Scotland sees around 1,000 brain and CNS tumour cases per year, about half of which are malignant, with only around one-third of patients surviving one year or more. Over 70% are diagnosed via emergency routes, reflecting the challenge of timely diagnosis, as most neurological symptoms are due to benign conditions and GPs encounter CNS cancers infrequently. As a result, many patients have multiple consultations before referral.
If brain/CNS cancer is suspected, assess for:
- History of HIV or cancers with brain metastasis risk (lung, breast, melanoma, renal)
- Headache suggestive of raised intracranial pressure (progressive, worse on waking, nocturnal, aggravated by bending, with nausea/vomiting)
- Papilloedema – if uncertain, refer urgently to an optometrist
- Focal neurological deficits (consider stroke)
- New seizures, including non-collapse episodes (vacant spells, transient motor/sensory changes)
- Changes in cognition or personality
- Speech changes, e.g., word-finding difficulty
- History of HIV or cancers with brain metastasis risk (lung, breast, melanoma, renal)
Who to refer:
Emergency (Same Day Referral):
If presents with two or more of the following (i.e. discuss with neurology registrar on the day):
- New headache
- New seizure
- Papilloedema*
- New focal neurological deficit**
* Refer urgently to an optometrist if there is uncertainty about papilloedema or visual field loss. If papilloedema is confirmed, same-day referral to secondary care should be considered. Ensure there is a clear plan identifying who will be responsible for following up the optometry results.
**e.g. Unilateral weakness, dysphasia, visual field defect, ataxia, loss of consciousness. Also consider the Stroke pathway – see Transient Ischaemic Attack (TIA) And Stroke – RefHelp
Urgent Suspicion of Cancer (USC) Referral
Headache where there is concern about a brain/CNS cancer plus one or more of the following features:
- Cognitive change† – symptomatic or noted by others††
- Personality change
- History of cancer (especially lung, breast, melanoma or renal)
- History of HIV
†The Semantic Verbal Fluency Test (SVFT) is a quick test which can be done easily in practice and may indicate cognitive deficit if the score is reduced (i.e. less than 17 different animals named in one minute). A headache concerning for a brain tumour along with a reduced SVFT score has been shown to have a PPV higher than 5%. Please note that a SVFT score may be reduced in other conditions such as dementia, previous serious head injury, stroke, learning disabilities or for those whose first language is not English. (source: Scottish Cancer Referral Guidelines Review). If the patient presents with weakness & also has cognitive changes, consider discussion with the stroke team in the first instance (see Transient Ischaemic Attack (TIA) And Stroke – RefHelp)
†† Changes in cognition may not be volunteered by a person presenting with signs and symptoms of a brain tumour and direct enquiry may have to be made (Source: Scottish Cancer Referral Guidelines Review)
If a patient partially fits the criteria but the referring GP has noted other significant concerning features or has a high index of suspicion that there is an underlying diagnosis of cancer*, then they can use this pathway to refer for an USC CT Head as long as the reasons for referral are clearly explained in the SCI Gateway form. It remains vital however that GPs do not delay urgent Clinical Review by arranging imaging, on call Neurology are available to discuss if the onward referral route is not clear
Who not to refer:
Do not use this pathway if low risk features/headache only – Patients with symptom of a headache alone, and in whom CT Head has a low positive predictive value. After discussion with the patient about the potential consequences and outcomes of CT Head, they can be referred for non-urgent CT Head using the alternative SCI Gateway pathway: WGH > Neuroradiology > LI Neuroradiology.
How to refer:
Emergency: discuss with neurology registrar (as per algorithm)
USOC: Via SCI Gateway:
- For CT scan request: WGH> Neuroradiology > Headache suspect brain cancer
- If Scan results show a mass ‡ : RIE > Neurosurgery (Using Urgent USOC Priority)
(Please note that DCN is now based at the RIE, however the referrals should still be sent to the WGH. When this changes this webpage will be updated and all GPs will be informed by email.)
‡ Neuroradiology would speak directly to the on-call neurosurgical registrar while the patient is still in the department if there is significant mass effect or hydrocephalus.
**IMPORTANT: responsibility for actioning scan results lies with the referring GP. If the scan results indicate a suspicion of cancer, please refer the patient to Neurosurgery via SCI Gateway (Royal Infirmary of Edinburgh> Neurosurgery), using the Urgent USOC priority **
