Nice | Suspected cancer in adults

This is a huge guideline from NICE on diagnosing cancer, far too big to summarise easily in a blog. I have done a separate post for diagnosing cancer in children.

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.

Lung Cancer

  • 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)

Pancreatic cancer

  • 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.

Bowel Cancer

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).

Endometrial Cancer

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
    • thrombocytosis
    • 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
    • Inflammation
    • Oozing
    • Change in sensation

Oral Cancer

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:

  • pallor
  • persistent fatigue
  • unexplained fever
  • unexplained persistent or recurrent infection
  • generalised lymphadenopathy
  • unexplained bruising or bleeding
  • unexplained petechiae
  • hepatosplenomegaly


  • 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.

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