Patients with a disease pattern suggesting a specific CUP subset should be referred to a relevant disease-specific oncology team. These include patients with lymphadenopathy restricted to the neck, and a biopsy showing squamous cell carcinoma should be referred to a specialist on a head and neck cancer MDT. Women with isolated axillary nodal metastases should be referred to a specialist on a breast cancer MDT.

When apparent metastatic disease without a clear primary site is recognised as CUP, patients should be referred to an oncologist with adequate experience in managing acute patients with CUP. Oncology services should identify oncologists with an interest in CUP within their services where available, and should provide clear routes of rapid access to specialist evaluation.

Patients who appear to fall into a non-specific CUP subset may be referred to the general medical oncology service, which can then triage the patient to be seen in the most appropriate clinic depending on the jurisdiction. Since most centres do not have a specific CUP clinic, this may include the patient being seen in a general oncology clinic or a disease-specific clinic depending on the presentation and suspected diagnosis.

Referral for suspected CUP should incorporate appropriate documentation sent with the patient including:

• the patient’s name, date of birth, contact details and next of kin
• details of the patient’s guardian, advance care plan or enduring power of attorney if relevant
• a letter that includes important psychosocial history and relevant past history, family history, current symptoms, medications and allergies
• results of current clinical investigations (imaging and pathology reports)
• results of all prior relevant investigations
• any prior imaging, particularly a hard copy or CD of previous chest x-rays and CT scans where online access is not available (lack of a hard copy should not delay referral)
• notification if an interpreter service is required.

Although referral to specialist oncology services is essential, it is important that regular communication between the oncology specialists and the referring GP occurs to ensure timely, coordinated care and support for the patient and their family.

Timeframe for referral to a specialist

Timeframes for specialist referral should be informed by evidence-based guidelines (where they exist) while recognising that shorter timelines for appropriate consultations and treatment can reduce patient distress.

Patients with CUP should be referred to a specialist for further investigation. The specialist appointment should take place within two weeks of the initial GP referral. A patient with uncontrolled symptoms or who is deteriorating may require urgent assessment, and the GP should call the medical oncology unit to expedite a review.