Page 2 for further info.

Breast 2WW Referral Criteria Lower GI 2WW Urgent Referral Criteria Dermatology 2WW Referral Criteria

 Urgent Referral = Age 30 and over, Urgent Referral = (a) Positive Faecal Occult Blood  Suspected Malignant Melanoma = (a)
unexplained axillary lump or Test (FOBT) or Faecal Immunochemical Test (FIT) (b) Dermoscopy suggests melanoma of skin (b) A
unexplained breast lump. Age 50 Aged 40 or over, with unexplained weight loss or suspicious pigmented skin lesion with a ‘Weighted
and over, nipple retraction or abdominal pain. (c) Aged 50 or over, with 7 point checklist score’ of 3 or more. (c) Pigmented
discharge which is unilateral. For all unexplained rectal bleeding and any of the or non-pigmented skin lesion that suggests
ages, if there are any skin changes following:- abdominal pain, change in bowel habit, nodular melanoma e.g. bleeding or vascular
across the breast. weight loss or iron deficiency anaemia (d) Aged 60 or nodule unless definite benign diagnosis.
 Non-Urgent Referral = over, with iron deficiency anaemia or changes in  Suspected SCC or BCC = depends on
Unexplained breast lump (with or bowel habit (e) Unexplained anal mass or anal characteristics, size and location of lesion.
without pain) under age of 30. ulceration.

BREAST, LOWER GI, DERMATOLOGY, UPPER GI and

GYNAECOLOGY 2WW CRITERIA

Upper GI: Urgent/Non-Urgent Referral Criteria Gynaecology 2WW Referral Criteria

 Urgent Referral = (a) Age 55 or over, weight loss plus any of the  Ovarian Cancer = If there are symptoms of early satiety, abdominal
following:- upper abdominal pain, reflux or dyspepsia. (b) In any age with bloating, pelvic/abdominal pain or increased urinary frequency.
concerns of dysphagia or abdominal mass. (c) Aged 40 and over with Consider urgent Ca-125. If serum Ca-125 is 35 IU/ml or greater,
jaundice. consider urgent pelvic ultrasound. If U/S findings are suspicious, then
 Urgent direct access CT scan or urgent U/S where CT not available to consider urgent referral.
assess pancreatic Ca in people aged 60 or over, with weight loss and any  Endometrial Cancer = Urgent 2WW referral for women >55 years old
of the following:- diarrhoea, back pain, abdominal pain, nausea, with post-menopausal bleeding and in women <55 years old with
vomiting, constipation or new onset diabetes. premature post-menopausal bleeding. Consider urgent access U/S scan
 Urgent access U/S scan for patients with upper abdominal mass for these women with unexplained PV discharge, thrombocytosis, and
consistent with enlarged liver. haematuria or high blood glucose levels.
 Non-urgent direct access endoscopy for people with hematemesis.  Cervical Cancer = Symptomology and risk factors of unexplained post-
Ensure to calculate Rockall Score in these patients for prognosis. coital bleed or intermenstrual bleed, high no. of sexual partners or any
FHx of cervical cancer. Urgent 2WW referral for those with suspicious
findings on smear test.
 Vulval Cancer (Less Common) = Refer if unexplained ulceration, bleed
or lump present around vulva.
 Vaginal Cancer (Rare) = Unexplained palpable mass at or near entrance
of vagina.
 KNOW YOUR CANCER PATHWAYS (adapted from NICE)!!
Part 2
The following flowchart represents the next 5 COMMON Referrals that are done at
Farnham Road Surgery. Please check pre-requisite criteria on Page 2 for further info.

Urology 2WW Referral Criteria ENT 2WW Referral Criteria Brain CNS Urgent/Non-Urgent Criteria.

 Suspected Prostate Cancer = Asymmetrical,  Suspected laryngeal/thyroid cancer – Age 45 and  Urgent 2WW Referral = Any of the following:-
irregular and firm prostate on DRE and over with (a) persistent unexplained hoarseness progressive headache or neurological deficit,
raised PSA level on second reading, >3 weeks or (b) an unexplained lump in the neck. cranial nerve palsy, unexplained cognitive
performed 6 weeks after the first. Ensure  Suspected oral cancer – Unexplained oral impairment or reduced GCS, new-onset seizures,
PSA test postponed 1 month after ulceration lasting >3 weeks or a unilateral sensorineural deafness for which brain
treatment for UTI. persistent/unexplained lump in the neck. tumour is suspected or any signs of raised ICP.
 Suspected Bladder and Renal Cancer = (a) Unexplained persistent sore throat if associated  Urgent 2WW Referral = Patients diagnosed with
Aged 45 and over, with unexplained visible with dysphagia, hoarseness or otalgia. any previous cancer who develop any of the
haematuria in the absence of UTI or  Consider urgent dental opinion within <2 weeks following symptoms:- (a) recent-onset seizure (b)
persistent visible haematuria despite for suspected oral cancer or a red/white patch in progressive neurological deficit (c) persistent
antibiotics for UTI. (b) Aged 60 and over, oral cavity. headaches (d) new mental or cognitive change (e)
unexplained non-visible haematuria with  Suspected Cerebellopontine angle tumour = new neurological signs.
raised WCC on blood test or soft tissue Unilateral sensorineural hearing loss associated  Non-urgent 2WW Referral or Neuro Discussion=
mass identified on urinary tract imaging. with any of the following such as tinnitus, vertigo, Unexplained headache symptoms of recent onset
 Suspected Testicular Cancer = Non-painful nausea or vomiting. that are present for at least 1 month and not
enlargement or change in shape or texture  Suspected Nasopharyngeal Carcinoma = Refer if accompanied with any features of raised ICP.
of testis. Consider direct access ultrasound there is a unilateral nasal polyp that is bleeding or
scan for scrotal mass. concerns of a neck lump, unilateral hearing loss or
 Suspected Penile Cancer = Penile mass or tinnitus. More common in smokers.

UROLOGY, ENT, BRAIN CNS, LUNG AND

HAEMATOLOGY 2WW CRITERIA

Lung 2WW Referral Criteria Haematology 2WW Referral Criteria

 Offer urgent CXR (to be performed <2 weeks) for age 40 or more for  Suspected Leukaemia -> Ensure urgent FBC performed within 48hrs
any of the 2 unexplained symptoms:- (a) unexplained haemoptysis  Suspected Myeloma -> Common in age >60 with persistent bone
(b) cough (c) fatigue (d) SOB (e) chest pain (f) weight loss (g) appetite pain or unexplained fracture -> Urgent FBC, calcium, ESR, protein
loss. electrophoresis and Bence-Jones protein urine test (within 48hrs).
 Offer urgent CXR (to be performed <2 weeks) for age 40 or more  Suspected Non-Hodgkin’s Lymphoma -> Unexplained
with any of the following: (a) Persistent or recurrent chest infection lymphadenopathy or splenomegaly (usually with associated B-
(b) finger clubbing (c) supraclavicular or cervical lymphadenopathy symptoms) in children or adults.
(d) chest signs consistent with lung cancer (e) thrombocytosis.  Suspected Hodgkin’s Lymphoma -> Unexplained lymphadenopathy
 Offer urgent CXR (to be performed <2 weeks) for age 40 or more (usually with associated B-symptoms) or ETOH-related lymph node
with either (a) finger clubbing or (b) chest signs compatible with pain in children or adults.
pleural disease.
 If there are any CXR or CT imaging suspicious of lung malignancy
then refer to Lung 2WW.