NICE Suspected Cancer Guideline (NG12): A Summary for Primary Care

🔑 Key principle – refer on the pattern, not on a normal test

NG12 is built for a world where cancer often hides behind ordinary symptoms. A normal examination, a normal chest X-ray, a low faecal immunochemical test or a normal scan never excludes cancer. If a patient meets a referral criterion, refer; if they do not but you remain concerned, use Advice & Guidance and safety-net – bring them back, re-examine, and re-investigate rather than reassure once and discharge.

➤ Massive haemoptysis → airway and haemodynamic risk → emergency admission

➤ Suspected superior vena cava obstruction (SVCO) (facial/neck/arm swelling, distended veins, breathlessness) → emergency admission

➤ Neutropenic sepsis (unwell or febrile during/soon after chemotherapy) → a medical emergency → immediate admission

➤ Suspected metastatic spinal cord compression (MSCC) → new/progressive back pain with limb weakness, a sensory level or bladder/bowel dysfunction in known or suspected cancer → emergency admission, nurse flat

➤ Raised intracranial pressure or status epilepticus → 999 / emergency admission

➤ Active haematemesis or melaena with haemodynamic compromise, or clot retention (unable to pass urine) → emergency admission

➤ Child with unexplained petechiae or hepatosplenomegaly → suspected leukaemia → immediate specialist assessment

• Chest X-ray findings suggesting lung cancer, OR aged ≥ 40 with unexplained haemoptysis → suspected cancer pathway referral

• Aged ≥ 40 with ≥ 2 unexplained symptoms (cough, fatigue, breathlessness, chest pain, weight loss, appetite loss) – or ≥ 1 if they have ever smoked → urgent direct-access chest X-ray (≤ 2 weeks)

• Aged ≥ 40 with persistent/recurrent chest infection, finger clubbing, supraclavicular or persistent cervical lymphadenopathy, chest signs of lung cancer, or thrombocytosis → consider urgent chest X-ray

• Mesothelioma: chest X-ray suggestive → pathway referral; aged ≥ 40 with asbestos exposure (or ever-smoked) and ≥ 1 symptom, or ≥ 2 symptoms, or finger clubbing / chest signs of pleural disease → urgent chest X-ray

⚠️ Common pitfall

Treating a normal chest X-ray as the end of the matter. A plain film misses a meaningful minority of lung cancers, particularly central tumours. If clinical suspicion persists after a normal X-ray – especially with ongoing haemoptysis, weight loss or clubbing – refer or arrange CT rather than reassure.

• Dysphagia (any age), OR aged ≥ 55 with weight loss plus upper abdominal pain, reflux or dyspepsia → suspected cancer pathway referral (oesophageal / stomach)

• Aged ≥ 40 with jaundice → suspected cancer pathway referral (pancreatic). Upper abdominal mass consistent with stomach cancer → consider pathway referral

• Aged ≥ 60 with weight loss plus any of diarrhoea, back pain, abdominal pain, nausea, vomiting, constipation or new-onset diabetes → urgent direct-access CT (≤ 2 weeks), or ultrasound if CT unavailable (pancreatic)

• Upper abdominal mass consistent with an enlarged gallbladder or liver → urgent direct-access ultrasound

• Aged ≥ 55 with treatment-resistant dyspepsia, or upper abdominal pain with low haemoglobin, or raised platelets / nausea-vomiting plus an upper-GI symptom → consider non-urgent direct-access endoscopy (OGD)

• Haematemesis → non-urgent direct-access endoscopy if stable; active or significant bleeding → emergency admission

• Offer FIT to adults with any of: an abdominal mass; a change in bowel habit; iron-deficiency anaemia; aged ≥ 40 with unexplained weight loss and abdominal pain; aged < 50 with rectal bleeding and (abdominal pain or weight loss); aged ≥ 50 with unexplained rectal bleeding, abdominal pain or weight loss; or aged ≥ 60 with anaemia even without iron deficiency

• FIT ≥ 10 micrograms haemoglobin per gram of faeces → suspected cancer pathway referral (offer FIT even after a negative bowel-screening test)

