“You said the first tests were normal — so I’m fine now, aren’t I?”

Significant unintentional weight loss (at 60 and over, more than 5% within 6 months — NICE NG12 (Suspected cancer: recognition and referral, last updated April 2026) recommendation 1.13.2 — and around a stone in 3 months here) is a RED-FLAG SYMPTOM in its own right, associated with malignancy (GI, lung, pancreatic, urological, ovarian, haematological) and with serious non-malignant disease — and under NICE NG12, recommendation 1.13.2, people aged 60 and over with unexplained weight loss of more than 5% within 6 months should be assessed for other symptoms, signs or findings pointing to a likely cancer and offered urgent investigation, a suspected cancer pathway referral, or a non-specific symptoms pathway referral. The core, examinable teaching is that NORMAL first-line tests (FBC, U&E, LFTs, bone profile, glucose, TFTs, CRP, coeliac, CXR) do NOT exclude cancer: pancreatic, ovarian, renal and early GI cancers can present with weight loss and entirely normal first-line bloods and a clear chest X-ray, so treating "tests normal" as "all clear" is the classic dangerous error. When first-line tests are unrevealing but weight loss is unexplained, the response is CONTINUED, STRUCTURED investigation — a focused re-history and examination, a face-to-face examination, targeted further tests (CA125, because NICE NG12 lists unexplained weight loss among the ovarian cancer symptoms and uses age-banded thresholds — at 60–69 a CA125 of 24 IU/mL or more → urgent direct-access pelvic and abdominal ultrasound; FIT per NICE HTG690; urinalysis, ferritin), the site-specific checks (55+ with weight loss and upper abdominal pain, reflux or dyspepsia → suspected cancer pathway referral for oesophageal or stomach cancer; 60+ with weight loss and pancreatic features → consider urgent direct-access CT) and, crucially, imaging (commonly CT chest/abdomen/pelvis) and/or a suspected cancer pathway or non-specific symptoms pathway referral, with many areas offering a non-site-specific-symptoms / rapid diagnostic centre pathway designed for exactly this presentation. Communicate uncertainty honestly and warmly (“reassuring so far, but not the same as nothing wrong, so we keep looking”), screen non-malignant and social/mood contributors without using them to dismiss the red flag, and resist the relief-driven avoidance — the patient’s and your own — that tempts premature discharge. Safety-net robustly, book definite review, and actively track the further results.