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General recommendations
- A patient who presents with symptoms suggestive of brain or CNS cancer should be referred to an appropriate specialist, depending on local arrangements (D).
- If a primary healthcare professional has concerns about the interpretation of a patient's symptoms and/or signs, a discussion with a local specialist should be considered. If rapid access to scanning is available, this investigation should also be considered as an alternative (D).
Basis for recommendation
This is a direct implementation of the National Institute for Health and Clinical Excellence guideline Referral guidelines for suspected cancer: brain and CNS cancer [NICE, 2005].
For further information on the evidence grading used, see the Supporting evidence section on Evidence grading.
Headaches
- In patients with headaches of recent onset accompanied by either features suggestive of raised intracranial pressure (for example, vomiting, drowsiness, posture-related headache, headache with pulse-synchronous tinnitus) or other focal or non-focal neurological symptoms (for example, blackout, change in personality or memory), an urgent referral should be made (C).
- In patients with unexplained headaches of recent onset, present for at least 1 month but not accompanied by features suggestive of raised intracranial pressure, discussion with a local specialist or referral (usually non-urgent) should be considered (D).
- In patients with a new, qualitatively different unexplained headache that becomes progressively severe, an urgent referral should be made (C).
- Re-assessment and re-examination is required if the patient does not progress according to expectations (D).
Basis for recommendation
This is a direct implementation of the National Institute for Health and Clinical Excellence guideline Referral guidelines for suspected cancer: brain and CNS cancer [NICE, 2005].
For further information on the evidence grading used, see the Supporting evidence section on Evidence grading.
Seizures
- A detailed history should be taken from the patient and an eyewitness to the event if possible, to determine whether or not a seizure is likely to have occurred (C).
- In patients presenting with a seizure, a physical examination (including cardiac, neurological, mental state) and developmental assessment, where appropriate, should be carried out (C).
- In any patient with suspected recent-onset seizures, an urgent referral to a neurologist should be made (C).
Basis for recommendation
This is a direct implementation of the National Institute for Health and Clinical Excellence guideline Referral guidelines for suspected cancer: brain and CNS cancer [NICE, 2005].
The recommendation to take a detailed seizure history is based on the National Institute for Health and Clinical Excellence guideline The epilepsies: the diagnosis and management of the epilepsies in adults and children in primary and secondary care [NICE, 2004].
For further information on the evidence grading used, see the Supporting evidence section on Evidence grading.
Other neurological features
- An urgent referral to an appropriate specialist should be considered for patients with rapid progression of:
- Subacute focal neurological deficit (B).
- Unexplained cognitive impairment, behavioural disturbance, or slowness or a combination of these (C).
- Personality changes confirmed by a witness (for example, a carer, friend or a family member) and for which there is no reasonable explanation even in the absence of the other symptoms and signs of a brain tumour (D).
Basis for recommendation
This is a direct implementation of the National Institute for Health and Clinical Excellence guideline Referral guidelines for suspected cancer: brain and CNS cancer [NICE, 2005].
For further information on the evidence grading used, see the Supporting evidence section on Evidence grading.
Risk factors
- In patients previously diagnosed with any cancer an urgent referral should be made if the patient develops any of the following symptoms: (C)
- Recent-onset seizure
- Progressive neurological deficit
- Persistent headaches
- New mental or cognitive changes
- New neurological signs
Basis for recommendation
This is a direct implementation of the National Institute for Health and Clinical Excellence guideline Referral guidelines for suspected cancer: brain and CNS cancer [NICE, 2005].
For further information on the evidence grading used, see the Supporting evidence section on Evidence grading.
Referral timelines
The referral timelines used in this guideline are as follows:
- Immediate: an acute admission or referral occurring within a few hours, or even more quickly if necessary.
- Urgent: the patient is seen within the national target for urgent referrals (currently 2 weeks).
- Non-urgent: all other referrals.
Basis for recommendation
This is a direct implementation of the National Institute for Health and Clinical Excellence guideline Referral guidelines for suspected cancer: brain and CNS cancer [NICE, 2005].
For further information on the evidence grading used, see the Supporting evidence section on Evidence grading.