Scottish Referral Guidelines for Suspected Cancer

The Scottish Referral Guidelines for Suspected Cancer (SRG) are recommendations to support GPs and the wider primary care team to manage patients who present with possible symptoms of cancer and facilitate appropriate referral to secondary care. Recommendations are arranged by cancer site, covering well known ‘red flags’ as well as vague, or non-specific symptoms.

The Scottish Referral Guidelines for Suspected Cancer (SRG) were updated in January 2019 and principle updates included [2]

• Recognising the importance of the wider primary care team

• Prompts for patient-centred, informed decision making during a consultation, e.g. what are the benefits/risks/side effects/alternative options?

• Safety netting to help appropriately manage patients

The update focuses on eight cancer pathways:

Lung	breast.png Breast	lower_gi.png Lower GI
upper_gi.png Upper GI	brain.png Brain	bladder.png Bladder
head_and_neck.png Head and Neck	children_and_young_people.png Children and Young People

NHS Scotland have produced a summary of key changes that have been made to the SRG guidelines

The Scottish Government have  produced a  number of resources (link is external)to help local teams understand and evaluate the impacts and costs of implementing the guidance

Pathways and availability of tests can vary locally so it’s also important to be aware of your specific Health Board guidance. If you’re unsure what’s available to you, contact your Local Medical Council or GP representative.

Click below for a helpful summary of the key actions you can take in managing people who present with non-specific signs or symptoms of cancer.

Read the GP Insight guide to managing patients with non-specific signs of cancer

GP perspective

Dr Anant Sachdev, Cancer Research UK GP highlights in this video, the importance of routinely using suspected cancer referral guidelines despite current complexities around the management of cancer referrals.

Dr Richard Roope, Cancer Research UK Primary Care Advisor highlights in this video, key considerations when managing people who present with non-specific symptoms.

Translating cancer guidelines into practice can be challenging, especially when people present with non-specific symptoms. If this happens, as well as using the Scottish Referral Guidelines, there are some key actions you can take.

Considerations for managing patients with non-specific symptoms

diagnosis-pink-icon.png	Use primary care investigations where available at point of care, to triage and manage the appropriate routes to send people. Chest X-rays, CT scans and blood tests are usually easily accessible and can help speed up cancer diagnosis. Each Health Board should have a pathway for imaging or, if not, urgent referral for investigation for these patients A FBC could reveal thrombocytosis, which can be a risk marker for cancer. Thrombocytosis is associated with Lung, Endometrium, Gastric, Oesophageal and Colorectal (LEGO-C) cancers. In patients who have a raised platelet count with no explanation, clinicians should assess for symptoms and risks of malignancy. A FBC can also reveal anaemia that might warrant further investigation Pathways and availability of tests can vary locally so it’s also important to be aware of your specific Health Board guidance. If you’re unsure what’s available to you, contact your local LMC or GP representative.
notes-blue-icon.jpg	Don’t be reassured by negative test results. Chest X-Rays, PSA and CA125 blood tests have false negative rates of 15-25%.
checklist-grey-icon.png	Implement robust and consistent safety netting to help manage diagnostic uncertainty. Safety netting is vital for all patients, whether they’re being referred for tests, or specialist advice or not and recorded on the clinical system.
ticked-checklist-blue-icon.png	Ensure you safety net patients who are not referred for suspected cancer until the symptoms are explained, resolved or the patient is referred. Patients should be given information about any tests they need to have, the next steps and follow up whether they are referred or not.
hammer-icon-pink.png	Use tools to make following the guidelines easier (see below) and be aware of local guidance.
sign-post-icon-blue.png	Use Early Cancer Diagnosis Centre (ECDCs) if available, which provide alternative routes for patients when GPs are unsure which site-specific route would be appropriate.
warning-icon-grey.png	Remember to act on clinical suspicion if you still have concerns.

Patient case study: test your Scottish Referral Guidelines (SRG) knowledge

Tony is 72 years old and presents to his GP with new appetite loss. He has diabetes and arthritis in his hands, which often makes it difficult for him to sleep and eat. Tony is a non-smoker and has had no exposure to asbestos.

The GP enquires if there are any additional symptoms, to understand if the appetite loss is related to Tony’s difficulty sleeping or not.

• If unexplained or persistent (more than 3 weeks) appetite loss, chest pain, change in cough or new cough, shortness of breath or weight loss is present then SRG recommends offering an urgent chest X-ray

The appetite loss is not persistent and there are no additional symptoms. The GP decides to request several blood tests for additional reassurance that nothing serious is going on.

Which blood tests would you order?

• Several tests could be done at this stage given the non-specificity of Tony’s presentation, but the GP includes: FBC, haematinics, U&E, LFT, TFT, HBA1C, bone profile & ESR

The GP asks Tony to book another appointment in five day’s time, when his blood test results are due back. The blood tests show iron deficiency anaemia, but everything else is normal.

What would you do next?

• Ask Tony to return for another anaemia blood test in a week’s time?
• Refer on to an urgent suspected colorectal cancer pathway? 
• Complete a Faecal Immunochemical Test (FIT) and wait for the result to determine whether to make a colorectal urgent referral?

Having discussed the options with Tony, the GP refers him to the urgent referral pathway for suspected colorectal cancer without doing a FIT*, as this is the SRG recommendation for people over 60 with iron-deficiency-anaemia.

Use tools to make following the guidelines easier. Find your preferred tool. 

The Scottish Primary Care Cancer Group have produced a quick visualisation tool and app.

A desktop Quick Guide has been developed by the Scottish Primary Care Cancer Group which has been used as the basis for an App for use on mobile devices.

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Scan the QR code or click here to download on an Apple device 

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Scan the QR code or click here to download on an Andriod device 

1. Public Health Scotland (2021). National Cancer Diagnosis Audit: Summary Information from an audit of patients diagnosed between 1 October 2018 and 30 September 2019. [Accessed August 2021]

2.  NHS Scotland. Scottish Referral Guidelines for Suspected Cancer: cancerreferral.scot.nhs.uk