Summary: Scottish Referral Guidelines for Suspected Cancer 2025

Key Changes

This section describes the key changes made to the previously published SRGs following feedback from peer review sessions (PRS), evidence summaries and wider stakeholder engagement. As part of the clinical review process, over a 12 month period, around 210 people attended a PRS, over 120 pieces of evidence were analysed and over 230 pieces of valuable feedback were received and considered from key stakeholders and networks across NHS Scotland.

Introduction

• Addition of wording to emphasise the importance of socio-economic deprivation and a link to practical guidance on how to address inequalities – Cancer Inequalities in Scotland: A Practical Guide for GP Practices.

Purpose and development of the Guidelines

• Expansion of the description of positive predictive value (PPV) in cancer and explanation of the reasoning for the selected threshold for this Guideline.
• Addition of terminology definitions used within the Guideline.
• Addition of an equality impact assessment (EQIA) used throughout the development process.

Referral Process

• Addition of information on how to apply Realistic Medicine – BRAN: helping patients ask the right questions | Right Decisions (scot.nhs.uk).
• Addition of information on prehabilitation – Prehabilitation for Scotland.
• Addition of information on social or practical support that the person may need to help facilitate their attendance at any appointments and reduce the risk of non-attendance – Applying a missingness lens to healthcare.
• Addition of a guide for health professionals on discussing cancer risk reduction with patients – Initiating A Brief Intervention.
• Expanded section on ‘Further considerations for assessment and referral’ including GP gut feeling, non-specific symptoms, updated thrombocytosis information, metastatic cancer and tumour markers.
• New guidance on regrading included – Urgent Suspicion of Cancer National Regrading Guidance.
• Addition of safety netting tools – Safety netting | Cancer Research UK and Safety netting in primary care consultations | Macmillan Cancer Support.

Brain and Central Nervous System Cancers

• New information on routes to diagnosis.
• New section on clinical assessment including the addition of ‘headache plus’.
• Expanded criteria for emergency/same day referral.
• New definitions for urgent suspicion of cancer (USC) referral including cognitive and personality change with headache.
• Link to CfSD National Headache Pathway to guide referral in scenarios where cancer isn’t suspected.
• Addition of semantic verbal fluency testing (SVFT) in good practice as an aid to assessment of cognition.

Breast Cancer

• Addition of incidence, staging data and risk factors.
• Addition of gender reassignment and demographic considerations.
• New section on clinical assessment including symptoms, signs and risk factors.
• Referral criteria expanded to include advice on managing those under 30 years of age with a breast lump or other suspicious features.
• Added criteria for referring axillary lumps.
• Removed breast nodularity as a USC referral criteria.
• Removed other categories of referral (urgent and routine) and instead linked to Breast pathways (referral pathways) | Right Decisions (scot.nhs.uk)
• Expanded good practice to include advice on benign breast nodularity, breast infection, male breast cancer, breast pain, skin and nipple changes, axillary lumps, breast implants, family history, recurrence of breast cancer and metastatic breast cancer.

Gynaecological Cancers

• New section on clinical assessment including presenting clinical features and the appropriate primary care tests to be arranged.
• Added detail on the risk assessment of post-menopausal bleeding on Hormone Replacement Therapy (HRT) – Management of unscheduled bleeding on HRT | British Menopause Society.
• Expanded good practice to include guidance on ultrasound scanning, abnormal vaginal bleeding, CA125 and overlap with other cancer pathways.

Haematological Cancers

• Clarified adult context for this guidance.
• Added information on routes to diagnosis.
• Refined advice on the monitoring of monoclonal gammopathy of unknown significance (MGUS).
• New section on clinical assessment including clinical features and appropriate testing in primary care.
• Added criteria for emergency/same day referral – acute leukaemia, chronic myeloid leukaemia and emergency assessment for myeloma.
• Refined criteria for USC referral – lymphocytosis with additional features, possible myeloma, lymphadenopathy (generalised and isolated).
• Expanded good practice to include guidance on lymphocytosis, raised paraproteins, safety netting, splenomegaly and rare blood cancers (with external links for information).

Head and Neck and Thyroid Cancers

• New section on clinical assessment including clinical features and assessing for risk factors.
• Redefined criteria for USC referrals including age 35+ for hoarseness and clearer descriptions of clinical features that should be referred (e.g. change from persistent pain in the throat to constant unilateral throat pain).
• Addition of good practice to include advice on the possible changing pattern of disease, neck lumps, symptom combinations, risk calculators, overlap with other cancer pathways, the role of dental practitioners and rare head and neck cancers to be aware of and consider.

