Cancer Musculoskeletal
Bone and soft tissue sarcoma - recognition and referral
Last revised in August 2025
Bone sarcoma is seen in both sexes, and is one of the most common cancers in children, teenagers and young people.
Bone and soft tissue sarcoma - recognition and referral: Summary
- Bone sarcoma
- Around 500 new bone sarcomas are diagnosed each year in the UK, meaning that a full time GP is unlikely to diagnose more than one bone sarcoma during their career.
- It is seen in both sexes, and is one of the more common cancers in children, teenagers, and young people.
- Pain and loss of function of the affected limb are the main presenting symptoms of bone sarcoma.
- X-ray may show abnormalities suggestive of the sarcoma.
- In adults:
- Consider a suspected cancer pathway referral for adults if an X-ray suggests the possibility of bone sarcoma.
- In children and young people:
- Consider a very urgent direct access X-ray (to be performed within 48 hours) to assess for bone sarcoma in children and young people with unexplained bone swelling or pain.
- Consider a very urgent referral (for an appointment within 48 hours) for specialist assessment for children and young people if an X-ray suggests the possibility of bone sarcoma.
- Soft tissue sarcoma
- Approximately 3000 new soft tissue sarcomas are diagnosed each year in the UK.
- A full time GP is likely to diagnose approximately one person with soft tissue sarcoma during their career.
- They occur in connective tissue.
- Most soft tissue sarcomas present with a mass, which may be painless, and may become quite large.
- The main method of diagnosis is by biopsy, which is performed in secondary care.
- In adults:
- Consider an urgent direct access ultrasound scan, to be performed within 2 weeks, to assess for soft tissue sarcoma in adults with an unexplained lump that is increasing in size.
- Consider a suspected cancer pathway referral for adults if they have ultrasound scan findings that are suggestive of soft tissue sarcoma OR if ultrasound findings are uncertain and clinical concern persists.
- In children and young people:
- Consider a very urgent direct access ultrasound scan (to be performed within 48 hours) to assess for soft tissue sarcoma in children and young people with an unexplained lump that is increasing in size.
- Consider a very urgent referral (for an appointment within 48 hours) for children and young people if they have ultrasound scan findings that are suggestive of soft tissue sarcoma OR if ultrasound findings are uncertain and clinical concern persists.
Have I got the right topic?
From birth onwards.
This CKS topic is based on the National Institute for Health and Care Excellence (NICE) guideline Suspected cancer: recognition and referral [NICE, 2025]. This topic covers the recognition and referral of suspected cancer.
This CKS topic does not cover other aspects of the management of patients with bone cancer and sarcoma.
The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary healthcare.
How up-to-date is this topic?
Changes
August 2025 — reviewed. This topic is a direct implementation of the National Institute for Health and Care Excellence (NICE) guideline Suspected cancer: recognition and referral. Minor structural changes have been made to this topic.
Previous changes
April 2025 — minor update. QOF indicators removed in line with NHS England's 2025 Quality and Outcomes Framework.
August 2020 — reviewed. This topic is a direct implementation of the National Institute for Health and Care Excellence guideline Suspected cancer: recognition and referral.
September to November 2015 — revised. This topic is a direct implementation of the National Institute for Health and Care Excellence guideline Suspected cancer: recognition and referral (2015). This CKS topic replaces the former topic on Bone cancer and sarcoma - suspected.
June 2009 — converted from CKS guidance to CKS topic structure. No changes to recommendations have been made. Issued in July 2009.
September 2008 — minor correction to the Changes section. Issued September 2008.
October 2005 — minor technical update. Issued in November 2005.
July 2005 — revised to reflect the update to the Referral guidelines for suspected cancer published by the National Institute for Health and Care Excellence in June 2005. Issued in July 2005.
April 2000 — issued in December 2000.
Update
New evidence
Evidence-based guidelines
No new evidence-based guidelines since 1 August 2025.
HTAs (Health Technology Assessments)
No new HTAs since 1 August 2025.
Economic appraisals
No new economic appraisals relevant to England since 1 August 2025.
Systematic reviews and meta-analyses
No new systematic reviews or meta-analysis which reach the CKS threshold for inclusion since 1 August 2025.