• Unexplained rectal or anal mass, or anal ulceration → refer directly (FIT not needed)

• FIT < 10 (or no sample returned) → safety-net; do not delay referral if clinical concern is strong, e.g. a palpable abdominal mass

• Aged ≥ 30 with an unexplained breast lump (with or without pain) → suspected cancer pathway referral

• Aged ≥ 50 with discharge, retraction or other change of concern in one nipple only → suspected cancer pathway referral

• Skin changes suggesting breast cancer (e.g. peau d’orange, tethering), OR aged ≥ 30 with an unexplained axillary lump → consider pathway referral

• Aged < 30 with an unexplained breast lump (with or without pain) → consider non-urgent referral

🧠 Clinical pearl

The age-stratified thresholds exist because a single cut-off does two things badly. In younger women CA125 gives false reassurance, so under 40 the test is dropped in favour of ultrasound. In older women the threshold is lowered (down to 24 IU/mL at 60–69) to catch more cancers – and a raised CA125 with a normal scan in an older woman can flag a non-ovarian cancer, so keep looking rather than simply reassuring.

• Aged ≥ 55 with unexplained postmenopausal bleeding not attributable to HRT → suspected cancer pathway referral (endometrial). Aged < 55 with the same → consider pathway referral

• Aged ≥ 55 with unexplained vaginal discharge (first presentation, or with thrombocytosis or haematuria), OR visible haematuria with low haemoglobin, thrombocytosis or high blood glucose → consider urgent direct-access ultrasound (endometrial)

• Unscheduled bleeding on HRT → evidence is limited; follow British Menopause Society guidance on assessment

• Cervix appearance consistent with cervical cancer → consider pathway referral (a smear is not required first, and a previous normal smear must not delay referral)

• Unexplained vulval lump, ulceration or bleeding → consider pathway referral (vulval). Unexplained palpable mass in or at the entrance to the vagina → consider pathway referral (vaginal)

• Prostate feels malignant on DRE → suspected cancer pathway referral

• Lower urinary tract symptoms (LUTS), erectile dysfunction, or visible haematuria → offer PSA + DRE; refer via pathway if PSA is above the age threshold below

• Aged ≥ 45 with unexplained visible haematuria without UTI, or visible haematuria persisting/recurring after UTI treatment → suspected cancer pathway referral (bladder and renal)

• Aged ≥ 60 with unexplained non-visible haematuria plus dysuria or a raised white-cell count → pathway referral (bladder). Aged ≥ 60 with recurrent/persistent unexplained UTI → consider non-urgent referral

• Non-painful enlargement or change in shape/texture of the testis → consider pathway referral; consider urgent direct-access ultrasound for unexplained or persistent testicular symptoms

• Penile mass or ulcerated lesion (sexually transmitted infection excluded), a persistent lesion after STI treatment, or unexplained/persistent foreskin or glans symptoms → consider pathway referral

• Major features (2 points each): change in size · irregular shape · irregular colour

• Minor features (1 point each): largest diameter ≥ 7 mm · inflammation · oozing · change in sensation

• Score ≥ 3, or dermoscopy suggesting melanoma → suspected cancer pathway referral

• Pigmented or non-pigmented lesion suggesting nodular melanoma → consider pathway referral

• Lesion raising suspicion of squamous cell carcinoma (SCC) – keratotic, ulcerated or rapidly growing → consider pathway referral

• Lesion raising suspicion of basal cell carcinoma (BCC) – pearly/waxy nodule, rolled edge, fine telangiectasia → consider routine referral (pathway referral only if site or size means a delay would matter)

• Aged ≥ 45 with persistent unexplained hoarseness, or an unexplained neck lump → consider pathway referral (laryngeal)

• Unexplained oral ulceration lasting > 3 weeks, or a persistent unexplained neck lump → consider pathway referral (oral)

• A lump on the lip / oral cavity, or a red (or red-and-white) patch suggesting erythroplakia or erythroleukoplakia → consider urgent referral to a dentist (who may refer via the cancer pathway)

