Referral Process
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 advanced nurse practitioners and other nursing staff, pharmacists, dentists, optometrists, NHS24, paramedics and others to ensure rapid referral is arranged. This may be by direct referral (with simultaneous notification of the GP) or by making arrangements for the person to see their GP urgently, clearly notifying the concern about suspected cancer.
The guidelines will also be brought to the attention of secondary care clinicians of all grades in order to encourage equity of access to investigation and to facilitate interdepartmental referrals.
2.2.2 Purpose of referral
The ‘urgent suspicion of cancer’ referral pathway is designed to allow the rapid assessment and investigation of a person to determine the cause of their symptoms. For people whose presenting symptoms persist, it is not acceptable to simply exclude cancer without providing an assessment of the likely underlying cause. This may involve individual hospital specialties making internal referrals to their colleagues to help determine the nature and cause of the presenting symptoms. These internal referrals should be undertaken with the minimum of delay and with good communication to both the patient and referring clinician. Where diagnostic tests are undertaken, the clinician requesting the test has a responsibility for acting on the result and ensuring that the patient receives this.
NHS boards may wish to consider to which diagnostic services primary care clinicians should have direct open access. In these situations the clinician 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 can be helpful for use in all clinical settings. Scottish Care Information (SCI) Gateway provides the means for electronic referrals incorporating structured proformas, 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 specialty to downgrade an urgent suspicion of cancer referral to urgent or routine. This should never occur without notifying the referring GP practice timeously. The clinician should have the opportunity to explain why an urgent suspected cancer 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 person is kept informed about any change in referral priority.
2.2.5 Feedback where no cancer is found
The referring clinician should receive timely feedback on the outcomes for all people with an urgent suspicion of cancer referral. Where negative results are found, and concerns still exist, the specialist should consider direct onward referral to another specialty. Information about inappropriate referrals should be fed back to the referring clinician detailing why it was felt to be inappropriate and suggesting an alternative course of action.
2.2.6 Opportunity for health promotion
Suspicion of cancer, whether warranting referral or not, is an opportunity to consider health promotion such as smoking cessation, alcohol, diet, obesity, exercise and engaging with national screening and immunisation programmes. People should be informed that 4 in 10 cancers are preventable5, and that addressing risk factors can help reduce their overall cancer risk.
2.2.7 General points about suspicion of cancer
- Cancer often presents with vague symptoms that do not help identify which pathway of investigation to follow. In particular, ovarian and pancreatic cancer often present very late so, in unwell people with nothing other than malaise and significant unexplained weight loss, most NHS Boards have pathways in place for Primary Care access to CT chest, abdomen and pelvis as first investigation
- Recent evidence has identified thrombocytosis as a strong risk marker for malignancy, in particular lung, endometrial, gastric, oesophageal and colorectal cancer (acronym “LEGO-C”). With a cancer incidence of 11.6% and 6.2% in males and females respectively, these figures well exceed the 3% threshold to warrant investigation6
- Metastatic disease is commonly the first presentation of a new cancer. The possibility of an underlying primary cancer should be considered especially with symptoms and signs suggesting lung, liver, bone or brain cancer. For example, bone metastases are commonly due to prostate, breast and lung cancer. Metastatic disease should be borne in mind when anybody with a previous history of cancer presents with new symptoms
- Tumour markers have a limited place in the decision to refer for suspected cancer: only PSA for prostate cancer in men, CA125 for ovarian cancer in women, and serum and urine paraproteins for myeloma should be routinely used in Primary Care
- It is good practice to include general fitness or performance status in the referral (e.g. ECOG/WHO scale) in order to facilitate discussion about the most appropriate pathway.
6 Clinical relevance of thrombocytosis in primary care: Br J Gen Pract 2017; 67 (659): e405-e413. DOI: https://doi.org/10.3399/bjgp17X691109
ECOG/WHO Performance Status Scale
| Grade | ECOG/WHO Performance Status |
| 0 | Fully active, able to carry on all pre-disease performance without restriction |
| 1 | Restricted in physically strenuous activity but ambulatory and able to carry work of a light or sedentary nature, e.g., light house work, office work |
| 2 | Ambulatory and capable of all self-care but unable to carry out any work activities; up and about more than 50% of waking hours |
| 3 | Capable of only limited self-care; confined to bed or chair more than 50% of waking hours |
| 4 | Completely disabled; cannot carry on any self-care; totally confined to bed or chair |
| 5 | Dead |