Scottish referral guidelines for suspected cancer · 2015-11-10 · Scottish referral guidelines for suspected cancer • 1 1 Introduction 1.1 BACkgRound Although cancer is a common

Scottish referral guidelines for suspected cancer

May 2014

© Healthcare Improvement Scotland 2014

First published October 2013. Updated May 2014.

You can copy or reproduce the information in this document for use within NHSScotland and for educational

purposes. You must not make a profit using information in this document. Commercial organisations must get our

written permission before reproducing this document.

www.healthcareimprovementscotland.org

Contents1 Introduction ....................................................................................................................................................................................1

1.1 Background ...............................................................................................................................................................................................................1

1.2 Purpose.......................................................................................................................................................................................................................2

1.3 Development of the guidelines .........................................................................................................................................................................2

1.3.1 Members of the guideline development team ............................................................................................................................................2

1.3.2 Methodology used .................................................................................................................................................................................................2

1.4 Achieving a balance ...............................................................................................................................................................................................3

1.5 Format of the guidelines ......................................................................................................................................................................................3

1.6 Referral timelines ....................................................................................................................................................................................................3

1.7 Dissemination of the guidelines .......................................................................................................................................................................4

1.8 Audit and review of the guidelines ..................................................................................................................................................................4

2 Common issues for cancer referrals ...........................................................................................................................................5

2.1 Patient issues ............................................................................................................................................................................................................5

2.1.1 Patients’ and carers’ needs ..................................................................................................................................................................................5

2.1.2 Impact of deprivation ...........................................................................................................................................................................................5

2.1.3 Demographic factors .............................................................................................................................................................................................5

2.1.4 Watch and wait ........................................................................................................................................................................................................5

2.1.5 Follow up ...................................................................................................................................................................................................................5

2.2 Referral process .......................................................................................................................................................................................................6

2.2.1 Use of the guidelines by all members of the primary care team...........................................................................................................6

2.2.2 Purpose of referral ..................................................................................................................................................................................................6

2.2.3 Clinical decision support tools and structured documentation and proformas for referral ......................................................6

2.2.4 Downgrading of urgent referrals ......................................................................................................................................................................6

2.2.5 Feedback where no cancer is found ................................................................................................................................................................6

3 Referral guidelines ........................................................................................................................................................................7

3.1 Lung cancer ..............................................................................................................................................................................................................8

3.2 Breast cancer ............................................................................................................................................................................................................9

3.3 Lower gastrointestinal cancer ............................................................................................................................................................................11

3.4 Oesophago-gastric, hepatobiliary and pancreatic cancers .....................................................................................................................12

3.5 Urological cancers ..................................................................................................................................................................................................14

3.6 Skin cancers ..............................................................................................................................................................................................................16

Reference list ..............................................................................................................................................................................................17

Appendices .................................................................................................................................................................................................18

Appendix 1: Glossary ..........................................................................................................................................................................................................18

Appendix 2: Members of guideline development team - steering group ......................................................................................................20

Appendix 3: Members of guideline development team - subgroups ...............................................................................................................21

Appemdix 4: Equality and diversity ...............................................................................................................................................................................23

Scottish referral guidelines for suspected cancer • 1

1 Introduction1.1 BACkgRound

Although cancer is a common problem with over 30,000 new cases being diagnosed in 2011 in Scotland (excluding

non-melanoma skin cancers), an individual general practitioner (GP) practice is likely to see about 31–32 new cases per

annum1. The average number of new cases per annum of individual cancer types for a GP practice with a list size of 5,518

patients is shown in Table 1. A GP practice is likely to see on average 4–5 new cases per annum of patients with each of

the most common cancers (lung, breast and colorectal cancer). An individual GP practice will also see only approximately

one new patient affected with either cancer of the bladder, kidney or oesophagus.

Table 1: Ten most common cancers in Scotland in 2011

Cancer ICd-10 code Total new cases no. cases per 5,518 population per annum1,2

Trachea, bronchus and lung C33-C34 5,069 5.32

Breast C50 4,604 4.83

Colorectal C18-C20 3,986 4.19

Prostate C61 2,806 2.95

Malignant melanoma of skin C43 1,202 1.26

Head and neck C00-C14, C30-C32 1,186 1.25

Non-Hodgkin’s lymphoma C82-C85 1,001 1.05

Oesophagus C15 836 0.88

Kidney C64-C65 835 0.88

Bladder C67 791 0.83

1. 5,518 represents an approximate estimate of the average list size per GP practice in Scotland as at October 2011

2. Rates are based on the total Scottish population of 5,254,800 as at 30 June 2011

Source: Scottish Cancer Registry, Information Services Division (ISD), April 2013; ISD Scotland, Practices and their Populations: http://www isdscotland.org/Health-Topics/General-Practice/Practices-and-Their-Populations/

The task for the GP is to differentiate between patients whose symptoms may be due to cancer and the much larger number

of patients with similar symptoms arising from other causes. For certain symptoms, it may be entirely appropriate for a

GP to wait to see if the symptom resolves. Persistence or worsening of the symptom may alert the GP to the possibility

of cancer. Wherever possible these factors have been taken into account in the development of these guidelines.

Cancer remains a national clinical priority for the Scottish Government and NHSScotland. The Scottish Government

launched the ‘Detect Cancer Early’ initiative, in February 2012, to improve the overall 5-year survival for people diagnosed

with cancer in Scotland by achieving a 25% increase in the proportion of people diagnosed and treated in the first stage of

breast, colorectal and lung cancer by 2015. The earlier a cancer is diagnosed and treated, the better the survival outcomes.

