Non-specific symptoms of cancer

Referring for assessment:

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 is also 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 to a RCDS or GP direct access to 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.

The most common modality used to assess those with non-specific symptoms which are a concern for cancer, is a CT scan. Therefore, this should be discussed with the relevant service and provision made for non-radiation exposing diagnostic tests (e.g. ultrasound) if referring a person who is pregnant.

Metastatic cancer can 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.

Bone pain:

Any cancer can spread to the bones, but it is more common in prostate cancer, breast cancer, lung cancer, kidney cancer, thyroid cancer and myeloma. If vertebral bones are involved there is a risk of spinal cord compression. If malignant spinal cord compression is suspected, then guidelines on assessment and investigation should be accessed.  

Rapid Cancer Diagnostic Services and GP direct access to CT:

Please follow local guidelines when referring to these services and note the tests that are required before referral. Please also reference available national guidelines for primary care on which service to use if both are available in your Health Board⁸³. For GP direct access, the referrer is responsible for the action taken regarding the findings of the CT, including a USC referral to another cancer pathway and assessing, treating, and referring any additional or incidental findings as appropriate.

Unprovoked deep venous thrombosis (DVT):

Data indicates that 3.9% of people had a new diagnosis of cancer in the year following a diagnosis of unprovoked DVT⁸⁶. It has therefore been suggested that investigation for cancer in this group would be beneficial. However, a randomised trial has shown that the addition of a CT abdomen and pelvis to standard assessment (history, examination, blood tests and routine screening for cancer) did not detect significantly more cancers or alter diagnostic intervals or cancer-related mortality⁶. On this basis it is recommended that unprovoked DVT alone should not prompt referral for a CT through either pathway – RCDS or direct access.

Unexplained thrombocytosis:

In cases of unexplained thrombocytosis, it is advisable to assess for any signs or symptoms of cancer and then to refer on a tumour specific USC pathway if appropriate¹⁷.

If isolated unexplained thrombocytosis is found, it is recommended that a chest x-ray is considered. If there is unexplained thrombocytosis combined with non-specific symptoms such as significant weight loss, or if there is associated GP ‘gut feeling’, it may also be appropriate to refer for further investigation through either a RCDS or GP direct access to imaging pathway.

‘Red flag’ or ‘alarm symptoms’ of cancer are usually associated with a higher predictive value for specific cancer types e.g. a breast lump (breast cancer) or haemoptysis (lung cancer). These symptoms are included in the SRGs under the relevant cancer type.

However, people can often 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'^12,13.

In these circumstances, a person may not meet the threshold for referral to a specific cancer pathway which has the potential to prolong diagnostic intervals and increase the risk of emergency presentation with possible worse outcomes⁸². In addition, people with non-specific symptoms are more likely to have multiple GP attendances and tests in primary care⁸².

This guideline is a new addition to the SRGs with the purpose of collating the current knowledge on non-specific clinical features concerning for cancer, to aid primary care referral. There are currently two clinical pathways for non-specific symptoms – RCDSs and GP direct access to CT⁸³.

Rapid Cancer Diagnostic Services:

In Spring 2021, CfSD, facilitated the implementation of early adopter RCDSs, with the aim of providing primary care clinicians with a new route to refer people with non-specific clinical features concerning for cancer. An independent evaluation report from the University of Strathclyde was published in December 2023⁸⁴. Over the 2-year evaluation period 3,616 people were referred (58.5% female, median overall age of 70 years). Unexplained weight loss was the most described clinical feature.

11.9% of the people assessed were diagnosed with cancer. Older age, GP ‘gut feeling’ and unexpected blood results were the features most strongly associated with a cancer diagnosis.

CT scanning was the most frequently used diagnostic test. The most frequently diagnosed cancers were lung, upper gastro-intestinal and colorectal.

GP direct access to CT:

At the time of publishing these Guidelines, not all Health Boards in Scotland have a RCDS. An alternative pathway is GP direct access to CT scanning. This has been shown to perform as well as secondary care triage and testing in terms of cancer detection and diagnostic interval⁸⁵.