This pathway is for those where a likely advanced or metastatic malignancy has been identified (typically on cross-sectional imaging), but the source of the primary cancer remains unclear after initial clinical assessment.
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 speciality.
In patients whom cancer is suspected, but cross-sectional imaging has NOT yet been performed, please see the GP Access to CT for Suspected Cancer (No Clinically Obvious Primary) guidelines. In the event that a metastatic cancer is identified following CT, with no apparent primary site, see below.
The CUP 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/metastatic malignancy without an obvious primary site – a Malignancy of Undefined Primary Origin (MUO)
- Enable early identification and workup 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 2194
Dr Colin Barrie (Consultant Medical Oncologists) 0131 537 2194
Dr Marj Maclennan (Consultant Clinical Oncologist – radiotherapy) 0131 537 1036
CUP Clinical Nurse Specialist Team
Rachel Haigh 0131 537 1341
Lynne Faragher 0131 537 4015 (Monday to Wednesday)
Jac Brown 0131 537 3578 (Tuesday to Thursday)
Monica Castro 0131 537 4015 (Thursday and Friday)
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, based on the information provided to us, regarding further 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), where clinically appropriate, to assess and arrange further selected investigations
- Contact patients by phone and provide support and communication throughout the diagnostic workup, where appropriate
- 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 or to enable early discharge from emergency care, where clinically stable
- Discharge back to GP if a benign diagnosis is confirmed by the MDT.
M.A & K.E 16-02-26
Who to refer:
- Patients with radiological suspicion of metastatic cancer without an obvious primary cancer site suggested, and where baseline assessments are complete (please see Primary Care Management page).
- If radiological suspicion of cancer (e.g. ultrasound or MRI) but not yet had a CT scan then please organise an URGENT CT using the GP Access to CT for Suspected Cancer (No Clinically Obvious Primary). If concerns about rapidly changing condition, then please also refer to the CUP team pending CT result.
Who not to refer:
- Previous invasive cancer on active follow-up should be referred back to the relevant oncology team via Sci-gateway, marked for the attention of the relevant site-specific disease speciality.
- Primary cancer suggested by clinical findings and/or radiology, please refer to the guidance on the relevant section on Refhelp
- Cancer emergency e.g. suspected malignant spinal cord compression – discuss with Oncology on call team (phone 07798774842) and see the following: RefHelp Malignant Spinal Cord Compression.
- Presentation of vague symptoms/weight loss but 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 loth.cupteam@nhs.scot to ensure prompt MDT discussion.
For those without access to SCI Gateway please email the paper referral form : loth.cupteam@nhs.scot
For clinical advice or discussion please phone anyone from the team at the above numbers or email us at: loth.cupteam@nhs.scot (CLINICIANS ONLY).
Primary Care Management prior to CUP/MUO Referral:
- History to determine if any symptoms are suggestive of a primary site
- Assess the rate of change of symptoms over time
- Assess recent and current fitness and co-morbidities
- Establish the 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.
In patients whom cancer is suspected, rapid clinical deterioration is not apparent, and they have not yet had cross-sectional imaging, please see GP Access to CT for Suspected Cancer (No Clinically Obvious Primary)guidelines.