• Unexplained thyroid lump → consider pathway referral (thyroid)

• Adults with progressive, sub-acute loss of central neurological function (evolving weakness, dysphasia, memory or personality change) → urgent direct-access MRI brain (CT if MRI contraindicated)

• Children / young people with newly abnormal cerebellar or other central neurological function → very urgent referral (≤ 48 hours)

• Papilloedema, or features of raised intracranial pressure (early-morning headache, vomiting, focal deficit) → urgent / emergency escalation

• Adults with pallor, persistent fatigue, unexplained fever, persistent/recurrent infection, generalised lymphadenopathy, unexplained bruising/bleeding/petechiae or hepatosplenomegaly → very urgent FBC (≤ 48 hours) for leukaemia

• Children / young people with the above features (plus persistent or unexplained bone pain) → very urgent FBC (≤ 48 hours); unexplained petechiae or hepatosplenomegaly → immediate specialist assessment

• Aged ≥ 60 with persistent bone pain (especially back) or unexplained fracture → myeloma screen: FBC, calcium, plasma viscosity or ESR, serum protein electrophoresis (paraprotein), and serum free light chains (Bence–Jones urine if serum free light chains unavailable); refer via pathway if results suggest myeloma

• Adults with unexplained lymphadenopathy or splenomegaly (weigh B symptoms – fever, night sweats, weight loss, pruritus; alcohol-induced node pain in Hodgkin) → consider pathway referral; children / young people → very urgent (≤ 48 hours)

• Adults – an unexplained lump increasing in size → urgent direct-access ultrasound; if suggestive or uncertain with concern → pathway referral (soft tissue)

• Adults – an X-ray suggesting bone sarcoma → consider pathway referral

• Children / young people – unexplained bone swelling or pain → very urgent direct-access X-ray; an unexplained lump increasing in size → very urgent direct-access ultrasound; suggestive or uncertain imaging → very urgent referral (≤ 48 hours)

• Palpable abdominal mass or unexplained enlarged abdominal organ → very urgent referral (≤ 48 hours) – neuroblastoma / Wilms’ tumour

• Unexplained visible haematuria → very urgent referral (≤ 48 hours) – Wilms’ tumour

• Absent fundal (‘red’) reflex / leukocoria → ophthalmology via the suspected cancer pathway – retinoblastoma (if with new-onset squint, see NICE NG127)

• Persistent parental concern about a child’s symptoms → consider referral even if a benign cause seems likely

• Aged ≥ 60 with unexplained weight loss (> 5% over ~6 months) – colorectal, gastro-oesophageal, lung, prostate, pancreatic, urological → assess for a localising feature, then offer urgent investigation, a suspected cancer pathway referral, or a non-specific symptoms pathway referral

• Unexplained appetite loss – lung, oesophageal, stomach, colorectal, pancreatic, bladder, renal → assess, then urgent investigation / pathway / non-specific pathway referral

• Unexplained (unprovoked) deep vein thrombosis (DVT) – urogenital, breast, colorectal, lung → assess, then consider urgent investigation / pathway / non-specific pathway referral

• Children / young people: persistent parental concern → consider referral

The symptoms you've described need further investigation. Although they are often caused by conditions other than cancer, it's important that we keep an open mind and rule out anything serious, including cancer. The best way to do that is to arrange an urgent test or specialist appointment.

This is called a suspected cancer referral, which means you'll usually be seen within two weeks. Most people referred through this pathway do not have cancer, but referring you promptly helps us reach a diagnosis as early as possible. If your symptoms change or worsen while you're waiting, please contact us straight away.

➤ Pre-referral symptom control

→ Analgesia: paracetamol first-line, adding a weak opioid (e.g. codeine) if needed. Use NSAIDs (ibuprofen, naproxen) cautiously and avoid where renal impairment is possible – particularly in suspected myeloma. Do not let analgesia mask progressive neurological symptoms.

➤ Avoid masking the diagnosis

→ Proton pump inhibitors (e.g. omeprazole, lansoprazole) can mask upper-GI cancer – ideally stop 2 weeks before endoscopy, but never delay referral.