Primary evidence
No new primary evidence which reaches the CKS threshold for inclusion published since 1 August 2025.
New policies
No new national policies or guidelines since 1 August 2025.
New safety alerts
No new safety alerts since 1 August 2025.
Changes in product availability
No changes in product availability since 1 August 2025.
Goals and outcome measures
Goals
To support primary healthcare professionals to:
- Recognize symptoms suggestive of bone and soft tissue sarcoma.
- Refer people with suspected bone and soft tissue sarcomas within appropriate timescales.
- Offer appropriate patient information and support for people with suspected cancer.
Outcome measures
No outcome measures were identified for this topic.
Audit criteria
No audit criteria were found during the review of this topic.
QOF indicators
No QOF indicators were found during the review of this topic.
QIPP - Options for local implementation
No QIPP indicators were found during the review of this topic.NICE quality standards
- GPs have direct access to diagnostic endoscopy, ultrasound, MRI, X-ray and CT for people with suspected cancer.
- People presenting in primary care with symptoms that suggest oesophageal or stomach cancer have an urgent direct access upper gastrointestinal endoscopy.
- Adults presenting in primary care with symptoms that suggest colorectal cancer, who do not meet the referral pathway criteria, have a test for blood in their faeces.
- People with suspected cancer who are referred to a cancer service are given written information encouraging them to attend.
Background information
How does it present?
- Bone sarcoma:
- Pain and loss of function of the affected limb are the main presenting symptoms of bone sarcoma.
- X-ray may show abnormalities suggestive of the sarcoma.
- Soft tissue sarcoma:
- Soft tissue sarcomas occur in connective tissue, so can occur in many parts of the body.
- Most cases present with a mass, which may be painless, and may become quite large.
- The main method of diagnosis is by biopsy, which is performed in secondary care.
How common is it?
- Bone sarcoma:
- Around 500 new bone sarcomas are diagnosed each year in the UK.
- A full time GP is unlikely to diagnose more than one bone sarcoma during their career.
- It is seen in both sexes, and is one of the more common cancers in children, teenagers, and young people.
- Soft tissue sarcoma:
- Approximately 3000 new soft tissue sarcomas are diagnosed each year in the UK.
- A full time GP is likely to diagnose approximately one person with soft tissue sarcoma during their career.
What it is the prognosis?
- Bone sarcoma — more than 65% of people survive for 5 years or more after diagnosis [CRUK, 2025].
- Soft tissue sarcoma — almost 70% of people survive for 5 years or more [CRUK, 2024]. This is highly dependent on the specific site [NICE, 2025].
Diagnosis of bone and soft tissue sarcoma
What symptoms are suggestive of bone or soft tissue sarcoma?
Table 1. Symptoms suggestive of bone and soft tissue sarcoma.
| Symptom and specific features | Possible cancer | Recommendation |
|---|---|---|
| Lump (unexplained) that is increasing in size in adults | Soft tissue sarcoma | Consider an urgent, direct access ultrasound scan (to be performed within 2 weeks) |
| Lump (unexplained) that is increasing in size in children and young people1 | Soft tissue sarcoma | Consider a very urgent direct access ultrasound scan (to be performed within 48 hours) |
| Bone pain (unexplained) in children and young people | Bone sarcoma | Consider a very urgent direct access X-ray (to be performed within 48 hours) |
| Bone swelling (unexplained) in children and young people | Bone sarcoma | Consider a very urgent direct access X-ray (to be performed within 48 hours) |
| 1Separate 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 years) may be referred using either an adult or children's pathway depending on their age and local arrangements. | ||
| Data from: [NICE, 2025] | ||
Basis for recommendation
This information is based on the National Institute for Health and Care Excellence (NICE) guideline Suspected cancer: recognition and referral [NICE, 2025].
How should I manage investigation results?
