Managing non-specific symptoms in primary care

The importance of managing non-specific symptoms

Less than 50% of patients that go on to be diagnosed with cancer initially present to primary care with ‘red flag’ symptoms (typically site-specific symptoms that are known to have a high risk of cancer - eg a breast lump) [1,2]. More commonly, people present with unexplained, non-specific signs and symptoms such as: 

  • unexplained weight loss 

  • fatigue 

  • abdominal symptoms (pain, bloating) 

  • nausea or vomiting, loss of appetite 

  • non-specific pain such as bone pain. 

  • unexplained abnormal test results - e.g. raised platelet count 

Managing people presenting with non-specific symptoms can be challenging as these symptoms commonly present in many other conditions. As they’re less likely to indicate specific cancers than ‘red flag’ symptoms, they often don’t meet the threshold for an urgent suspected cancer referral. As a result, these patients are more likely to experience longer times to diagnosis and worse outcomes [3].  

This page aims to support GPs with the timely management of non-specific cancer symptoms. It provides an overview of national referral guidelines and pathways, as well as practical tips, a case study, and further resources.

How to refer patients with non-specific symptoms

Referral pathways are being developed across parts of the UK for patients with non-specific but concerning symptoms of cancer. These pathways can: 

  • provide a route to investigation for adults where there is clinical suspicion (gut feeling), symptoms do not fit site-specific urgent suspected cancer (USC) referral criteria and other common causes have been excluded 

  • provide a more managed route for patients who do not experience alarm symptoms, but are still at an increased risk of cancer 

Referral pathways use different terminology and operate differently by nation. They may also differ locally, so it is important to consult local guidelines. Click on your nation below to see guidelines and referral pathways available to you.

Referral guidelines and pathways in the UK

Top tips for effectively managing patients with non-specific symptoms

Refer to national guidelines and non-specific symptom pathways where available. Don't forget to explain the nature of the pathway to the patient [4].  
Complete all recommended filter function tests or bundle tests (If referring on a non-specific symptom pathway, depending on your nation) prior to referral to exclude other causes.
Fill out referral forms with as much detail as possible. This will improve the quality of your referral. For example, provide information on pre-existing conditions, outline investigations or management to date and give detailed descriptions symptoms [5] e.g. abdominal pain location, quantifying weight loss.  
Act on clinical suspicion if you still have concerns. Gut feeling is a health professional’s intuitive feeling that there may be a serious underlying pathology.  There is strong evidence to demonstrate that GP gut feeling is a helpful predictor of significant disease [6-9]. 
Take advantage of Advice and Guidance services. If available, these can inform decision-making and assessment of suspicion of cancer prior to referral in areas of uncertainty. 
Safety net patients. It’s important to safety net those who are not referred for further investigation until the symptoms are explained, resolved or the patient is referred. For patients having onward tests or referrals, provide information about any tests they need to have, the next steps and follow up they should expect. For more information, visit our safety netting webpage and resources. 

Patient case study: test your non-specific symptom knowledge

Developed with Dr Tina George, Cancer Research UK GP & Clinical Lead for Early Diagnosis, Kent and Medway Cancer Alliance.  

Navy icon of person and presentation

Name: Tony 

Age: 72 

Presenting with: Unexplained weight loss 

Additional notes:

  • Diabetic.
  • Arthritis in hands, making it difficult to sleep and eat.
  • Non-smoker, no asbestos exposure.  

The GP asks if there are any additional symptoms, to understand if the weight loss is related to Tony’s difficulty sleeping or not. 

Tony is also experiencing some chest pain. The GP decides to request several blood tests and a chest x-ray for reassurance that nothing serious is going on. 

Which blood tests would you order? 

The GP could request several tests to be done at this stage given that Tony has presented with non-site-specific symptoms, including FBC, haematinics, U&E, LFT, TFT, HBA1C, bone profile and ESR.  

The GP asks Tony to book another appointment in five days’ time when his blood test results are due back. Tony returns in five days and says he is becoming increasingly tired. The blood tests and CXR are all within normal range.  

What would you do next? 

  • Ask Tony to return if his symptoms do not go away? 

  • Refer on to an urgent suspected colorectal cancer pathway?  

  • Refer onto a non-specific symptoms pathway? 

Outcome 

  • Tony would be a good candidate for referral onto a non-specific symptom pathway. Remember to complete relevant filter function tests recommended in referral criteria and provide as much information as possible on the referral form.  

  • If non-specific symptom pathway is not available in your area, continue to investigate until his symptoms are either explained or resolved. 

References

[1] Ingeman ML, Christensen MB, Bro F, Knudsen ST, Vedsted P. The Danish cancer pathway for patients with serious non-specific symptoms and signs of cancer-a cross-sectional study of patient characteristics and cancer probability. BMC Cancer. 2015;15:421. Published 2015 May 20. doi:10.1186/s12885-015-1424-5 

[2] Neal RD, Din NU, Hamilton W, et al. Comparison of cancer diagnostic intervals before and after implementation of NICE guidelines: analysis of data from the UK General Practice Research Database. Br J Cancer. 2014;110(3):584-592. doi:10.1038/bjc.2013.791 

[3] Pearson C, Poirier V, Fitzgerald K, Rubin G, Hamilton W. Cross-sectional study using primary care and cancer registration data to investigate patients with cancer presenting with non-specific symptoms. BMJ Open. 2020;10(1):e033008. Published 2020 Jan 10. doi:10.1136/bmjopen-2019-033008 

[4] Black, G.B., Moreland, J.A., Fulop, N.J., Lyratzopoulos, G., Nicholson, B.D. and Whitaker, K.L., 2024. Personal and organisational health literacy in the non‐specific symptom pathway for cancer: An ethnographic study. Health Expectations, 27(3), p.e14062. 

[5] Black GB, Nicholson BD, Moreland J, et al. Doing ‘detective work’ to find a cancer: how are non-specific symptom pathways for cancer investigation organised, and what are the implications for safety and quality of care? A multisite qualitative approach. BMJ Quality & Safety Published Online First: 29 January 2025. doi: 10.1136/bmjqs-2024-017749 

[6] Smith CF, Drew S, Ziebland S, Nicholson BD. Understanding the role of GPs' gut feelings in diagnosing cancer in primary care: a systematic review and meta-analysis of existing evidence. Br J Gen Pract. 2020;70(698):e612-e621. Published 2020 Aug 27. doi:10.3399/bjgp20X712301 

[7] Donker GA, Wiersma E, van der Hoek L, Heins M. Determinants of general practitioner's cancer-related gut feelings-a prospective cohort study. BMJ Open. 2016;6(9):e012511. Published 2016 Sep 13. doi:10.1136/bmjopen-2016-012511 

[8] Yao M, Kaneko M, Watson J, Irving G. Gut feeling for the diagnosis of cancer in general practice: a diagnostic accuracy review. BMJ Open. 2023;13(8):e068549. Published 2023 Aug 11. doi:10.1136/bmjopen-2022-068549 

[9] Oliva-Fanlo B, March S, Gadea-Ruiz C, Stolper E, Esteva M; CORap group. Prospective Observational Study on the Prevalence and Diagnostic Value of General Practitioners' Gut Feelings for Cancer and Serious Diseases. J Gen Intern Med. 2022;37(15):3823-3831. doi:10.1007/s11606-021-07352-w