Improving the percentage of early stage diagnoses will reduce premature deaths from cancer and subsequently have

a positive effect on overall life expectancy. One of the objectives of the programme is to work with GPs and the wider

primary care team to promote referral or investigation at the earliest reasonable opportunity for patients who may be

showing a suspicion of cancer while making the most efficient use of NHS resources and avoiding adverse impact on

access.

http://www.isdscotland.org/Health-Topics/General-Practice/Practices-and-Their-Populations/

http://www.isdscotland.org/Health-Topics/General-Practice/Practices-and-Their-Populations/

2 • Scottish referral guidelines for suspected cancer

1.2 PuRPose

The Scottish Referral Guidelines for Suspected Cancer were first published in 2002 and subsequently revised in 2007.

This version updates referral guidelines for the lung, breast and lower gastrointestinal cancer and takes account of new

research evidence and the findings of audits undertaken since the last revision. The recommendations here supersede

those in previous guidelines.

In line with the previous referral guidelines, the aim of these updated guidelines is to facilitate appropriate referral

between primary and secondary care for patients whom a GP suspects may have cancer. The guidelines should help

GPs, the wider primary care team, other clinicians and patients and carers to identify those patients who are most likely

to have cancer and who therefore require urgent assessment by a specialist. Equally it is hoped that the guidelines will

help GPs to identify patients who are unlikely to have cancer and who may appropriately be observed in a primary care

setting or who may require non-urgent referral to a hospital.

1.3 develoPmenT of The guIdelInes

A multidisciplinary steering group was convened in 2012 to produce a relevant, evidence-based, clinically useful and

user-friendly document for practitioners in primary care. The first meeting was aimed at establishing the processes of

guideline development and making decisions about the scope of the guideline.

1.3.1. members of the guideline development team

The members reflected the diverse range of stakeholders to which the guideline will apply, including clinicians from

both primary and secondary care, pharmacists, nurses, doctors in training, cancer networks and patient representatives.

The knowledge and experience of the team was important to bridge the gap between international expert opinion,

limited robust evidence, patient experience and clinical practice in NHSScotland. Membership of the steering group is

shown in Appendix 2.

The full group was supplemented by three subgroups, representing each tumour type for which the guidelines are being

updated. The subgroups consisted of specialists in the tumour types, GPs, nurses, pharmacists and representatives from

the relevant patient organisations. The subgroups reviewed the extant guidelines and the associated evidence tables.

Each subgroup met two times to reach consensus. Membership of the subgroups is shown in Appendix 3.

1.3.2 methodology used

The steering group agreed that the starting point for the revision process would be the existing referral guidelines,

enhanced by a review of evidence-based recommendations for referral from across the world. These recommendations

were identified from a search of the websites for a number of guideline-producing organisations in June 2012. This was

supplemented with a search for relevant guidelines in Medline and Embase. The search was updated in January 2013 to

ensure that all relevant guidelines were identified. Only guidelines published in English were considered.


All the guidelines identified by the search were appraised for methodological quality using the Appraisal of Guidelines

for Research and Evaluation II (AGREEII) instrument. AGREEII is a validated tool used for the assessment of clinical practice

guidelines. It consists of 23 items organised into six quality domains that cover separate dimensions of guideline

quality. Each guideline is assigned an overall quality rating and a decision regarding whether the guideline would be

recommended for practice is also made. Each item is rated on a 7-point scale (1=strongly disagree to 7=strongly agree).

An overall summary of recommendations and quality rating for each guideline was compiled into evidence tables which

are available at www.healthcareimprovementscotland.org

The groups identified, reviewed and systematically considered differences in recommendations emerging from the

guidelines, in the light of their clinical and practical experience as well as their expert knowledge of the literature, while

taking account of the Scottish context. Where Scottish Intercollegiate Guidelines Network (SIGN) guidelines are in place

or are being revised, effort was made to ensure consistency between these guidelines and the related SIGN guideline.

1.4 AChIevIng A BAlAnCe

Members of the subgroups were aware of the need to achieve a balance when setting criteria for urgent referral. If the

threshold is set too high, patients with a significant possibility of having cancer will be excluded. Furthermore the criteria

would be likely to be limited to patients with the most obvious symptoms, who may be most likely to have advanced

and/or incurable disease. Conversely, if the threshold is set too low, a large number of patients might be unnecessarily

referred urgently causing them avoidable anxiety and distress. This could overwhelm hospital clinics to the detriment

of patients with cancer and also to those with other serious illnesses.

1.5 foRmAT of The guIdelInes

The guidelines covering the three tumour groups that have been revised are presented separately. There is not complete

uniformity in the layout of the guidelines as members of specific subgroups advised slightly different formats that

reflect the distinct nature of symptoms and patterns of disease. However, for each tumour group the guidelines include

information on:

z key points about the pattern of the relevant cancer, and

z guidelines for referral.

1.6 RefeRRAl TImelInes

The referral timelines used in the guidelines include:

z urgent suspicion of cancer: the patient is seen within the Scottish Government target for urgent referrals

z routine: all other referrals, and

z primary care management.

All staff involved in the referral process should be aware of the difference and importance of using these terms.

http://www.healthcareimprovementscotland.org


1.7 dIssemInATIon of The guIdelInes

The guidelines will be widely disseminated in a variety of formats. The current guidelines will be made available on both

the Scottish Government and the Healthcare Improvement Scotland websites.