Table 2. Primary care investigations for bone and soft tissue sarcoma.
| Investigation results | Possible cancer | Referral recommendation |
|---|---|---|
| X-ray suggests the possibility of bone sarcoma in adults1 | Bone sarcoma | Consider a suspected cancer pathway referral (for an appointment within 2 weeks) |
| X-ray suggests the possibility of bone sarcoma in children and young people1 | Bone sarcoma | Consider a very urgent referral (for an appointment within 48 hours) for specialist assessment |
| Ultrasound suggests soft tissue sarcoma or is uncertain and clinical concern persists in adults1 | Soft tissue sarcoma | Consider a suspected cancer pathway referral (for an appointment within 2 weeks) |
| Ultrasound scan suggests soft tissue sarcoma or is uncertain and clinical concern persists in children and young people1 | Soft tissue sarcoma | Consider a very urgent referral (for an appointment within 48 hours) for specialist assessment |
| 1Separate 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 years) may be referred using either an adult or children's pathway depending on their age and local arrangements. | ||
| Data from: [NICE, 2025] | ||
Basis for recommendation
These recommendations are based on the National Institute for Health and Care Excellence (NICE) guideline Suspected cancer: recognition and referral [NICE, 2025].
Management
Scenario: Referral for suspected bone and soft tissue sarcoma
From age 16 years onwards.
When should I refer a person with suspected bone sarcoma?
Adults
- Consider a suspected cancer pathway referral for adults if an X-ray suggests the possibility of bone sarcoma.
- 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 years) may be referred using either an adult or children's pathway depending on their age and local arrangements.
Children and young people
- Consider a very urgent direct access X-ray (to be performed within 48 hours) to assess for bone sarcoma in children and young people with unexplained bone swelling or pain.
- Consider a very urgent referral (for an appointment within 48 hours) for specialist assessment for children and young people if an X-ray suggests the possibility of bone sarcoma.
Basis for recommendation
These recommendations are based on the National Institute for Health and Care Excellence (NICE) guideline Suspected cancer: recognition and referral [NICE, 2025].
When should I refer a person with suspected soft tissue sarcoma?
Adults
- Consider an urgent direct access ultrasound scan, to be performed within 2 weeks, to assess for soft tissue sarcoma in adults with an unexplained lump that is increasing in size.
- Consider a suspected cancer pathway referral for adults if they have ultrasound scan findings that are suggestive of soft tissue sarcoma OR if ultrasound findings are uncertain and clinical concern persists.
- Note: 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 years) may be referred using either an adult or children's pathway depending on their age and local arrangements.
Children and young people
- Consider a very urgent direct access ultrasound scan (to be performed within 48 hours) to assess for soft tissue sarcoma in children and young people with an unexplained lump that is increasing in size.
- Consider a very urgent referral (for an appointment within 48 hours) for children and young people if they have ultrasound scan findings that are suggestive of soft tissue sarcoma OR if ultrasound findings are uncertain and clinical concern persists.
Basis for recommendation
These recommendations are based on the National Institute for Health and Care Excellence (NICE) guideline Suspected cancer: recognition and referral [NICE, 2025].
Referral timelines
- The terms used in the National Institute for Health and Care Excellence (NICE) guideline Suspected cancer: recognition and referral are as follows:
- Immediate: an acute admission or referral occurring within a few hours, or even more quickly if necessary.
- Very urgent: to happen within 48 hours.
- Urgent: to happen/be performed within 2 weeks.
- Non-urgent: the timescale generally used for a referral or investigation that is not considered very urgent or urgent.
- Suspected cancer pathway referral: the person is to receive a diagnosis or ruling out of cancer within 28 days of being referred urgently by their GP for suspected cancer.
Basis for recommendation
This information is based on the National Institute for Health and Care Excellence (NICE) guideline Suspected cancer: recognition and referral [NICE, 2025].
Diagnostic and referral process
- Discussion with a specialist (for example, by telephone or email) should be considered if there is uncertainty about the interpretation of symptoms and signs, and whether a referral is needed. This may also enable the primary healthcare professional to communicate their concerns and a sense of urgency to secondary healthcare professionals when symptoms are not classical.
- Put in place local arrangements to ensure that letters about non-urgent referrals are assessed by the specialist, so that the person can be seen more urgently if necessary.
- Put in place local arrangements to ensure that there is a maximum waiting period for non-urgent referrals, in accordance with national targets and local arrangements.
- Ensure local arrangements are in place to identify people who miss their appointments so that they can be followed up.
- Include all appropriate information in referral correspondence, including whether the referral is urgent or non-urgent.
- Use local referral proformas if these are in use.
