GPAtlas🧭 When to suspect
Childhood cancer is rare – but it is the leading medical cause of death in children beyond infancy, and outcome depends heavily on early recognition.
The diagnostic challenge is that childhood cancers seldom announce themselves:
• Most present with non-specific symptoms – fatigue, intermittent pain, recurrent infection, vague abdominal complaints.
• These symptoms overlap almost entirely with the common, benign illnesses a GP sees every day.
• Only around one in five children later diagnosed with cancer presents with a classic ‘alarm’ symptom.
Two features make the primary-care task distinctive.
First, the positive predictive value of any single symptom is very low. Yet because the disease is serious and frequently curable, investigation and referral are justified at a far lower threshold than in adults.
Second, the referral routes are faster and different:
• Most suspected childhood cancers follow a very urgent (48-hour) pathway rather than the adult suspected cancer pathway (previously the two-week wait).
• Some require immediate, same-day specialist assessment.
You do not need to diagnose the tumour: recognise the pattern, act on the correct urgent pathway, and listen to parents – whose persistent concern is itself a NICE-recognised reason to refer.
| Tumour group | Hallmark primary-care presentation | NICE NG12 action |
|---|---|---|
| Leukaemia | Pallor, persistent fatigue, fever, recurrent infection, generalised lymphadenopathy, persistent bone pain, bruising or bleeding | • Very urgent FBC (48h) • Immediate referral if petechiae or hepatosplenomegaly |
| Brain/CNS | • Early-morning or persistent headache with vomiting • Abnormal balance, coordination or gait • Visual change • New-onset squint |
Very urgent referral (48h) for newly abnormal central neurological function |
| Lymphoma | Unexplained, persistent or enlarging lymphadenopathy or splenomegaly (± fever, night sweats, weight loss) | Very urgent referral (48h) |
| Neuroblastoma or Wilms’ tumour | • Palpable abdominal mass or enlarged abdominal organ • Wilms’ may also show visible haematuria |
Very urgent referral (48h) |
| Bone sarcoma | Unexplained bone pain or swelling – classically waking the child at night | Very urgent direct-access X-ray (48h) |
| Soft tissue sarcoma | Unexplained lump that is increasing in size | Very urgent direct-access ultrasound (48h) |
| Retinoblastoma | Absent red (fundal) reflex, white pupil (leukocoria) or new-onset squint | Ophthalmology on the suspected cancer pathway |
Source: NICE NG12 · Children’s Cancer and Leukaemia Group
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