1.8 AudIT And RevIew of The guIdelInes

Audit and monitoring of the guidelines in practice should generate a valuable amount of new information which will

be used to revise the guidelines in the future. It is strongly recommended that the Regional Cancer Networks undertake

prospective audit of the guidelines.


2 Common issues for cancer referrals2.1 PATIenT Issues

2.1.1 Patients’ and carers’ needs

All healthcare professionals should be sensitive to the needs of patients, carers and relatives when cancer is suspected.

Good practice includes:

z being sensitive to the patient’s wishes to be involved in decisions about their care

z providing understandable information at a level appropriate to the patient’s wishes to be informed

z providing information about any referral to other services in a variety of formats, whether to secondary or tertiary

care, including how long they might have to wait, who they are likely to see, and what is likely to happen to them

z considering carefully the need for physical and emotional support while awaiting an appointment with a specialist

z considering any carer’s needs for support and information, taking issues of confidentiality into consideration

z taking the individual’s particular circumstances into account, for example age, family, work and culture

z being aware of, and offering to provide access to, sources of information in various formats

z maintaining a high standard of communication skills, including, for example, in the process of breaking bad news.

2.1.2 Impact of deprivation

Deprivation affects the incidence of and mortality associated with cancers. It also impacts materially on the ability of

patients to access healthcare services. It is essential that any consultation or other opportunity where a patient from a

deprived area presents with symptoms suggestive of possible cancer is used to full advantage.

2.1.3 demographic factors

As with deprivation, the increasing number of patients with long-term conditions and comorbidity pose major clinical

challenges and affect both the incidence of and mortality from cancer. Chronic disease management programmes afford

an opportunity to identify symptoms suggestive of possible cancer.

2.1.4 watch and wait

It is not always appropriate for a GP to refer a patient immediately with new symptoms or signs which could be cancer

(for example, 1 week of diarrhoea or a sore throat for 10 days) and an initial ‘watch and wait’ strategy may be appropriate.

It is also important for GPs to provide a ‘safety net’ and ensure patients know when to return if their condition does not

improve or change. However, in some cases, patients will be unwilling to watch and wait due to high levels of anxiety.

In such cases, the referring GP should ensure that this is detailed in the referral documentation.

2.1.5 follow up

It is good practice for the referrer to consider ways of supporting the patient to attend investigations or reviews and

addressing any concerns the patient may have about their referral. Reminders, such as text messaging, have been shown

to be effective in increasing the attendance rate for reviews.


2.2 RefeRRAl PRoCess

2.2.1 use of the guidelines by all members of the primary care team

The guidelines are designed for use in any primary care setting, by any member of the clinical team. Local arrangements

should be in place in each NHS board area for pharmacists, NHS24, nursing staff and others to ensure rapid referral is

arranged. Most commonly this would be by making arrangements for the patient to see their GP urgently, clearly notifying

the concern about suspected cancer.

2.2.2 Purpose of referral

The ‘urgent suspicion of cancer’ referral pathway is designed to allow the rapid assessment and investigation of a patient

to determine the cause of their symptoms. For patients with persisting symptoms it is not acceptable to simply exclude

cancer without providing an assessment of the likely underlying cause. This may involve individual hospital specialities

making internal referrals to their colleagues to help determine the nature and cause of the patient’s symptoms. These

internal referrals should be undertaken with the minimum of delay and with good communication to both the patient

and GP. Where diagnostic tests are undertaken, the person requesting the test has a responsibility for acting on the result

and ensuring that the patient receives this.

NHS boards may wish to consider which diagnostic services GPs should have direct open access to. In these situations

the GP would be responsible for communicating the result to the patient and arranging any subsequent follow up.

2.2.3 Clinical decision support tools and structured documentation and proformas for referral

To achieve consistency, clinical decision support systems and structured proformas for referral would be helpful for use

in all clinical settings. Scottish Care Information (SCI) Gateway provides the means for electronic referrals, but clinical

decision support systems vary across NHSScotland.

2.2.4 downgrading of urgent referrals

On rare occasions it may be acceptable for the receiving hospital speciality to downgrade an urgent suspicion of cancer

referral to routine. This should never occur without first contacting the GP practice and allowing the GP the opportunity

to explain why an urgent referral was requested. Vital information may have been omitted from the referral or may

have become available since the referral was made. It is essential that the patient is kept informed about any change in

referral priority.

2.2.5 feedback where no cancer is found

The referring GP should receive timely feedback on the outcomes for all patients with an urgent suspicion of cancer

referral. Where negative results are found, this allows the GP to consider alternative courses of action. Likewise, information

about inappropriate referrals should be fed back to the referring GP detailing why it was felt to be inappropriate and

suggesting an alternative course of action.


3 Referral guidelines


3.1 lung CAnCeR

More than 90% of patients with lung cancer are symptomatic at the time of diagnosis2. However, many symptoms

associated with lung cancer (particularly cough and fatigue) are common presentations in primary care, associated

with chronic diseases such as chronic obstructive pulmonary disease (COPD). It is therefore important that changes in

symptoms are identified and acted upon.