- Once the decision to refer has been made, make sure that the referral is made within 1 working day.
- Take part in continuing education, peer review, and other activities to improve and maintain clinical consulting, reasoning, and diagnostic skills, in order to identify at an early stage people who may have cancer, and to communicate the possibility of cancer to the person.
Basis for recommendation
This information is based on the National Institute for Health and Care Excellence (NICE) guideline Suspected cancer: recognition and referral [NICE, 2025].
What patient information and support should I offer?
- Discuss with people with suspected cancer (and their carers as appropriate, taking account of the need for confidentiality) their preferences for being involved in decision-making about referral options and further investigations including their potential risks and benefits.
- Explain to people who are being referred with suspected cancer that they are being referred to a cancer service. Reassure them, as appropriate, that most people referred will not have a diagnosis of cancer, and discuss alternative diagnoses with them.
- Give the person information on the possible diagnosis (both benign and malignant) in accordance with their wishes for information.
- The information given to people with suspected cancer and their families and/or carers should cover, among other issues:
- Where the person is being referred to.
- How long they will have to wait for the appointment.
- How to obtain further information about the type of cancer suspected or help before the specialist appointment.
- What to expect from the service the person will be attending.
- What type of tests may be carried out, and what will happen during diagnostic procedures.
- How long it will take to get a diagnosis or test results.
- Whether they can take someone with them to the appointment.
- Who to contact if they do not receive confirmation of an appointment.
- Other sources of support.
- Provide information that is appropriate for the person in terms of language, ability, and culture, recognizing the potential for different cultural meanings associated with the possibility of cancer.
- Have information available in a variety of formats on both local and national sources of information and support for people who are being referred with suspected cancer.
- When referring a person with suspected cancer to a specialist service, assess their need for continuing support while waiting for their referral appointment. This should include inviting the person to contact their healthcare professional again if they have more concerns or questions before they see a specialist.
- If the person has additional support needs because of their personal circumstances, inform the specialist (with the person's agreement).
- When cancer is suspected in a child, discuss the referral decision and information to be given to the child with the parents or carers (and the child if appropriate).
Basis for recommendation
These recommendations are based on the National Institute for Health and Care Excellence (NICE) guideline Suspected cancer: recognition and referral [NICE, 2025].
Safety netting
- Safety netting involves:
- Timely review and action after investigations.
- Active monitoring of symptoms in people at low risk (but not no risk) of having cancer to see if their risk of cancer changes.
- Explain to people who are being offered safety netting which symptoms to look out for and when they should return for re-evaluation. It may be appropriate to provide written information.
- Reassure people in the safety netting group who are concerned that they may have cancer that with their current symptoms their risk of having cancer is low.
- Ensure that the results of investigations are reviewed and acted upon appropriately, with the healthcare professional who ordered the investigation taking or explicitly passing on responsibility for this. Be aware of the possibility of false-negative results for chest X-rays and tests for occult blood in faeces.
- Consider a review for people with any symptom that is associated with an increased risk of cancer, but who do not meet the criteria for referral or other investigative action. The review may be:
- Planned within a time frame agreed with the person, or
- Patient-initiated if new symptoms develop, the person continues to be concerned, or their symptoms recur, persist, or worsen.
Basis for recommendation
These recommendations are based on the National Institute for Health and Care Excellence (NICE) guideline Suspected cancer: recognition and referral [NICE, 2025].
Supporting evidence
This CKS topic is based on the National Institute for Health and Care Excellence (NICE) guideline Suspected cancer: recognition and referral [NICE, 2025].
How this topic was developed
This section briefly describes the processes used in developing and updating this topic. Further details on the full process can be found in the About Us section and on the Clarity Informatics website.
Search strategy
Scope of search
A full literature search was not conducted as this CKS topic is primarily based on the National Institute for Health and Care Excellence (NICE) guideline Suspected cancer: recognition and referral [NICE, 2015].
Search dates
August 2020 - August 2025
Key search terms
A full literature search was not conducted as this CKS topic is primarily based on the National Institute for Health and Care Excellence (NICE) guideline Suspected cancer: recognition and referral [NICE, 2015].
