Red flag symptoms
- Persistent cough for >3 weeks
- Change in bowel habit for >6 weeks with rectal bleeding
- Change in bowel habit in patients >55 years (with or without rectal bleeding)
- Persistent low mood for >2 weeks
- Persistent abdominal pain
- Gradually worsening memory problems
- Polyuria, polydipsia
- Unexplained fatigue
- Persistent palpable lumps in neck, axilla or groin region
- Persistent night sweats
- History of unexplained persistent fever and recent foreign travel
- Postmenopausal, intermenstrual or postcoital bleeding
- Any reported breast lumps
- Vomiting, dysphagia or odynophagia
- Persistent dyspnoea
- Symptoms suggestive of thyrotoxicosis
- In women, early satiety or abdominal fullness
- Persistent early morning headache and vomiting
- History of worsening memory
- Risk of sexually transmitted infection
- New neurological symptoms, such as limb weakness or change in speech
- New mouth lesions
- Persistent bone pain
Weight loss can be a manifestation of serious underlying pathology. It may present as a sole symptom or be found in the systemic enquiry, and is defined as a loss of 5% of total body weight over the past month.
The aetiology is unlikely to be discovered in a 10-minute consultation and may require follow-up consultations and/or referral. It is important to clarify whether the loss is intentional or not. Unintended weight loss will require a detailed history and examination.
If the patient has lost weight unintentionally, explore their ideas, concerns and expectations, to allow your management plan to reflect them.
Possible questions to ask the patient
- How much weight have you lost and in what period of time?
- Why do you think you are losing weight?
- Do you have a reduced appetite?
- Have you changed your diet?
- Have you started any new medication?
- Do you smoke, drink alcohol or take recreational drugs?
- Have you noticed any respiratory symptoms — persistent cough, dyspnoea, haemoptysis, chest pain?
- Have you noticed any GI symptoms — abdominal pain, dysphagia, odynophagia, reflux, change in bowel habit or rectal bleeding?
- Have you noticed any urological symptoms — haematuria or lower urinary tract symptoms?
- Have there been any neurological symptoms, such as headache, or focal neurological symptoms?
- Ask about breast lumps and in postmenopausal women, any history of postmenopausal bleeding
- Clarify smear history and any history of postcoital or intermenstrual bleeding in women of reproductive age/.
- Check for any endocrine symptoms that may suggest thyrotoxicosis or diabetes.
- Has there been any recent life trauma that may have precipitated the problem, such as a bereavement?
- Have you travelled abroad recently?
- Ask about the risk of having contracted HIV.
- Have you experienced mood changes?
- Do you have any concerns about your memory?
- Have you noticed any new lumps or bumps?
- Explore the possibility of an eating disorder.
A detailed systemic enquiry may be relevant. It may be important to screen for depression and anxiety, obtaining a Hospital Anxiety and Depression (HAD) or Patient Health Questionnaire (PHQ-9) score if a psychological cause of weight loss is suspected.
Consider also a cognitive screen using the Six-Item Cognitive Impairment Test (6CIT) or Mini Mental State Examination (MMSE) if the weight loss is thought to be due to underlying dementia.
Weight loss may also be a result of infection, such as TB and HIV, so questions about history of fever, or recent foreign travel may be appropriate. Skin lesions may be subtle; ask about any changing lesions as metastatic lesions may result in weight loss.
Haematological conditions, such as leukaemia, lymphoma and myeloma, may present with weight loss. Complete the history to ensure you have a record of all medications, particularly any that may induce weight loss.
A detailed family history may also be relevant, as well as smoking and alcohol history.
Cancer risk assessment tools allow GPs to work out which collection of symptoms have the highest and lowest positive predictive values, with unintentional weight loss featuring on many of these.1
- Malignancy of any organ/system, ranging from focal to metastatic disease
- Acute infection, such as glandular fever or gastroenteritis
- Chronic infection, such as TB or HIV
- Dementia of any type
- Psychological conditions, such as anxiety, depression or eating disorders, or laxative abuse
- Endocrine causes, such as diabetes mellitus, Addison’s disease or thyrotoxicosis
- Drugs such as glucagon-like peptide-1 analogues, over-the counter orlistat
- Ageing — for example, moderate to severe frailty
- Malnutrition secondary to alcohol excess and other lifestyle factors
- Malabsorptive conditions, such as coeliac disease and parasitic infections
- Inflammatory bowel disease
- Autoimmune conditions, such as rheumatoid arthritis and systemic lupus erythematosus
- Chronic respiratory conditions, such as chronic obstructive pulmonary disease (COPD)
- Severe heart failure
Examination and investigations
Examination will be guided by the history. First, weigh the patient to obtain an accurate baseline weight. Compare this weight to any previous weight measurement recorded in the notes. Calculate a body mass index (BMI). Be prepared to examine a variety of systems and signpost the patient accordingly. Investigations will depend on the symptoms.
CA-125 has been approved by NICE for detecting ovarian cancer and may be used in primary care. However, the result must be interpreted with caution.2 Other tumour markers such as CA19-9 and carcinoembryonic antigen (CEA) are not recommended for use in primary care. The tests that you are able to order will depend on local availability.
- Baseline weight and BMI
- FBC, ferritin, tissue transglutaminase, U&Es, LFTs, HbA1c, TSH, ESR, calcium
- PSA, CA-125, HIV, anti-cyclic citrullinated peptide, autoantibody screen and myeloma screen
- Chest X-ray
- MMSE, 6-CIT, GP assessment of cognition (GPCOG)
- Ultrasound abdomen and pelvis
- HAD score or PHQ-9
- Faecal calprotectin, if inflammatory bowel disease is suspected
- Computerised tomography (CT) scan
- Magnetic resonance imaging (MRI) scan
- Bone scan
- Faecal immunochemical test (FIT) will now be required for any lower GI referrals
Referral will depend on the clinician’s level of concern as to the aetiology of the perceived problem. It may be necessary to gather more information, and follow-up in primary care may be appropriate, reviewing the patient with results and a further weight measurement to see objectively how things are progressing.
If a malignancy is suspected, refer the patient to the relevant specialty under the 2-week rule; if a cancer of unknown aetiology is suspected, refer to the local pathway for this.
If your patient is in a care home, it may not be appropriate to refer; a discussion with the patient, and possibly a relative or advocate, may be necessary to decide whether further investigations are useful or not. Document any discussions in an emergency health care plan.
Elderly patients with complex comorbidities that require further investigations may benefit from your rapid access elderly care service to decide on what those should be.
Key learning points
- Weight loss is defined as a loss of 5% of total body weight over the past month.
- A detailed systemic enquiry may be relevant, including screening for depression and anxiety.
- Follow-up in primary care may be appropriate, reviewing the patient with results and a further weight measurement to see objectively how things are progressing.
- If a malignancy is suspected, refer the patient to the relevant specialty under the 2-week rule.
- If your patient is in a care home, a discussion with the patient, and possibly a relative or advocate, may be necessary to decide on the best course of action.
- Dr Singh is a GP in Northumberland
Cancer Research UK. Cancer risk assessment tools. [Accessed 9 February 2021].
CKS. Scenario: Referral for suspected gynaecological cancer. August 2020.