Document type: Clinical pathways
Place: South and West Hertfordshire
Output type: Clinical Pathways
Pathway: CT Request and 2WW Non-Specific Symptoms Referral Pathway

CT Request and 2WW Non-Specific Symptoms Referral Pathway

If a patient presents to their GP with worrying non-specific signs and symptoms or a GP has a ‘gut feeling’ that there is an underlying cancer but the signs and symptoms don’t fit a tumor specific NG12 two week wait pathway, the following non-specific symptoms pathway is recommended to aid clinical assessment and diagnosis.

Symptoms that may cause GP to have a high index of suspicion of malignancy:

• New and unintentional weight loss (either documented >5% in 3 months or with strong clinical suspicion)
• New unexplained constitutional symptoms of four weeks or more (less if significant concern) Symptoms include: loss of appetite, fatigue, nausea, malaise, bloating, sweats
• New unexplained vague abdominal pain of four weeks or more (less if very significant concern)
• New unexplained, unexpected or progressive pain, including bone pain of four weeks or more
• Abnormal laboratory findings not explained by established or self-limiting disease and not needing admission (e.g. significantly raised CRP and infection excluded, ALP>X2, raised calcium, platelets >400men, or >450 women alongside other symptoms)
• GP ‘gut feeling’ of cancer diagnosis- reason to be clearly described at referral

Guidance based on NHS England and NHS Improvement RDC Vision and Implementation Specification 2019/2020

If symptoms, signs, or test results fit with a NG12 2 Week Wait referral criteria- use the appropriate 2 week wait referral pathway, otherwise referral for non-specific symptom pathway referral to be considered.

Criteria for referral for NSS Direct Access CT and NSS 2WW referral

Patient aged 40 and over: Previous direct access pilots have shown that younger patients (under 50), are unlikely to have cancer diagnosed via this route. The risks of ionising radiation are important considerations in the younger age group. For the under 40s please pursue alternative diagnostic investigations e.g. Ultrasound. If you have exhausted all alternative diagnostics, please submit a referral clearly detailing all previous investigations with outcomes and reports and the referral will be considered.

Patient has undergone recommended examination, and tests recommended on the WHTHT/ South and West Herts Non-Specific Symptoms pathway and there is no clear indication of diagnosis or indication to refer the patient on a 2WW site-specific pathway. If symptoms, signs, or test results fit with a NG12 2 Week Wait referral criteria- use the appropriate 2 week wait referral pathway, otherwise referral for non-specific symptom pathway referral to be considered.

Patient presents with symptoms that cause GP to have a high index of suspicion of malignancy:
• New and unintentional weight loss (either documented >5% in 3 months or with strong clinical suspicion)
• New unexplained constitutional symptoms of four weeks or more (less if significant concern) Symptoms include: loss of appetite, fatigue, nausea, malaise, bloating, sweats
• New unexplained non-specific abdominal pain of four weeks or more (less if very significant concern)
• New unexplained, unexpected or progressive pain, including bone pain of four weeks or more
• Abnormal laboratory findings not explained by established or self-limiting disease and not needing admission (e.g. significantly raised CRP and infection excluded, ALP>x2, raised calcium, platelets >400men, or >450 women alongside other symptoms

GP ‘gut feeling’ of cancer diagnosis- reason to be clearly described at referral

Exclusion criteria for referral for NSS Direct Access CT and NSS 2WW referral

Patient has specific alarm symptoms warranting referral onto site-specific two week wait pathway (in line with NG12)
Patient aged under 40 CT scan contraindicated Contraindications to CT scan/contrast include:
• Renal Failure eGFR 220kg)
• Possibility of pregnancy
• CT/ Chest/Abdomen/Pelvis in the last 12 months Patient is too unwell or unable to attend as an outpatient or needs acute admission Patient is likely to have a non-cancer diagnosis suitable for another specialist pathway

Please see document attached for further information.

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