Chest x-ray findings are abnormal in over 96% of symptomatic patients with lung cancer2. In most cases where lung

cancer is suspected, it is appropriate to arrange an urgent chest x-ray before urgent referral to a chest physician. However,

a normal chest x-ray does not exclude a diagnosis of lung cancer. If the chest x-ray is normal but there is a high suspicion

of lung cancer, patients should be offered urgent referral to a respiratory physician. In patients with a history of asbestos

exposure, mesothelioma should be considered.

urgent chest x-ray

Any haemoptysis

Unexplained/persistent (more than 3 weeks) � change in cough

� dyspnoea

� chest/shoulder pain

� weight loss

� chest signs

� hoarseness

� fatigue in a smoker aged over 50 years

Finger clubbing

Features suggestive of metastatic disease

Cervical and/or persistent supraclavicular lymphadenopathy

Any person who has been referred for an urgent chest x-ray and has been found with consolidation should have a repeat chest x-ray no more than 6 weeks later to confirm resolution.

urgent suspicion of cancer referral

Any symptoms or signs detailed above persisting for longer than 6 weeks despite a normal chest x-ray

Chest x-ray suggestive/suspicious of lung cancer (including pleural effusion, pleural mass and slowly resolving consolidation)

Persistent haemoptysis in smokers/ex-smokers over 50 years of age

mesothelioma

In mesothelioma, 80–90% of patients will have a history of asbestos exposure2 and it is essential that a career history is

taken to identify any possible asbestos exposure.


Individuals over 50 years with history of asbestos exposure and recent onset of: � chest pain

� dyspnoea

� unexplained systemic symptoms


3.2 BReAsT CAnCeR

Breast symptoms are a relatively uncommon presentation in primary care. It is estimated that between 0.35% and 0.6%

of all consultations in Scotland are for breast symptoms. Many of these consultations will be in young women, whereas

the biggest risk factor, after gender, is increasing age. Incidence of breast cancer in women aged 30-35 is 33 per 100,000

population and approximately 81% of breast cancers occur in women over the age of 50.

Breast cancer accounts for 30% of cancers in women and around 4,400 people are diagnosed with breast cancer in Scotland

each year; approximately 20 of these are men. The following recommendations seek to improve the referral and effective

management of breast symptoms in women and men in primary care. Guidance for referral to regional genetics centres

for those with a family history of breast cancer is available at www.sehd.scot.nhs.uk/mels/CEL2009_06.pdf


Routine referral Primary care managementIssue relevant advice leaflet

lump � Any new discrete lump (in patients over 35 years)

� New asymmetrical nodularity that persists at review after menstruation (in patients over 35 years)

� Unilateral isolated axillary lymph node in women

� Cyst persistently refilling or recurrent cyst

� Any new discrete lump in patients under 35 years with no other suspicious features

� New asymmetrical nodularity that persists at review after menstruation (in patients under 35 years)

� Women with longstanding tender lumpy breast and no focal lesion

� Tender developing breasts in adolescents

nipple symptoms

� Bloodstained discharge

� New nipple retraction

� Nipple eczema if unresponsive to topical steroids (such as 1% hydrocortisone) after a minimum of 2 weeks

� Persistent discharge sufficient to stain outer clothes

� Transient nipple discharge which is not bloodstained

� Check prolactin levels when discharge present

� Longstanding nipple retraction

� Nipple eczema if eczema present elsewhere

skin changes � Skin tethering

� Fixation

� Ulceration

� Peau d’orange

� Obvious simple skin lesions such as sebaceous cysts

Abscess/infection

� Mastitis or breast inflammation which does not settle after one course of antibiotics

� Abscess or breast inflammation even after settled in patients over 35 years

� Abscess* or inflammation – try one course of antibiotics to cover staphylococcus and streptococcus (also consider possible anaerobic infection as per local guidelines)

www.sehd.scot.nhs.uk/mels/CEL2009_06.pdf



Routine referral Primary care managementIssue relevant advice leaflet

Pain � Unilateral persistent pain in post menopausal women

� Intractable pain that interferes with the patient’s lifestyle or sleep

� Women with moderate degrees of breast pain and no discrete palpable lesion

gynaecomastia � Exceptional aesthetics referral to plastic surgery pathway if required

� Exclude or treat any endocrine cause prior to referral

� Examine and exclude abnormalities such as lymphadenopathy or evidence of endocrine condition

� Review to exclude drug causes

� Measure hormones (oestrogen, testosterone, prolactin, human chorionic gonadotropin and alpha-fetoprotein)

� Reassure

* Any acute abscess requires immediate discussion with secondary care.


3.3 loweR gAsTRoInTesTInAl CAnCeR

Lower gastrointestinal symptoms are common presentations in primary care. Rectal bleeding for instance is estimated to

affect 14,000 individuals per 100,000 population each year2. There are large differences in the predictive value of rectal

bleeding for cancer according to its association with other symptoms and signs and the age of the patient. For example,

the positive predictive value of rectal bleeding alone is 2.4%, which rises to 8.5% in combination with an abnormal rectal

examination.

Different management strategies should be adopted according to cancer risk so that those patients with transient low-

risk symptoms caused by benign disease avoid unnecessary investigation.

The following guideline is recommended for managing patients with features associated with a possible diagnosis of

colorectal cancer. Guidance for referral to regional genetics centres for those with a family history of colorectal cancer

is available available at www.sehd.scot.nhs.uk/mels/HDL2001_24Guide.pdf. In patients with ulcerative colitis, a plan for

follow up should be agreed.

