In reality the 2 week wait referrals will be directed by what is on the referral form, so I have ignored those bits of the guideline.
There is also a lot of information about when we should be referring to direct access services and when we should be doing simple blood tests. I would strongly encourage you to invest half an hour in skim-reading it.
I'll highlight a couple of points I found interesting, but please bear in mind that there may be lots of other occasions when these investigations or referrals would be advised too.
For a good summary and 'infomatic', see the BMJ review on the guideline.
- Do an urgent CXR (within 2w) for:
- People who are over 40 and have ever smoked and have anorexia.
- Consider one in people over 40 with thrombocytosis.
Oesophageal and Stomach Cancer
- Consider a direct access upper GI endoscopy for people aged 55 or over with a raised platelet count and GI symptoms (eg nausea, vomiting, reflux etc)
- Consider an urgent direct access CT or USS for people aged 60 or over with weight loss and any of: diarrhoea, back pain, abdominal pain, nausea, vomiting, constipation or new onset diabetes.
Offer faecal occult blood testing if:
- over 50 with unexplained abdominal pain or weight loss.
- under 60 with change in bowel habit or iron deficiency anaemia.
- 60 or over with anaemia (even if not iron deficient).
Consider an USS in women aged 55 or over with:
- Unexplained vaginal discharge who
- are presenting for the first time OR
- have thrombocytosis OR
- report haematuria OR
- Visible haematuria AND
- low Hb
- high blood glucose levels
Refer on 2ww if people score 3 or more on the following:
- Major features (2 points each)
- Change in size
- Irregular shape
- Irregular colour
- Minor features (1 point each)
- Largest diameter 7mm or more
- Change in sensation
Consider urgent referral (within 2 weeks) to a dentist anyone with:
- a lump on the lip or in the oral cavity or
- a red or white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia.
- Consider a direct access MRI (or CT if MRI is contraindicated) for progressive sub-acute loss of neurological function.
Consider a FBC within 48 hrs for adults with:
- persistent fatigue
- unexplained fever
- unexplained persistent or recurrent infection
- generalised lymphadenopathy
- unexplained bruising or bleeding
- unexplained petechiae
- Persistent bone pain (especially back pain) or fractures in people > 60 - offer a FBC, calcium and ESR / plasma viscosity.
- Consider a protein electrophoresis and Bence Jones Protein within 48 hrs if there is a raised ESR or plasma viscosity and a presentation consistent with myeloma.
Soft tissue sarcoma
- Consider an USS within 2 weeks for anyone with an unexplained lump that is increasing in size.
Symptoms of concern
- Unexplained weight loss and loss of appetite can be associated with cancer, so NICE advises investigation and referral to a 2ww service after assessment. This may see new clinics for these symptoms of concern where there is no obvious underlying cause.