Please note that Radiology will NOT automatically refer onwards on the basis of an abnormal scan: the GP will need to decide on further management, including any subsequent referrals.
Background
This pathway has been based on the principles outlined in the document Quality Imaging Services for Primary Care: A Good Practice Guide (2012) and the new Scottish Referral Guidelines for Suspected Cancer 2025
This service is for patients with symptoms suggestive of cancer, and no specific localising signs or symptoms to suggest a specific underlying primary.
The pathway allows GPs to refer directly for CT scan of the chest / abdomen / pelvis for those with non-specific features suggestive for malignancy.Previously, this group of patients would usually have been referred to a secondary care specialty, and only then subsequently have had cross-sectional imaging arranged. This fast-track service can enable more rapid and appropriate specialist referral, or other management where indicated.
This service was set up after an NHS Lothian pilot demonstrated a very appropriate use of the service. A power point with details of this pilot can be accessed at Pilot-Audit-Results-120419.pdf . The latest audit of this service can be accessed at USOC Audit presentation.
Pathway in Practice
This pathway should be used when clinical assessment of patient by General Practitioner leads to a very strong suspicion of suspected underlying malignancy with, for example, unexplained significant weight loss of > 5% body weight or GP “gut feeling”. More comprehensive guidance is available in the Non-Specific Symptoms of Cancer section (page 54) of the Scottish Referral Guidelines for Suspected Cancer 2025) – See Referral Guidelines Section
If there is any indication of localising signs, symptoms or laboratory tests to suggest malignancy in a specific system, direct referral should be made using the appropriate established pathway without ordering a CT scan.
Prior to requesting a CT scan of chest/abdomen/pelvis the GP must follow the guidance under the Primary care guidelines section.
The pathway is available at the three major Lothian hospitals: RIE, SJH and WGH.
Please note that Radiology will NOT automatically refer onwards on the basis of an abnormal scan: the GP will need to decide on further management, including any subsequent referrals.
After scanning, the report will be returned to the GP who then needs to decide management including any ongoing referral. Responsibility for READING and ACTING ON the results lies with the Referring GP. Responsibility for ONWARD REFERRAL lies with the Referring GP.
The following advice may be helpful regarding onward referral:
- If Imaging demonstrates a Clear Primary with Metastatic Disease, then Refer to the relevant Specialist Cancer Team (e.g., Breast / Colorectal)
- If imaging demonstrates Metastatic Disease with no obvious primary but the patient has a PMH of Previous Cancer, then Refer to the Specialist Cancer Team for the previous cancer (e.g., Breast / Colorectal) OR direct to Oncology Consultant if already known to one in the past.
- If imaging demonstrates Metastatic Disease with no obvious primary and no PMH of Previous Cancer then refer directly to the Cancer of Unknown Primary (CUP) team
- If imaging demonstrates lesions on CT that are Possibly Malignant with no obvious primary and No PMH of Previous Cancer, then:
- If the lesions are Lung Lesions, then refer to the Lung MDM who will decide on Bronchoscopy / EUS biopsies.
- For other lesions then refer to the Cancer of Unknown Primary (CUP) team
- If imaging does not demonstrate any abnormality but there is persistent weight loss then refer to General Medicine / GI / Surgery / MOE (dependent on age) as per usual practice
J.B & S.G. 11-09-25
Who to refer:
People with non-specific symptoms or signs where malignancy is suspected (commonly weight loss) after the above assessment has taken place.
Refer patients with any of the following symptom (who do not meet the criteria for a site-specific pathway, & ONLY after following the guidance under Primary Care Management section) especially if accompanied by GP ‘gut feeling’ of a cancer diagnosis:
- New unexplained weight loss (documented ≥ 5% of body weight in 3 months*)
- New unexplained loss of appetite, fatigue, nausea, malaise, or bloating for ≥ 4 weeks*.
- New unexplained, unexpected, or progressive pain, including bone pain, for ≥ 4 weeks
* or with strong clinical suspicion
More comprehensive guidance is available in the Non-Specific Symptoms of Cancer section (page 54) of the Scottish Referral Guidelines for Suspected Cancer 2025)
Who not to refer:
- Those where there are localising symptoms or signs (e.g. a Breast lump) where the GP should refer to the relevant specialist (see Scottish Referral Guidelines for Suspected Cancer 2025 )
- Do not use this pathway when there is an alternative appropriate radiology pathway (e.g., PMB, Testicular Cancer, Abnormal CXR all have their own dedicated fast track pathways and these should be used, rather than requesting a CT under this pathway. This could lead to unnecessary delay.)
How to refer:
Using SCI Gateway to RIE, SJH and WGH under Clinical Radiology. Exact pathways below:
- RIE >> Clinical Radiology >> LI USOC Chest Abdo Pelvis
- SJH >> Clinical Radiology >> LI USOC Chest Abdo Pelvis
- WGH >> Clinical Radiology >> LI USOC Chest Abdo Pelvis
Contacting Radiology
By Phone
PLEASE NOTE THESE NUMBERS ARE FOR PROFESSIONAL USE ONLY, THEY ARE NOT FOR PATIENTS
If GPs have any specific queries they can contact the Duty Radiologist for advice on the numbers below. (Patient department contact numbers can be found on the Plain x-ray and Ultrasound page).
- WGH: GP contact number for Duty Radiologist 0131 537 2315
- SJH: GP contact number for Duty Radiologist 01506 524 352
- RIE: GP contact number for Duty Radiologist 0131 242 3572
- RHCYP: GP contact number for Duty Radiologist 0131 312 0120
By Email
The email addresses below can be used for administrative enquiries/ expediting reports/ changing appointments etc, but not for specific individual purely clinical questions. PLEASE NOTE THESE EMAIL CONTACTS ARE FOR PROFESSIONAL USE ONLY, THEY ARE NOT FOR PATIENTS
- WGH: wgh.radiology@nhslothian.scot.nhs.uk
- WGH Mammography: wgh.mammography@nhslothian.scot.nhs.uk
- RIE: radiology.rie@nhslothian.scot.nhs.uk
- SJH: sjh.radiology@nhslothian.scot.nhs.uk
If GPs have a query about a specific radiological report they can also email the reporting Radiologist directly.
Prior to requesting a CT scan of chest/abdomen/pelvis the GP must ensure the following has been completed:
- History and Examination including, where appropriate, assessment of mood.
- Investigation, within the past 2 months, of relevant Biochemical and Haematological testing including:
- Urinalysis (for haematuria – Link to Urological Cancer Guidance)
- FBC
- ESR and/or CPR
- Cr + Es
- LFTs
- TFTs
- HbA1c
- Bone profile (Albumin/Calcium)
- Myeloma Screen
- Vitamin B12, folate, ferritin and folate.
- PSA (If clinically appropriate – see Link to Prostate Cancer Guidance)
- CA125 (If clinically appropriate – see – Link to Ovarian/Gynaecological Cancer Guidance)
- Imaging a CXR, with no evidence of Primary Intrapulmonary Malignancy. (If this was present, then referral should be via the Lung Cancer Referral Pathway. If CXR, Skeletal Radiographs or USS show metastatic disease with no known primary, then discuss with Cancer of Unknown Primary (CUP) team.
- If the patient is < 40 years of age, discussion with the duty radiologist must take place in the first instance prior to requesting a CT scan; an urgent ultrasound of abdomen/pelvis may be more appropriate as the next test.
After scanning, the report will be returned to the GP who then needs to decide management including any ongoing referral. Responsibility for READING and ACTING ON the results lies with the Referring GP. Responsibility for ONWARD REFERRAL lies with the Referring GP.
