Non-specific symptoms of cancer

Full guideline available here:

Scottish Referral Guidelines for Suspected Cancer – Non specific symptoms of cancer

People can present with non-specific symptoms of cancer including:

unexplained weight loss
fatigue
abdominal symptoms (pain, bloating)
nausea/vomiting
loss of appetite
non-specific pain.

Unexpected blood results such as anaemia or thrombocytosis can also occur prior to a cancer diagnosis. Additionally, a GP may have an intuition about an underlying diagnosis of cancer despite a lack of specific clinical features – commonly referred to as GP ‘gut feeling’. In these circumstances, a person may not meet the threshold for referral to a specific cancer. This guideline is a new addition to the Scottish Referral Guidelines with the purpose of collating the current knowledge on non-specific clinical features concerning for cancer to aid primary care in referring people for further diagnostic assessment.

Primary Care investigation

Assessment of suspected cancer in a person with non-specific clinical features

Non-specific symptoms often lead to repeated GP visits and extended diagnostic intervals. Thorough initial assessments and adherence to referral pathways are critical to minimising delays and improving outcomes.

The selection of initial investigations should be guided by the clinical context and local pathways, avoiding unnecessary testing where symptoms strongly suggest an alternative diagnosis.

The following tests may be helpful in a person with non-specific symptoms where there is a concern about an underlying cancer diagnosis:

urinalysis (for haematuria see Urological cancer guideline)
full blood count
ESR and/or C-Reactive Protein (CRP)
renal function (especially if considering a contrast enhanced CT)
Liver function tests
thyroid function tests
glycosylated haemoglobin (HBA1c)
bone profile
blood borne virus screen
CA125 (see Gynaecological cancer guidelines for who to test and thresholds for referral)
PSA (see Urological cancer guidelines for who to test and thresholds for referral)
vitamin B12 levels, ferritin, and folate
chest x-ray (see Lung and pleural cancer guideline)

The results of the tests may guide the need for referral for a GP Direct Access CT CAP, or may help to identify a concern about a site-specific cancer diagnosis (e.g. raised PSA and prostate cancer or raised CA125 and ovarian cancer)

Some pathways have tests that are required before referral – please see local guidelines. The above list is not intended as a minimum set of tests required for referral.

Who to refer

Refer a person with any of the following for GP direct access CT CAP +/- ICE Bundle that covers symptoms as a USC (Urgent Suspicion of Cancer) priority, especially if accompanied by GP ‘gut feeling’ of a cancer diagnosis:

New unexplained weight loss (either documented 5% or more of body weight in three months or with strong clinical suspicion)
New unexplained loss of appetite, fatigue, nausea, malaise, or bloating of four weeks or more (less if strong clinical suspicion)
New unexplained, unexpected, or progressive pain, including bone pain, of four weeks or more.

A person with non-site specific symptoms should not meet criteria for site-specific pathways. However, if a person presents with symptom combinations which could indicate several different cancer types, they should be referred for GP direct access to CT CAP as a USC priority.

If a person is being referred for investigation for a suspected cancer, it is critical this is made clear to them and documented in the referral. It also is especially important that the wishes of the person and their functional status (e.g. ECOG/WHO performance status and Clinical Frailty Scale) are considered. This may need to include a collateral history from a carer or relative. Frailty or poorer performance status should not prevent a referral for GP direct access CT. However, the decision should be made with the person to ensure it aligns with their overall goals of care and that the benefits and risks of further diagnostic assessment are understood.

Metastatic cancer can also present with non-specific symptoms, so it is important to check for a previous cancer diagnosis and refer to the relevant tumour specific service, if appropriate.

How to refer

Patients with non-specific symptoms should be referred as a USC priority using:

ICE - for direct access to CT CAP or X-Ray as well as bloods as part of an ICE Bundle.

SCI Gateway – for direct access to Endoscopy.

For GP direct access CT or X-ray, the referrer is responsible for the action taken regarding the findings of the investigation, including a USC referral to another cancer pathway and assessing, treating, and referring any additional or incidental findings as appropriate.

Depending on the results of the investigation, patients with non-specific symptoms should be referred via SCI Gateway to a site-specific pathway as a USC, and in accordance with the Scottish Referral Guidelines for Suspected Cancer, or direct to MDT discussion.

If you are unsure about whether this is the correct referral route, please consider using the SCI Advice Option for further information.

Useful resources and information

The Genomic Test Directory Scotland contains information on any genetic conditions that predispose to cancer.