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Practice Guidelines

Suspected cancer (part 1—children and young adults): visual overview of updated NICE guidance

BMJ 2015; 350 doi: (Published 23 June 2015) Cite this as: BMJ 2015;350:h3036

Childhood cancers infographic
Click here to see a printable infographic, showing cancer referral pathways by presenting symptom.

  1. William Hamilton, professor of primary care diagnostics1,
  2. Steve Hajioff, director of public health2,
  3. John Graham, director and consultant in clinical oncology3,
  4. Mia Schmidt-Hansen, researcher3
  1. 1University of Exeter, Exeter EX1 2LU, UK
  2. 2London Borough of Hillingdon, Uxbridge UB8 1UW, UK
  3. 3National Collaborating Centre for Cancer, Cardiff CF10 3AF, UK
  1. Correspondence to: W Hamilton w.hamilton{at}

The bottom line

  • Nearly all possible childhood cancers require referral for investigation, as primary care testing is only of use in sarcomas (very urgent ultrasound or x ray) and leukaemias (full blood counts)

  • Abnormal primary care tests for cancer all warrant urgent referral

It is generally believed that early diagnosis of cancer reduces mortality and morbidity. The National Institute for Health and Care Excellence (NICE) has updated its 2005 guidance on the recognition and referral from primary care of people with suspected cancer.1 The full guidance will be available on This summary of the full guidance is in two parts: part 1 on recommendations for children (up to 15 years old) and young adults (16-24 years), and part 2 on those for adults. Separate recommendations have been made for adults and for children and young people to reflect that there are different referral pathways. However, in practice, young people (aged 16-24) may be referred using either an adult or children’s pathway depending on their age and local arrangements.

Key changes in the updated guidance are:

  • Reliance on new evidence derived from primary, rather than secondary, care

  • Explicit use of a threshold risk of cancer to underpin recommendations for urgent investigation—the first cancer guidance to do so.2

This guidance:

  • Assumes that patients will have had a full history, clinical examination, and appropriate initial blood tests

  • Recommends urgent investigation in adults with a 3% or higher cancer risk, but uses a lower threshold for children and young people and when primary care testing is available

  • Relies …

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