Publication - Advice and guidance

Scottish referral guidelines for suspected cancer: quick reference guide

User-friendly visual aid to the urgent referral criteria as well as routine referral criteria and primary care management and good practice points.

Urgent suspicion of cancer referral

Ovarian cancer	Abnormal ultrasound scan and/or CA125 level Ascites and/or ultrasound-confirmed pelvic or abdominal mass (that is not obviously uterine fibroids, gastrointestinal or urological in origin)
Endometrial cancer	Any woman on hormone replacement therapy (HRT), presenting with persistent or unexplained postmenopausal bleeding, after cessation of HRT for four weeks Unscheduled vaginal bleeding in a patient taking tamoxifen Postmenopausal bleeding Persistent intermenstrual bleeding, especially with other risk factors despite a normal pelvic examination A woman presenting with a palpable abdominal or pelvic mass on examination that is not obviously uterine fibroids, gastrointestinal or urological in origin should be referred urgently for an ultrasound scan and, if significant concern, simultaneously to a specialist. Awaiting results of the ultrasound scan should not delay referral
Cervical cancer	Any woman with clinical features (vaginal discharge, postmenopausal, postcoital or persistent intermenstrual bleeding) and abnormality suggestive of cervical cancer on examination of the cervix
Vulval cancer	Any unexplained vulval lump found on examination Vulval bleeding due to ulceration
Vaginal cancer	Any suspicious abnormality of the vagina on speculum examination

Good practice points

An abdominal palpation should be undertaken, CA125 blood serum level measured and urgent pelvic ultrasound scan carried out in:

any woman over 50 years who has experienced new symptoms within the last 12 months that suggest irritable bowel syndrome or
women (especially those over 50 years) with one or more unexplained and recurrent symptoms (most days) of:
abdominal distension or persistent bloating
feeling full quickly or difficulty eating
loss of appetite
pelvic or abdominal pain
increased urinary urgency and/or frequency
change in bowel habit

A full pelvic examination, including speculum examination of the cervix, should be carried out in women presenting with:

A vulval examination should be carried out for any woman presenting with any vulval symptom.

If there is significant concern, awaiting the results of any investigation should not delay referral.

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

Primary care management

Symptoms (as above) persisting or worsening for any woman who has a normal CA125 with normal ultrasound, assess for other clinical causes and investigate as appropriate or refer to appropriate secondary care services, depending on local arrangement
Women presenting with vulval symptoms of pruritus or pain should be examined prior to initiation of any treatment and follow up should also include examination until symptoms are resolved or a diagnosis is confirmed
Refer urgently or routinely, if symptoms persist, depending on the symptoms and the degree of concern about cancer

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