GPAtlas🧭 When to suspect
Upper gastrointestinal cancers – of the oesophagus, stomach, pancreas, liver and gallbladder – are among the less survivable cancers in the UK, chiefly because they present late. Five-year survival ranges from around 7% for pancreatic cancer (the lowest of any common cancer) to roughly 15–20% for oesophageal and stomach cancer. The single biggest lever a GP holds is earlier diagnosis: outcomes improve markedly when disease is caught at an earlier stage.
The primary-care task is pattern recognition against age and symptom thresholds, then matching each pattern to the correct route – a suspected cancer pathway referral, an urgent direct-access scan, or a non-urgent endoscopy. A small number of features act as alarm symptoms that bypass all other criteria: dysphagia at any age, an upper abdominal mass, or jaundice in someone aged 40 or over.
| Cancer (5-yr survival) | Key presenting features | First-line action |
|---|---|---|
| Oesophageal (~15%) | Dysphagia at any age; or aged ≥ 55 with weight loss and any of upper abdominal pain, reflux, or dyspepsia | Suspected cancer pathway referral (delivered as urgent upper GI endoscopy) |
| Stomach (~20%) | As for oesophageal; or an upper abdominal mass consistent with stomach cancer | Suspected cancer pathway referral (urgent endoscopy; mass → pathway referral) |
| Pancreatic (~7%, lowest of common cancers) | Jaundice if aged ≥ 40; or aged ≥ 60 with weight loss and any of diarrhoea, back pain, abdominal pain, nausea, vomiting, constipation, or new-onset diabetes | Jaundice ≥ 40 → suspected cancer pathway referral; ≥ 60 cluster → urgent direct-access CT (ultrasound if CT unavailable) |
| Gallbladder (> 10%, commoner in women) | Upper abdominal mass consistent with an enlarged gallbladder | Urgent direct-access ultrasound |
| Liver (~15%) | Upper abdominal mass consistent with an enlarged liver | Urgent direct-access ultrasound |
NICE updated the upper GI recommendations on 1 May 2025: oesophageal and stomach symptoms carrying a 3% or greater probability of cancer now warrant a suspected cancer pathway referral rather than a GP-booked direct-access endoscopy (in practice still delivered as an urgent upper GI endoscopy). The suspected cancer pathway is governed by the Faster Diagnosis Standard – a diagnosis given or ruled out within 28 days. The 2026 amendments also recognise a non-specific-symptoms pathway for unexplained weight loss (aged 60 and over) or appetite loss where no single cancer is clearly indicated. Raise suspicion further with a history of smoking or excess alcohol, long-standing reflux or Barrett's oesophagus, obesity, Helicobacter pylori infection, and – for gallbladder cancer – female sex.
Source: NICE NG12 · Cancer Research UK
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