An abdominal and rectal examination and a full blood count should be performed on all patients with symptoms

suggestive of colorectal cancer. These findings can facilitate appropriate triage in secondary care. A negative

rectal examination, or a recent negative faecal occult blood result, should not rule out the need to refer. The

carcinogenic embryonic antigen (CEA) test should not be used as a screening tool.

high-risk featuresurgent suspicion of cancer referralBleeding � Repeated rectal bleeding without an obvious anal cause

� Any blood mixed with the stoolBowel habit � Persistent change in bowel habit especially to looser stools (more than 4 weeks)mass � Right-sided abdominal mass

� Palpable rectal massIron deficiency anaemia � Unexplained iron deficiency anaemiaother � Past history of lower gastrointestinal cancer with any of the symptoms above

Primary care management

low-risk features

� Transient symptoms (less than 4 weeks)

� Patients over 40 years in absence of high-risk features

watch and wait (4 weeks)

� Assessment and review

� Consider bowel diary

� Appropriate information, counselling and agreed plan for review with GP

Refer if symptoms persist or recur

www.sehd.scot.nhs.uk/mels/HDL2001_24Guide.pdf


3.4 oesoPhAgo-gAsTRIC, hePAToBIlIARy And PAnCReATIC CAnCeRs

Approximately 3,000 people are diagnosed with a primary oesophago-gastric, hepatobiliary or pancreatic cancer in

Scotland every year1.

Common symptoms of oesophago-gastric cancer include weight loss, dysphagia, heartburn or pain, vomiting and

anaemia. Common symptoms of hepatobiliary or pancreatic cancer include jaundice, abdominal mass, epigastric pain

and weight loss. The risk of developing an oesophago-gastric cancer is higher in patients of East Asian origin and a higher

suspicion of risk should be used in these patients.

An abdominal examination and appropriate blood tests (for example, full blood count, ferritin, urea and electrolytes

test [U&Es] and liver function tests [LFTs]) should be performed on all patients with symptoms suggestive of these

cancers. These findings can facilitate triage in secondary care.

Referral should not be influenced by Helicobacter pylori (H pylori) status. Proton pump inhibitors should be avoided

if possible prior to investigation. H2 antagonists may be used for symptomatic relief.

All patients with high-risk features should be referred to a team specialising in the management of oesophago-gastric,

hepatobiliary or pancreatic cancers, depending on local arrangements.


oesophago-gastric cancer

� Dysphagia (interference of the swallowing mechanism that occurs within 5 seconds of the swallowing process) or odynophagia (pain on swallowing) at any age

� New onset upper gastrointestinal pain or discomfort in people over 55 years

� New or worsening upper gastrointestinal pain or discomfort combined with one or more of the following features:

{{ unexplained weight loss

{{ unexplained iron deficiency anaemia

� Persistent vomiting more than 4 weeks.

� Upper gastrointestinal pain or discomfort combined with at least one of the following risk factors:

{{ family history of oesophago-gastric cancer in more than two first-degree relatives

{{ family history of familial adenomatous polyposis in any first-degree relative

{{ Barrett’s oesophagus

{{ pernicious anaemia

{{ gastric surgery over 20 years ago

{{ known dysplasia, atrophic gastritis or intestinal metaplasia


hepatobiliary and pancreatic cancer

� Features of hepatobiliary or pancreatic cancer can be vague and non-specific, and may include:

{{ unexplained obstructive jaundice

{{ upper abdominal or epigastric mass

{{ unexplained back pain (consider other cancer causes such as malignant spinal cord compression)

{{ unexplained weight loss

{{ any suspicious abnormality, in the hepatobiliary tract, found on imaging (such as biliary dilatation or pancreatic/liver lesion)

Primary care management

� Dyspepsia under 55 years without accompanying symptoms or risk factors should be managed according to local or national guidelines


3.5 uRologICAl CAnCeRs

Prostate cancer

Prostate cancer is the most common cancer in males in Scotland, with approximately 2,800 new cases diagnosed every

year1. Risk increases with age and approximately 99% of cases are diagnosed in men aged over 50 years. Men are 2.5

times more likely to be diagnosed with prostate cancer, if their father or brother has had it. In the UK, the lifetime risk of

prostate cancer in Black men (1 in 4) is double that of the lifetime risk of all men combined (1 in 8).

Men presenting with unexplained possible symptoms and signs suggestive of prostate cancer such as changes to

urinary patterns, erectile dysfunction, haematuria, lower back pain, bone pain or weight loss should have a digital rectal

examination and a prostate specific antigen (PSA) test with counselling. A PSA test should not be performed within 1

month of a proven urinary tract infection (UTI). It should be noted that the majority of men with prostate cancer have

no symptoms at all.

Bladder and kidney cancer

Visible haematuria is the most common presenting symptom for both bladder and kidney cancer. Other presenting

features include loin pain, renal masses, non-visible haematuria, anaemia, weight loss and pyrexia. Both cancers are

uncommon, with around 800 new bladder and 860 new kidney cancers each year1.

Testicular and penile cancer

Although scrotal swellings are a common presentation in general practice, testicular cancer is relatively rare, with around

200 new cases per annum, of which approximately 70% are between 15 and 45 years1. Solid swellings affecting the body

of the testis have a high probability (> 50%) of being due to cancer. Cancer of the penis is rare, with around 60 new cases

each year in Scotland, but its incidence is rising1.

All patients presenting with symptoms or signs suggestive of urological cancer should be referred to a team specialising

in the management of urological cancer, depending on local arrangements.


