Publication - Advice and guidance

Scottish referral guidelines for suspected cancer: quick reference guide

User-friendly visual aid to the urgent referral criteria as well as routine referral criteria and primary care management and good practice points.

Urgent Suspicion of cancer referral

Unexplained petechiae or purpura is always an indication for emergency referral.
Unexplained fatigue, persistent pallor, failure to thrive or weight loss.
Any new persistent unexplained pain, particularly back pain or nocturnal pain.
Unexplained abdominal mass or distension.
Unexplained visible haematuria.

Bone pain, especially if:	diffuse or involves the back persistently localised at any site nocturnal pain limping requiring analgesia, or limiting activity
Lymphadenopathy, if:	non-tender, firm/hard and greater than 2cms in maximum diameter progressively enlarging associated with other signs of general ill health, fever or weight loss involves axillary nodes (no local infection or dermatitis) or any supraclavicular lymphadenopathy
Headache, if increasing in severity or frequency and:	worse in the morning or causing early wakening or associated with vomiting or any new neurological signs
Any new neurological signs, (such as weakness, loss of balance, etc.) especially if:	associated with behavioural change or deterioration in normal daily or school performance
Other possible signs of brain tumours:	increasing head circumference failure of fontanelle closure abnormal head position such as wry neck, head tilt or stiff neck
Soft tissue mass, if:	shows rapid or progressive growth size greater than 2cm maximum diameter deep to fascia, fixed or immobile, regardless of size recurrence after previous excision of sarcoma associated with regional lymph node enlargement
Eyes:	any new squint, if associated with headache or other neurological signs (otherwise consider optometrist and ophthalmology assessment) change in pupillary red reflex to absent or white

Good practice points

Consider referral for any patient with repeat presentations (three or more times) of any symptoms which do not appear to be resolving or following an expected pattern, taking into account parental or carer and patient concern
In a child where symptoms and signs do not clearly fit with these guidelines but nevertheless lead to concern about excluding cancer, the referrer should consider discussing the case with a senior paediatric colleague at their earliest convenience
Many of the tumour specific guidelines in this document are relevant to all ages e.g. melanoma, brain and CNS, sarcoma etc

Primary care management

X-ray if there is unexplained bone pain of:
increasing severity
persistent
tender
non-mechanical bone pain particularly if disturbing rest or sleep
If symptoms persist but X-ray is normal, repeat X-ray (after discussion with a radiologist) and consider referral, especially if the patient presents three or more times
Spontaneous or minor trauma fracture should raise suspicion of bone cancer

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