Sources of guidelines
- National Institute for Health and Care Excellence (NICE)
- Scottish Intercollegiate Guidelines Network (SIGN)
- Royal College of Physicians
- Royal College of General Practitioners
- Royal College of Nursing
- NICE Evidence
- World Health Organization
- Guidelines International Network
- TRIP database
- Agency for Healthcare Research and Quality
- National Health and Medical Research Council (Australia)
- Royal Australian College of General Practitioners
- British Columbia Medical Association
- Canadian Medical Association
- Alberta Medical Association
- Michigan Quality Improvement Consortium
- Singapore Ministry of Health
- National Resource for Infection Control
- RefHELP NHS Lothian Referral Guidelines
- Medline (with guideline filter)
- Driver and Vehicle Licensing Agency
- NHS Health at Work (occupational health practice)
Sources of systematic reviews and meta-analyses
- The Cochrane Library:
- Systematic reviews
- Protocols
- Database of Abstracts of Reviews of Effects
- Medline (with systematic review filter)
- EMBASE (with systematic review filter)
Sources of health technology assessments and economic appraisals
- NIHR Health Technology Assessment programme
- The Cochrane Library:
- NHS Economic Evaluations
- Health Technology Assessments
- Canadian Agency for Drugs and Technologies in Health
- International Network of Agencies for Health Technology Assessment
Sources of randomized controlled trials
- The Cochrane Library:
- Central Register of Controlled Trials
- Medline (with randomized controlled trial filter)
- EMBASE (with randomized controlled trial filter)
Sources of evidence based reviews and evidence summaries
Sources of national policy
- Department of Health
- Health Management Information Consortium (HMIC)
Patient experiences
Sources of medicines information
The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.
Stakeholder engagement
Our policy
The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:
- Clinical accuracy.
- Consistency with other providers of clinical knowledge for primary care.
- Accuracy of implementation of national guidance (in particular NICE guidelines).
- Usability.
Principles of the consultation process
- The process is inclusive and any individual may participate.
- To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
- Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
- Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
- External reviewers are not paid for commenting on the draft topics.
- Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
- All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
- All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.
Stakeholders
- Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
- Stakeholders identified from the following groups are invited to review draft topics:
- Experts in the topic area.
- Professional organizations and societies (for example, Royal Colleges).
- Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
- Guideline development groups where the topic is an implementation of a guideline.
- The British National Formulary team.
- The editorial team that develop MeReC Publications.
- Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.
Patient engagement
Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:
- Topic selection
- Scoping of topic
- Selection of clinical scenarios
- First draft internal review
- Second draft internal review
- External review
- Final draft and pre-publication
Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.
Evidence exclusion criteria
Our policy
Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.
Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.
Standard exclusions for scoping literature:
- Animal studies
- Original research is not written in English
Possible exclusions for reviewed literature:
- Sample size too small or study underpowered
- Bias evident or promotional literature
- Population not relevant
- Intervention/treatment not relevant
- Outcomes not relevant
- Outcomes have no clear evidence of clinical effectiveness
- Setting not relevant
- Not relevant to UK
- Incorrect study type
- Review article
- Duplicate reference
Organizational, behavioural and financial barriers
Our policy
The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.
- Feasibility
- Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
- Organizational and Financial Impact Analysis
- Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
- Eligible population
- Current interventions
- Likely uptake of new intervention or recommendation
- Cost of the current or new intervention mix
- Impact on other costs
- Condition-related costs
- In-direct costs and service impacts
- Time dependencies
- Cost-effectiveness or cost-benefit analysis studies are identified where available.
We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.
Declarations of interest
Our policy
Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:
- Personal financial interests
- Personal family interest
- Personal non-financial interest
- Non-personal financial gain or benefit
Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.
Who should declare competing interests?
Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.
Competing interests declared for this topic:
None.
References
- CRUK (2024) Survival for soft tissue sarcomas. Cancer Research UK. https://www.cancerresearchuk.org [Free Full-text]
- CRUK (2025) Survival for bone cancer. Cancer Research UK. https://www.cancerresearchuk.org [Free Full-text]
- NICE (2021) QS124: Suspected Cancer. National Institute for Health and Care Excellence. https://www.nice.org.uk [Free Full-text]
- NICE (2025) Suspected cancer: recognition and referral. National Institute for Health and Care Excellence. https://www.nice.org.uk [Free Full-text]