Prostate cancer

� Evidence from digital rectal examination of a hard, irregular prostate

� Elevated or rising age-specific PSA. Rough guide to normal PSA levels:

{{ men less than 60 years - less than 3ng/ml

{{ men aged 60–69 years - less than 4ng/ml

{{ men aged 70 years and over - less than 5ng/ml

Bladder and kidney cancer

� Patients with painless visible haematuria

� Patients with visible haematuria and symptoms suggestive of UTI but with sterile mid-stream urine (MSU)

� Abdominal mass identified clinically or on imaging that is thought to arise from the urinary tract


Testicular and penile cancer

� Swelling in the body of the testis

� Suspicious scrotal mass found on imaging

� Men considered to have epididymo-orchitis or orchitis which is not responding to treatment

� Any non-healing lesion on the penis or painful phimosis

non urgent referral

� Elevated age-specific PSA where urgent referral will not affect outcome due to age or comorbidity

� Asymptomatic persistent non-visible haematuria without obvious cause

� Patients over 40 who present with recurrent UTI associated with any haematuria


3.6 skIn CAnCeRs

Approximately 12,000 people are diagnosed every year with skin cancer in Scotland, of which around 1,200 are malignant

melanoma and 3,000 are squamous cell carcinomas (SCC)1. The incidence of skin cancer is rising.

Risk factors for all skin cancer types include excessive sunlight exposure, sun bed use, fair skin and susceptibility to

sunburn. For melanoma, a large number of benign melanocytic naevi and family history are risk factors. For SCC, multiple

small actinic keratoses, high levels of previous UV-A photochemotherapy and immuno-suppression are also risk factors.

Patients with multiple atypical naevi and a strong family history may have an increased risk of developing skin cancer.

Skin cancers are very infrequent in people with dark skin and in children under 15 years.

Guides for assessment include the 7-point checklist and the ABCD (Asymmetry, Border irregular, Colour irregular, Diameter

increasing) checklist (www.sign.ac.uk/pdf/qrg72.pdf ). Some melanomas will have no major features.

The dermoscope is a useful tool for trained clinicians screening pigmented lesions as it can increase diagnostic accuracy.

good practice points

� Lesions which are suspicious for melanoma should not be removed in primary care. All excised skin specimens should be sent for pathological examination.

� Lesions suspicious of basal cell carcinomas (BCC) may not require urgent referral, except those invading potentially dangerous areas.

� A change in a mole should be examined and reviewed (in 2 weeks) in pregnant women and women who have had a baby within 12 months.

� Referrals should be accompanied by an accurate description of the lesion (including size, pain and tenderness) and photos if possible, subject to clinical governance arrangements, to permit appropriate triage.

A patient presenting with a skin lesion suggestive of cancer should normally be referred to a dermatologist, depending

on local arrangements.


Lesions on any part of the body which have one or more of the following features: � change in colour, size or shape in an existing mole

� moles with Asymmetry, Border irregularity, Colour irregularity, Diameter increasing or >6mm

� new growing nodule with or without pigment

� persistent (more than 4 weeks) ulceration, bleeding or oozing

� persistent (more than 4 weeks) surrounding inflammation or altered sensation

� new or changing pigmented line in a nail or unexplained lesion in a nail

� slow growing, non-healing or keratinising lesions with induration (thickened base)

� any melanoma or invasive SCC or high risk BCC diagnosed from biopsy

� any unexplained skin lesion in an immuno-suppressed patient

� BCC invading potentially dangerous areas, for example peri-ocular, auditory meatus or any major vessel or nerve

http://www.sign.ac.uk/pdf/qrg72.pdf


Reference list1. Information Services Division. Cancer incidence in Scotland (2011). 2013 [cited 12 Sept 2013]; Available at: http://

www.isdscotland.org/Health-Topics/Cancer/Publications/2013-04-30/2013-04-30-Cancer-Incidence-Report.

pdf?64773195982

2. Scottish Executive. Scottish referral guidelines for suspected cancer. 2007 [cited 12 Sept 2013]; Available at: http://

www.sehd.scot.nhs.uk/mels/HDL2007_09.pdf

http://www.isdscotland.org/Health-Topics/Cancer/Publications/2013-04-30/2013-04-30-Cancer-Incidence-Report.pdf?64773195982



http://www.sehd.scot.nhs.uk/mels/HDL2007_09.pdf

http://www.sehd.scot.nhs.uk/mels/HDL2007_09.pdf


AppendicesAPPendIx 1: glossARy

Actinic keratoses Dry scaly patches of skin caused by damage from years of sun exposureAnaemia Condition where there is less than the normal number of red blood cells or less than the

normal quantity of haemoglobin in the bloodAtypical naevi An unusual mole whose appearance is different (larger than average and irregular in shape)

from that of common molesAuditory meatus Either of the passages in the outer ear from the auricle to the tympanic membraneBarrett’s oesophagus An abnormal change in the cells of the lower end of the oesophagus thought to be caused

by damage from chronic acid exposureBenign tumour A tumour that does not invade and destroy local tissue or spread to other sites in the bodyCarcinogenic embryonic antigen test

Test used to measure the amount of this protein that may appear in the blood of some people who have certain kinds of cancers, especially large intestine (colon and rectal) cancer

