GP Access to CT for Suspected Cancer (No Clinically Obvious Primary)

Background

This pathway has been based on the principles outlined in the document Quality Imaging Services for Primary Care: A Good Practice Guide (2012).

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 here.

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 > 10% body weight.

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 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 FBC, ESR, Cr + Es, BG, LFTs, TFTs, Myeloma Screen, Albumin and Calcium, LDH, CRP, Coagulation Screen
• 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.

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