→ Antibiotics: treat genuine infection (e.g. flucloxacillin for mastitis; nitrofurantoin or trimethoprim for a confirmed UTI – avoid nitrofurantoin if eGFR < 45), but if an inflammatory breast change or haematuria persists after treatment, refer rather than re-treat repeatedly.

➤ Do not pre-empt the pathway

→ Avoid starting alpha-blockers (e.g. tamsulosin) for LUTS until prostate cancer is excluded; start anti-epileptics only on specialist advice for a confirmed seizure.

➤ Definitive therapy is specialist-led

→ Surgery, chemotherapy, radiotherapy and targeted / immunotherapy are decided in secondary care; the GP’s job is recognition, prompt referral, symptom control and safety-netting.

📌 DVLA – driving with a suspected brain/CNS tumour or new seizures

• Any seizure: the patient must stop driving immediately and notify the DVLA. Group 1 (car/motorcycle): after a single unprovoked seizure with normal investigations, driving may resume after 6 months seizure-free; if epilepsy (two or more seizures) is diagnosed, 12 months seizure-free is required, and an underlying cause such as a brain tumour usually means longer off the road. Group 2 (bus/lorry): far stricter – typically 5 years off after a single seizure (10 years for epilepsy), subject to conditions.

• Brain or CNS tumour: the patient must not drive and must notify the DVLA. Re-licensing depends on tumour type, grade, site and any residual deficit (for example, a high-grade glioma usually means at least 2 years off driving); any brain tumour diagnosed in childhood (aged 16 or under) must be notified.

🧭 AKT – high-yield facts

• Suspected cancer pathway referral (formerly the "two-week wait") = seen within 2 weeks; Faster Diagnosis Standard = diagnose or exclude within 28 days.

• FIT ≥ 10 µg Hb/g → colorectal pathway referral; offer FIT even after a negative bowel-screening test; a rectal/anal mass or anal ulceration is referred without FIT.

• Ovarian (2026): ≤ 39 → ultrasound (CA125 unreliable); ≥ 40 → CA125 with age thresholds (40–49 ≥ 35, 50–59 ≥ 31, 60–69 ≥ 24, 70–79 ≥ 25, 80+ ≥ 31 IU/mL).

• Age thresholds to memorise: breast lump ≥ 30; postmenopausal bleeding ≥ 55; visible haematuria ≥ 45; hoarseness ≥ 45; jaundice ≥ 40; lung symptoms ≥ 40; weight loss ≥ 60 (> 5%/6 months).

• Melanoma weighted 7-point checklist: 3 major (size change, irregular shape, irregular colour = 2 each) + 4 minor (≥ 7 mm, inflammation, oozing, sensation change = 1 each); refer if ≥ 3.

• Age-specific PSA (µg/L): 40–49 > 2.5; 50–59 > 3.5; 60–69 > 4.5; 70–79 > 6.5.

• Myeloma screen (≥ 60, persistent back pain): FBC, calcium, ESR/plasma viscosity, serum protein electrophoresis, serum free light chains (Bence–Jones if unavailable).

🎯 SCA

A 56-year-old man requests another prescription of omeprazole. His reflux and dyspepsia have settled on it, but on review he has lost around 6 kg over three months without trying. He is keen to avoid an endoscopy – he feels well and is busy at work – and assumes the tablets have fixed the problem. The dilemma is that symptomatic improvement on a proton pump inhibitor is reassuring to him but clinically misleading: at 55 and over, weight loss with dyspepsia now warrants a suspected cancer pathway referral, and the PPI may be masking an upper-GI cancer.

A strong consultation explores his ideas, concerns and expectations (his reluctance, and what the weight loss might mean to him); explains honestly why feeling better on a PPI does not exclude something serious and why urgent referral is needed; agrees a shared plan for a suspected cancer pathway referral (ideally stopping the PPI two weeks before endoscopy if that will not delay things); and safety-nets clearly about worsening swallowing, vomiting or bleeding – all while acknowledging his anxiety and respecting his autonomy.