GP assessments will include routine tests for a patient with apparent or suspected metastatic disease, guided by the symptoms of the individual patient.

Assessments that should be undertaken by the GP for a patient with apparent or suspected metastatic disease include:

• a thorough medical history and physical examination, including systematic review to identify signs and symptoms that might suggest a possible primary site
• routine blood tests
• contrast-enhanced computed tomography (CT) of the chest/abdomen and pelvis
• arrangement of a biopsy in patients with readily accessible disease to allow early diagnosis of those with specific CUP subsets and established treatment pathways (Note: Consideration should be given as to whether this is best done by the GP or the specialist team, depending on the jurisdiction. In general, a core biopsy rather than a fine needle aspiration (FNA) is preferred to increase the chances of collecting sufficient material for a specific diagnosis (Berner et al. 2003))
• additional investigations as indicated based on the specific presentation, clinical symptoms and signs of the patient. (These are discussed in section 3.1). In some situations, if they can be easily obtained, it may be appropriate for the GP to organise some of these tests in parallel with specialist referral to expedite the work-up of the patient.)

Further important considerations

• Patients with CUP may present as clinically unwell with poorly controlled symptoms. Symptomatic care must be provided in parallel with the investigation process.
• Patients with suspected CUP and poor performance status are at risk of over-investigation, and results from exhaustive tests commonly will not result in useful action. Early specialist input should be sought to limit the extent of futile investigation.
• Early specialist input will also assist in dealing with the uncertainty that patients and their carers experience during the confusing period when clear answers to their diagnosis and prognosis are not apparent.