Colorectal Relating to or involving both the colon and the rectumConsolidation Condition where the alveolar (tiny air sacs in the lungs) space now contains fluid instead of

airdermoscope Device used to examine moles through a thin layer of liquid to provide a highly accurate

assessment of what is going on directly below the skin’s surfacedyspepsia Pain or discomfort in the chest or stomach, sometimes accompanied by symptoms (such

as heartburn, bloating, belching, quickly feeling full after eating, nausea or vomiting), that may develop soon after eating or drinking

dysphagia Interference of the swallowing mechanism that occurs within 5 seconds of the swallowing process

dyspnoea Difficulty or pain in breathingepididymo-orchitis Inflammation of the epididymis (the coiled tube that collects sperm from the testicle) and

or testis, usually due to infectionepigastric pain Pain that is localised to the region of the upper abdomen directly below the ribsfamilial adenomatous polyposis

A rare, inherited condition that causes extra tissue (polyps) to form in the large intestine and in the upper part of the small intestine (duodenum)

finger clubbing Changes in the areas under and around the fingernailsgastrointestinal Relating to the stomach and intestineshaematuria Presence of blood in the urine

Non-visible haematuria: blood that can only be detected with laboratory testing

Visible haematuria: blood that is obvious with the naked eyehaemoptysis A condition in which someone coughs up blood from the lungshelicobacter pylori (h pylori)

A spiral shaped bacterium that lives on the gastric epithelium under the mucus layer of the stomach and duodenum. The bacterium is thought to damage this mucus layer, which is the stomach and duodenum's natural protection from gastric acids

hepatobiliary and pancreatic cancers

Include cancers of the liver, gallbladder, bile ducts, and pancreas

hoarseness Abnormal voice changes

Incidence Number of new cases of a condition in a defined population during a defined period and is typically expressed as the number of new cases per 100,000 population per year (or other


Jaundice Yellowing of the skin and the whites of the eyes

lymphadenopathy A chronic, abnormal enlargement of the lymph nodes

melanocytic naevi Moles that arise as a result of proliferation of melanocytes, the cells in the skin that produce pigment

metaplasia The transformation of one type of tissue into a different kind

metastasis Spreading of malignant disease from one part of the body to another through the bloodstream or the lymphatic vessels

mesothelioma Cancer of the mesothelial cells, which are the cells that make up the membrane (lining) that covers the outer surface of most of the body organs

obstructive jaundice A yellowish discolouration of the skin, the conjunctival membranes over the sclerae (whites of the eyes), and other mucous membranes caused by hyperbilirubinaemia (increased levels of bilirubin in the blood) as a result of interruption to the drainage of bile in the biliary system

odynophagia Pain on swallowing

oesophago-gastric cancer

Cancer of the stomach and cancer of the oesophagus, also known as the gullet

Peri-ocular Situated around the eye

Phimosis A condition where the foreskin is too tight to be pulled back over the head of the penis (glans)

Photochemotherapy A type of ultraviolet radiation treatment used for severe skin diseases

Pleural effusion Collection of fluid between a lung and the chest wall

Positive predictive value

The probability that a person with a positive test result has, or will get, the disease

Primary care Primary-level health, disability, social and community services care provided by a range of health workers including general practitioners, nurses, pharmacists and allied health care professionals

Prostate specific antigen (PsA) test

A test which measures the blood level of PSA, a protein that is produced by the prostate gland

Rectal Relating to, or situated near the rectum

sebaceous cyst A benign or harmless growth which forms when the release of sebum (a fluid produced by sebaceous glands in the skin), is blocked

secondary care Public hospitals, hospital-based services and specialist services

squamous cell carcinomas (sCC)

An uncontrolled growth of abnormal cells arising in the squamous cells, which compose most of the skin’s upper layers (the epidermis)

stridor A sharp high pitched sound made when air passes an obstruction in the upper airway (larynx)

supraclavicular Pertaining to the area above the clavicle or collar bone

symptoms and signs What the patient reports or what is observed that may indicate a condition or disease

Persistent: refers to signs or symptoms that continue to occur beyond a period of time that would normally be indicative of a self-limiting condition

Unexplained: refers to signs or symptoms where no diagnosis has been made to identify the cause after the patient has been assessed by a healthcare practitioner

urea and electrolytes test

A test which includes the measurement of the urea, sodium, potassium, CO2 and chloride concentrations in venous blood

urinary tract infection (uTI)

Develops when part of the urinary tract becomes infected, usually by bacteria


APPendIx 2: memBeRs of guIdelIne develoPmenT TeAm - sTeeRIng gRouP

Bob grant ChairPeter hutchison Deputy Chair, General Practitioner, NHS Dumfries and GallowayAlistair dorward Consultant Respiratory Physician, NHS Greater Glasgow and ClydeAnn graham Junior Doctor, NHS Lothiandawn Crosby Head of Service Strategy and Policy, Teenage Cancer Trustdouglas Rigg General Practitioner, NHS Greater Glasgow and Clydeelaine Anderson Consultant Breast Surgeon, NHS Lothianhilda emengo Health Services Researcher, Healthcare Improvement ScotlandJacquie dougall (from September 2013)

Cancer Delivery Programme Manager, Scottish Government

Jim little (until September 2013)

Cancer Delivery Programme Manager, Scottish Government

lisa Cooper Clinical Team Leader, NHS24lorraine sloan Primary and Community Care Programme Manager, MacMillan UKmoira Adams Patient and carer representativePaul Baughan General Practitioner, NHS Forth ValleyRobert Atkinson Patient and carer representativesally Arnison Pharmacist, NHS Lothiansara Twaddle Director of Evidence (Interim), Healthcare Improvement Scotlandshirley fife Consultant Cancer and Palliative Care Nurse, NHS Lothiansteven Beaven General Practitioner, NHS Tayside


