Scottish referral guidelines for suspected cancer: quick reference guide

Lung Cancer

Urgent suspicion of cancer chest X-ray

• Any unexplained haemoptysis
• Unexplained and persistent (more than three weeks):
• change in cough or new cough
• dyspnoea
• chest/shoulder pain
• loss of appetite
• weight loss
• chest signs
• hoarseness (if no other symptoms present to suggest lung cancer refer via Head & Neck pathway)
• fatigue in a smoker aged over 40 years
• New or not previously documented finger clubbing
• Persistent or recurrent chest infection
• Cervical and/or persistent supraclavicular lymphadenopathy*
• Thrombocytosis where symptoms and signs do not suggest other specific cancer**
• Any person who has consolidation on chest X-ray should have further imaging no more than six weeks later to confirm resolution

* if CXR normal, refer via Head & Neck pathway

** if CXR normal, consider alternative diagnosis including other cancers

Urgent suspicion of cancer referral

• Any unexplained symptoms or signs detailed above persisting for longer than six weeks despite a normal chest X-ray (other than isolated thrombocytosis or cervical and/or persistent supraclavicular lymphadenopathy)
• Chest X-ray suggestive/suspicious of lung cancer (including pleural effusion, pleural mass and slowly resolving consolidation)
• Persistent haemoptysis in smokers/ex-smokers over 40 years of age

Good practice points

• There should be a locally agreed pathway for radiology to notify the respiratory team of an abnormal chest X-ray suggestive of cancer
• It is good practice for the referrer to consider taking bloods including full blood count and an assessment of renal function if not done in preceding three months in order to expedite further imaging
• In people with features suggestive of cancer including suspected metastatic disease, but no other signs to suggest the primary source, consider CT chest, abdomen and pelvis in accordance with local guidelines about the investigation of an unknown primary cancer

Note: a normal chest X-ray does not exclude a diagnosis of lung cancer

There is emerging evidence that thrombocytosis is a risk marker for underlying cancer, including lung. Remember “LEGO-C”.