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. 

Update

Goals

To support primary healthcare professionals to:

• Recognize symptoms suggestive of upper gastrointestinal cancers.
• Refer people with suspected upper gastrointestinal cancers within the 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

NICE quality standards

Suspected Cancer

• 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.

[NICE, 2021]

Presentation

• Oesophageal cancer:
  • Oesophageal cancer can present with a number of different symptoms. The most classical is dysphagia, often accompanied by pain, acid reflux, loss of appetite, and loss of weight. Anaemia may occur.
  • A small percentage of oesophageal cancers are identified during endoscopic surveillance of a precursor lesion, Barrett’s oesophagus.
  • The symptoms overlap with stomach cancer, but the usual investigative strategy, upper gastrointestinal endoscopy, is the same for both cancers.
  • Most oesophageal cancers can be identified on endoscopy, and a biopsy taken. This can be under the clinical responsibility of primary care, though the procedure is usually performed in secondary care. Older imaging techniques, such as barium swallow, are rarely used.
• Pancreatic cancer:
  • Pancreatic cancer can present with a number of different symptoms, and there are often multiple symptoms simultaneously. Symptoms include pain, loss of appetite, and loss of weight. Lesions near the head of the pancreas may lead to obstructive jaundice. Endocrine cancers may produce symptoms from the secretion of hormones, such as insulin.
  • There is no standard pathway for all features of possible pancreatic cancer.
  • CT provides a more complete assessment for pancreatic cancer, although ultrasound may also be of some use. Interpretation of pancreatic imaging is often performed by sub-specialist radiologists.
  • Definitive diagnosis requires biopsy, often guided by imaging. This is performed in secondary care.
• Stomach cancer:
  • Stomach cancer can present with a number of different symptoms, including dysphagia, pain, acid reflux, loss of appetite, and loss of weight. Anaemia may also be a presenting feature.
  • The symptoms overlap with oesophageal cancer, but the usual investigative strategy, upper gastrointestinal endoscopy, is the same for both cancers.
  • Most stomach cancers can be identified on endoscopy, and a biopsy taken. In some areas, this is currently available under the clinical responsibility of primary care. Older imaging techniques, such as barium meal, are rarely used.
• Small intestinal cancer:
  • This is a rare cancer of the duodenum, jejunum, or ileum, with different histological subtypes.
  • Small intestinal cancer may present with similar symptoms to stomach or colorectal cancers.
  • The main method of diagnosis is by biopsy, which is performed in secondary care.
• Gallbladder cancer:
  • Pain and jaundice are thought to be the main presenting symptoms of gallbladder cancer.
  • Due to the rarity of gallbladder cancer there is no standard diagnostic pathway.
  • Ultrasound in primary care may show abnormalities suggestive of cancer, but definitive diagnosis requires biopsy, which is performed in secondary care.
• Liver cancer:
  • Primary liver cancer often presents as a complication of cirrhosis, usually following chronic viral hepatitis or alcoholic liver disease. Pain and worsening of liver function, enlargement of the liver, and jaundice are thought to be the main presenting symptoms of liver cancer.
  • Liver cancer may be identified on ultrasound or other imaging techniques, although definitive diagnosis requires biopsy, which is performed in secondary care.

[NICE, 2025]

How common is it?

• Oesophageal cancer
  • Over 8000 new oesophageal cancers are diagnosed each year in the UK.
  • A full-time GP is likely to diagnose approximately one person with oesophageal cancer every 3–5 years.
  • It is seen in both sexes, though two-thirds of new diagnoses are in males.
• Pancreatic cancer
  • Nearly 9000 new pancreatic cancers are diagnosed each year in the UK.
  • A full-time GP is likely to diagnose approximately one person with pancreatic cancer every 3–5 years.
  • Most occur in the exocrine pancreas, though endocrine tumours also occur.
• Stomach cancer
  • Over 7000 new stomach cancers are diagnosed each year in the UK.
  • A full-time GP is likely to diagnose approximately one person with stomach cancer every 3–5 years.
  • It is seen in both sexes, though two-thirds of new diagnoses are in males.
• Small intestinal cancer
  • This is a rare cancer.
  • Most GPs will not diagnose a case during their career.
• Gallbladder cancer
  • Around 700 new gallbladder cancers are diagnosed each year in the UK.
  • It is seen in almost twice as many women as men.
  • A full-time GP is unlikely to diagnose more than one person with gallbladder cancer in their career.
• Liver cancer
  • Over 4000 new primary liver cancers are diagnosed each year in the UK.
  • A full time GP is likely to diagnose approximately 2–4 people with liver cancer in their whole career.

[NICE, 2025]

What is the prognosis?

• Oesophageal cancer
  • The 5-year survival is approximately 15%.
• Pancreatic cancer
  • The 5-year survival is below 5%.
• Stomach cancer
  • The 5 year survival is approximately 20%.
• Gallbladder cancer
  • The 5-year survival rate is more than 10% [CRUK, 2023]. 
• Liver cancer 
  • The 5-year survival rate is almost 15% [CRUK, 2025]. 

[NICE, 2025]

What symptoms are suggestive of gastrointestinal tract (upper) cancers?

Table 1. Symptoms suggestive of gastrointestinal tract (upper) cancers.

Scenario: Referral for suspected gastrointestinal tract (upper) cancer

From birth onwards.

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.

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.

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
• Institute for Clinical Systems Improvement
• 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

• Bandolier
• Drug and Therapeutics Bulletin
• TRIP database
• Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

• Department of Health
• Health Management Information Consortium (HMIC)

Patient experiences

• Healthtalk
• BMJ - Patient Journeys

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.

• British National Formulary (BNF)
• electronic Medicines Compendium (eMC)
• European Medicines Agency (EMEA)
• LactMed
• Medicines and Healthcare products Regulatory Agency (MHRA)
• REPROTOX
• Scottish Medicines Consortium
• Stockley's Drug Interactions
• TERIS
• TOXBASE
• Micromedex
• UK Medicines Information

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.