Cancer of Unknown Primary (CUP)

This pathway is for those where a likely advanced malignancy has been identified (normally on imaging) but the source of the primary cancer is unknown. Patients with metastatic disease with an established invasive cancer, or where the clinical picture is suggestive of a primary source, should be referred to the relevant specialty.

The pathway requires some baseline investigations to be done prior to referral – please see Primary Care Management for full details.

This pathway is intended to:

improve the pathway to diagnosis for patients who present de novo with advanced malignancy without an obvious primary site – a Malignancy of Undefined Primary Origin (MUO)
enable early identification of patients who would benefit from anti-cancer treatment
prevent unnecessary investigations in those patients who are unfit for treatment or do not wish further investigation.

The Clinical Team.

The team is based at the Western General Hospital. Please note that the contact details below are for use by clinicians only:

Medical

Dr Sally Clive (Consultant Medical Oncologists) 0131 537 2263

Dr Colin Barrie (Consultant Medical Oncologists) 0131 537 3097

Dr Marj McLennan (Consultant Clinical Oncologist – radiotherapy) 0131 537 1036

Nursing

Gillian Knowles (Nurse Consultant) 0131 537 3793

Rachel Haigh (Clinical Nurse Specialist) 0131 537 1341

The clinical team will:

Provide Multidisciplinary Team (MDT) review of radiological imaging +/- pathology of patients with suspected CUP. MDT meetings are held first thing on Monday mornings
Provide advice regarding management of patients with suspected Malignancy of Undefined Primary Origin
Discuss patients out-with the multidisciplinary meeting where that is requested
See patients urgently in CUP oncology clinics (Wed and Thurs) to assess and arrange further selected investigations as is clinically appropriate
Contact patients by phone and provide support and communication throughout the diagnostic workup
Refer to site-specific cancer MDTs and oncologists/haematologists if a primary cancer site is found after further targeted investigation
Facilitate diagnostic work-up without the need for hospital admission
Discharge back to GP if a benign diagnosis is confirmed by the MDT.

Prior to referral, please ensure patient is informed of suspicion of cancer, is aware of referral to the CUP team, and knows to expect a phone call from cancer nurses. Please also complete the assessments outlined in the Primary Care Management guidance.

Who to refer:

Patients with radiological suspicion of metastatic cancer (e.g. ultrasound with liver metastases) without an obvious primary cancer site suggested, and where baseline assessments are complete (please see Primary Care Management page).

Who not to refer:

Previous invasive cancer on active follow up should be referred back via Sci-gateway and marked for the attention of the relevant site-specific disease speciality.
Primary cancer suggested by clinical findings and/or radiology – refer to site-specific disease speciality via Sci-gateway.
Cancer emergency e.g. suspected malignant spinal cord compression – discuss with Oncology on call team (phone 07798774842) RefHelp Malignant Spinal Cord Compression.
Presentation of vague symptoms/weight loss without radiology result suggesting cancer. Such patients may be suitable for the CT for suspected cancer pathway- here.
New enlarged lymph node without radiology suggesting cancer.

How to refer:

By SCI Gateway to: Western General Hospital Oncology. The ideal is to also email the team at CUPteam@nhslothian.scot.nhs.uk to ensure prompt MDT discussion.

For those without access to SCI Gateway please email the paper referral form : CUPteam@nhslothian.scot.nhs.uk.

For clinical advice or discussion please phone anyone from the team at the above numbers or email us at: CUPteam@nhslothian.scot.nhs.uk (CLINICIANS ONLY).

Primary Care Management Prior to CUP/MUO Referral:

History to determine if any symptoms suggestive of a primary site
Assess rate of change of symptoms over time
Assess recent and current fitness and co-morbidities
Establish patient’s expectations and wishes
Clinical examination directed by symptoms (consider: rectal, breast, skin, nodal, testicular or vaginal examinations)
Laboratory investigations including:
- Full blood count
- Creatinine and electrolytes
- Liver function tests
- Albumin and calcium
- LDH
- CRP
- Coagulation screen
If bone-only metastases on Xray or scan, then:
- PSA in men to exclude prostate cancer
- Breast examination in both women and men to exclude breast cancer
- If possible, then immunoglobulins, electrophoresis and urinary Bence Jones proteins to exclude myeloma
Ensure the patient is informed of suspicion of cancer, aware of referral to the CUP team and knows to expect a phone call from the cancer nurses.
Consider early referral to community palliative care if symptomatic or rapidly deteriorating clinical picture. The CUP team is happy to discuss this by phone.