When should I consider referring a patient with thoracic back pain for specialist assessment?

Consider referring a patient with thoracic back pain for specialist assessment if they are aged 60 or over and have persistent back pain or bone pain, especially if accompanied by weight loss. In such cases, urgent investigations for possible myeloma or pancreatic cancer should be initiated, including blood tests (full blood count, calcium, plasma viscosity or ESR, paraprotein, serum free light chains) and imaging (urgent CT or ultrasound) as appropriate.

Referral is also warranted if there are other red flag symptoms or signs suggestive of cancer or serious pathology, such as unexplained weight loss, persistent pain, or systemic symptoms.