Lower Gastrointestinal Cancers

• Added routes to diagnosis information.
• Added inequalities information.
• Added clinical features of colorectal cancer.
• New section on clinical assessment added to indicate initial tests to be arranged.
• Aligned qFIT guidance with the national qFIT consensus document – new qFIT threshold for USC referral: ≥20µgHb/g faeces.
• Expanded good practice to include advice on qFIT testing, hereditary colon cancer and overlap with other pathways (benign and cancer).

Lung and Pleural Cancers

• Changed criteria for an USC chest x-ray request depending on smoking status or asbestos exposure – e.g. added symptom combinations for never smokers as a criteria for a USC chest x-ray.
• Moved abnormal radiology to the top of the list for USC referral criteria.
• Removed the age limit on USC referral for ‘unexplained haemoptysis’.
• Further defined criteria for USC referral in the context of normal chest x-ray based on symptom combinations.
• Expanded good practice section to provide advice on haemoptysis, referral process, overlap with other cancer pathways and thrombocytosis.

Sarcoma and Bone Cancers

• Clarified adult context for this guidance.
• Added information on inequalities and possible delays to diagnosis.
• New section on clinical assessment added to aid recognition and initial investigation(s).
• Redefined USC referral criteria e.g. added additional descriptors to soft tissue mass – hard or craggy, fungating.
• Expanded good practice section to include advice on soft tissue lesions including lipoma, bone cancer assessment and risk factors.

Skin Cancers

• Expanded introduction including incidence data, risk factors and inequalities.
• New section on clinical assessment describing clinical features that are suspicious for malignant melanoma, squamous cell carcinoma, basal cell carcinoma, other malignant skin lesions and cancers involving the nail apparatus.
•  USC referral criteria based on the clinical features in the new assessment section.
• Link added to Dermatology pathways | Right Decisions (scot.nhs.uk) for primary care management of skin lesions not referred as a USC.
• Expanded good practice to include advice on assessing pigmented lesions, appropriate referral practice and the role of the GP with special interest.

Upper Gastrointestinal Cancers

• Renamed from ‘Oesophago-gastric, Hepatobiliary and Pancreatic Cancers’.
• Expanded clinical assessment section to emphasise symptom combinations and aid recognition.
•  USC referral criteria redefined, including the removal of vomiting alone, removal of odynophagia, removal of iron deficiency anaemia, addition of a new age threshold for jaundice (40+), and addition of symptom combinations with age.
• Expanded good practice to include referral advice, clarify overlap with other cancer pathways and emphasise thrombocytosis as a risk marker.

Urological Cancers

• Added information on risk factors for urological cancer.
• New section on clinical assessment added to aid recognition and initial investigation(s) where appropriate.
• Added advice on Prostate Specific Antigen (PSA) testing in older adults and in the context of a proven or suspected urinary tract infection (UTI).
• Redefined PSA thresholds for USC referral in line with published guidance –
  • under 70: ≥3 ng/ml
    
  • 70-79: ≥5 ng/ml
  • 80 and above: ≥20 ng/ml - see good practice.
• Link to the Prostate Cancer Risk Management guidance added with advice on referral if a PSA is checked in this context.
• Added advice to good practice section on assessment and referral of patients with suspected prostate cancer in the context of gender reassignment.
• Added advice to good practice section on haematuria assessment and referral.
• Added a link to an online risk calculator for bladder cancer.
• Added advice on investigation for kidney cancer in patients presenting with abdominal pain and microcytosis.

Non-Specific Symptoms of Cancer

• New addition to the SRGs.
• Defines criteria for the referral of patients with symptoms that don’t fit a specific cancer pathway.
• Advice on primary care testing and the use of Rapid Cancer Diagnostic Services (RCDSs) and GP direct access to CT.
• Good practice covering referral processes, bone pain, unprovoked deep venous thrombosis and thrombocytosis.

Cancer in Children and Young People

• Title of the Guideline has changed from ‘Children, Teenagers and Young Adults’.
• Additional information on incidence, routes to diagnosis and possible delays added.
• Expanded section on cancer types found in this age group e.g. additional description of the features of the more frequent cancers diagnosed.
• New section added on assessment to aid recognition of cancers in children e.g. added features that should raise suspicion of cancer including attendance patterns, persistent symptoms or parent/carer concerns.
• New section added on assessment to aid recognition of cancers in young people e.g. added possible reasons for symptoms of cancer to be misattributed.
• Expanded section on USC referral e.g. added clinical features of each cancer type in a table derived from published guidelines to aid recognition and referral.
• Good practice section covering persistent symptoms, lymphadenopathy, emergency referral and thyroid cancer.

Malignant Spinal Cord Compression

• Removed as a stand-alone section.
• Link to national guidance added throughout the Guideline where appropriate – Malignant Spinal Cord Compression.