APPendIx 3: memBeRs of guIdelIne develoPmenT TeAm - suBgRouPs

lung cancer guideline team

Bob grant Chair Alistair dorward Consultant Respiratory Physician, NHS Greater Glasgow and ClydeChris miller Pharmacist, NHS Forth ValleyColin selby Consultant Respiratory Physician, NHS Fifediana Borthwick Lung Clinical Nurse Specialist, Edinburgh Cancer Centredouglas Rigg General Practitioner, NHS Greater Glasgow and ClydeJayne oliver General Practitioner, NHS Forth Valleylorraine dallas Director of Information and Support, The Roy Castle Lung Cancer Foundationlouise gorman General Practitioner, NHS Forth Valleyluke daines Junior Doctor sarah muir General Practitioner, NHS Forth Valley

Breast cancer guideline team

Bob grant Chair Ann graham Junior Doctor, NHS Lothiandavid stevenson General Practitioner, NHS Forth Valleyelaine Anderson Consultant Breast Surgeon, NHS Lothianelizabeth smyth Consultant Breast Surgeon, NHS Grampian hilary Campbell Head of Scotland Services, Breast Cancer Caremoira Adams Patient and carer representativePam Chisholm Lead Pharmacist, Lothian Palliative Care Network Peter hutchison General Practitioner, NHS Dumfries and Galloway Philippa whitford Consultant Breast Surgeon, NHS Ayrshire and ArranRosalie dunn General Practitioner, NHS Lanarkshire sarah muir General Practitioner, NHS Forth Valley

lower gastrointestinal cancer guideline team

Bob grant Chair Ann graham Junior Doctor, NHS Lothian emma Anderson Scotland Operations Manager, Bowel Cancer UKhelen macleod General Practitioner, Central and Eastern Cheshire Primary Care NHS Trusthugh Brown General Practitioner, NHS Ayrshire and Arran James mander Consultant Colorectal Surgeon, NHS Lothian Janice oman Pharmacist, NHS Forth Valley michael fyall General Practitioner, NHS Forth Valley Paul horgan Consultant Colorectal Surgeon, NHS Greater Glasgow and ClydeRhoda Abel General Practitioner, NHS Forth Valley Robert Atkinson Patient and carer representativesteven Beaven General Practitioner, NHS Tayside


oesophagogastric, hepatobiliary and pancreatic cancer guideline team

Bob grant ChairPeter hutchison Deputy Chair, General Practitioner, NHS Dumfries and GallowayAlastair macmillan Consultant Gastrointestinal Surgeon, NHS FifeAllan lapsley Chair, Oesophageal cancer has reached everywhere (OCHRE)david stevenson General Practitioner, NHS Forth ValleyIrfan Ahmed Consultant Upper HPB Surgeon, NHS Grampiankate Cunningham Campaign Director, OCHRElindsay Campbell Managed Clinical Network National Manager for Sarcoma, HPB and Neuro Cancerslouise gorman General Practitioner, NHS Forth Valleyneil Pryde General Practitioner, NHS Fifesami shimi Consultant Gastrointestinal Surgeon, NHS Taysidestuart Paterson Consultant Gastroenterologist, NHS Forth Valley

urological cancer guideline team

Bob grant ChairPeter hutchison Deputy Chair, General Practitioner, NHS Dumfries & GallowayAdam gaines Director, Prostate ScotlandAlan mcneil Consultant Urologist, NHS GrampianAlistair haw Campaigns and Media Manager - Scotland, Prostate Cancer UKChris miller Pharmacist, NHS Forth Valleydavid stevenson General Practitioner, NHS Forth Valleyhugh Brown General Practitioner, NHS Ayrshire and ArranJustine Royle Consultant Urologist, NHS Lothianmichael fyall General Practitioner, NHS Forth Valleysteven Beaven General Practitioner, NHS Tayside

skin cancer guideline team

Bob grant ChairPeter hutchison Deputy Chair, General Practitioner, NHS Dumfries and GallowayAlex holme Consultant Dermatologist, NHS LothianColin fleming Consultant Dermatologist, NHS Taysidedavid stevenson General Practitioner, NHS Forth Valleydouglas Rigg General Practitioner, NHS Forth Valleyleigh smith Chair, Melanoma Action and Support Scotland (MASSCOT)louise gorman General Practitioner, NHS Forth Valleymark darling Consultant Dermatologist, NHS Greater Glasgow and Clydeneil Pryde General Practitioner, NHS Fife


APPendIx 4: equAlITy And dIveRsITy

The Scottish Government and Healthcare Improvement Scotland are committed to equality and diversity in respect of

the nine equality groups defined by age, disability, gender reassignment, marriage and civil partnership, pregnancy and

maternity, race, religion, sex, and sexual orientation.

The guideline development process has been assessed and the guideline is expected to have a positive impact on certain

age groups (depending on the tumour type) and more deprived populations in Scotland. The completed equality and

diversity checklist is available on www.healthcareimprovementscotland.org

http://www.healthcareimprovementscotland.org

http://www.healthcareimprovementscotland.org/

mailto:[email protected]

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Scottish referral guidelines for suspected cancer · 2015-11-10 · Scottish referral guidelines for suspected cancer • 1 1 Introduction 1.1 BACkgRound Although cancer is a common