All patients who are suspected of having lung cancer should have a CXR performed first. (with the exception of those who present with haemoptysis who should have a CXR requested and an Urgent Suspicion of Cancer (USOC) referral made to Respiratory simultaneously.)
If the CXR is suspicious of lung cancer, the referrer will be informed and asked to make an USOC referral to Respiratory (see under Referral Guidelines tab below)
Some patients may still be suitable for an Urgent Suspicion of Cancer referral despite a normal CXR (see below)
Overlap with other pathways:
Head and neck cancer and lung cancer symptoms overlap (e.g. hoarseness and neck lumps). If the chest x-ray is normal, consider referring according to the Head and neck and thyroid cancer guideline (see Scottish Referral Guidelines for Suspected Cancer 2025) where appropriate.
D.M & P.R 17-02-26
Who to refer:
Referral for Chest x-ray
USC chest x-ray should be requested if a person has:
- Unexplained haemoptysis (refer to respiratory USOC simultaneously) In addition to lung cancer, there are a range of benign causes including infection, bronchiectasis, pulmonary embolism and vasculitis.
- Unexplained symptoms lasting three weeks or longer (one or more symptom in an ever-smoker or a person exposed to asbestos, two or more symptoms for all other people):
- new cough or a change in a cough
- breathlessness
- chest or shoulder pain
- weight loss
- loss of appetite
- fatigue
- hoarseness – constant with voice never normal
- Examination findings:
- focal chest signs (e.g. rhonchi, reduced breath sounds or dullness to percussion)
- new or not previously documented finger clubbing
- supraclavicular lymphadenopathy
- A chest infection or exacerbation of airways disease that does not resolve after two courses of antibiotics
- Thrombocytosis where clinical features do not suggest another cause. Thrombocytosis is a risk marker for malignancy. This especially applies to the ‘LEGO-C’ group –Lung, Endometrial, Gastric, Oesophageal and Colorectal cancer. For further details see Thrombocytosis – RefHelp
Refer a person with any of the following to the Respiratory Service as an USOC referral:
- Chest x-ray (or CT scan) that is concerning for lung or pleural cancer including unilateral pleural effusion, pleural mass and slowly resolving consolidation. (If the chest x-ray shows consolidation, repeat imaging should be arranged six weeks later to confirm resolution. A USOC referral to respiratory should be made if it remains abnormal.)
- Unexplained haemoptysis (arrange a USC chest x-ray but no need to wait for the result prior to referral to the respiratory clinic). Haemoptysis is bleeding arising from below the glottis.
- If the chest X-ray is not suspicious for lung or pleural cancer an USOC referral should still be considered particularly if there are concerning symptom combinations:
In smokers:
- Breathlessness with weight loss or appetite loss
- Chest pain with weight loss, appetite loss or thrombocytosis
- Weight loss and appetite loss together*
In all people:
- Weight loss and thrombocytosis together*
* GP Access to CT for Suspected Cancer (No Clinically Obvious Primary) – RefHelp, pathway may be a suitable alternative for this symptom combination especially in the absence of respiratory symptoms or a smoking history.
How to refer:
For CXR:
In the usual way via Sci-Gateway:
RIE or WGH or SJH > Clinical Radiology > LI Radiology Plain X-Ray > select Chest for investigation. Choose priority Urgent Suspicion of Cancer
For Respiratory Medicine: Via Sci-Gateway:
SJH or WGH or RIE > Respiratory Medicine > LI Suspected Lung Cancer
Please arrange bloods including a full blood count (FBC) and renal function if not done in the preceding three months to expedite any further imaging required.
After Referral:
CXR reports with findings suspicious of cancer will be emailed by radiology to the Clinical Inbox of the referring GP practice and will require the GP to inform the patient and to send a USOC SCI Gateway referral. It will also be emailed to the appropriate lung cancer clinic. The email to the GP will contain the following information along with the CXR report:
Dear GP,
URGENT EMAIL, GP ACTION REQUIRED
Please see the report below. I would be grateful if you could inform the patient of the result, warn the patient to expect an urgent appointment and send a formal USOC referral to Respiratory via SCI Gateway:
SCI GATEWAY > SJH or WGH or RIE > Respiratory Medicine > LI Suspected Lung Cancer
This email is being sent to the Practice Clinical Inbox and will also be emailed to the [SJH/WGH/RIE] Lung Cancer Clinic (email address). A SCI GW referral is still needed.
Include what the patient has been told about their condition in the referral
