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Bevan Exemplar Cohort 5 Projects

Enabling Primary Care Access to ‘Cancer of Unknown’ Services

Samah Massalha, Anna Mullard, Elaine Hampton and  Dawn Griffiths

Betsi Cadwaladr University Health Board


Patients presenting with cancer with no obvious primary do not fit into existing Primary Care cancer referral pathways, such as USC (Urgent Suspected Cancer) referrals. As a result, most patients present as an emergency to hospital.

Once admitted to hospital, these patients will be picked up by the Acute Oncology Service (AOS) and enter into the Unknown Primary Service (UPS).

A pilot project was initiated so that if GPs had a patient with radiological evidence of malignancy with no obvious primary, they could access UPS. The pilot was not extended into routine practice due to difficulties in CT access for these patients.

Project Aims:

  • To share our learning with other regions looking to improve services for this patient group.
  • To collate the resources that were developed for the service, such as structures, governance and evaluation tools into a toolkit for use by other Acute Oncology Teams to support development of similar pathways in other regions.
  • To provide support for the toolkit in the form of advice and contacts to discuss the contents and any aspects of the service.


  • Lack of Primary Care access to CT scanning in some areas.
  • Establishing where responsibility lay for the patient under investigation.
  • Putting in place a system to track patients under investigation
  • Accessing outpatient consultation rooms for patient assessment.
  • Designing quantitative and qualitative evaluations to compare the traditional and new pathways.

Key Outcomes:

  • Opportunities were taken to advertise the Pathway to primary care colleagues, many of whom were delighted to hear of it.
  • The pilot was of only limited success, as although we had been informed there was agreement for Primary care access to CT scanning following either email or telephone authorisation from a consultant Radiologist, it quickly became apparent that the Radiology team at the Pilot site were not in agreement. This situation is not yet resolved.
  • Positively, the patient who was allowed a CT scan via primary care was successfully assessed and a management plan agreed within 4 days of referral.
  • The Acute Oncology Nurse Practitioner adapted her system for tracking in patient under investigation of CUP for those being investigated as outpatients.
  • The qualitative evaluation also ran into problems as the Patient Questionnaires were returned to the Health Board Patient experience evaluation team, who were unable locate them.
  • Although disheartened at the outcome of the pilot and the evaluation we felt that we put together our Toolkit of resources to enable development of a similar pathway elsewhere.

Next Steps:

  • To send out the Toolkit to Malignancy of Unknown Origin services that have already shown interest.
  • To use the Bevan Exemplar and Adopt and Spread scheme to enable wider distribution.
  • To investigate alternative entry points to the Pathway.
  • To continue work to allow Primary Care access to CT scanning on our pilot site.
  • To develop the Pathway on the alternative sites, where Primary care access to CT scanning is already available.
  • Further evaluation of patient experience of the Cancer of Unknown Primary Service.
  • Pilot the use of a ‘virtual ward’ on Welsh Clinical Portal to track patients.

Our Exemplar Experience:

Being a Bevan Exemplar has enabled a more professional development and spread of the Toolkit.