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During cancer treatment you should have a phone number answered day and night. A trained nurse asks set questions about each symptom and grades it green, amber or red. Green means advice for home, one amber a review within 24 hours, and red (or two ambers) being seen in person as soon as possible. A temperature of 37.5 °C or more, or below 36 °C, always means urgent assessment.
The UK model: everyone on systemic anticancer therapy (SACT) or radiotherapy has a 24-hour number for specialist advice, and calls are triaged with the UKONS Triage Assessment Tool, now version 3. Each symptom is graded from 0 to 4 against NCI-CTCAE-based descriptors and assigned a colour: all green is self-care advice; one amber is a review within 24 hours; two or more ambers escalate to red; red is a face-to-face assessment as soon as possible. Some symptoms are red at any grade: chest pain (stop SACT, advise 999, disconnect an infusion pump), and fever on SACT, where a temperature of 37.5 °C or above, below 36.0 °C, or feeling generally unwell means urgent assessment on the neutropenia pathway, with a caution that analgesia, steroids or dehydration can mask a temperature. Version 3 includes prompts for checkpoint inhibitor toxicity at any time, for ICANS and CRS after cell therapy, for MSCC with back pain and for SVCO with breathlessness.
The UKAOS four-nations review (June 2025) found 99% of UK providers support 24/7 access and 90% use the UKONS tool, but variation in who answers (41 providers used non-clinical staff first), in cut-off periods after treatment, and in records; it recommends a national framework, trained and competency-assessed triage staff, and standardised data. In Clatterbridge's year of calls, 45.2% of clinical calls were red, and 72.3% of out-of-hours reds went to the emergency department against 38.3% in hours. Scotland's Cancer Treatment Helpline routes out-of-hours calls through NHS24 call handlers using UKONS questions. Canada's COSTaRS practice guides (updated 2020 and 2026) are the main national alternative.
Why: Problems from treatment can become dangerous within hours, often at night or at weekends.
“All SACT patients and/or carers should receive a 24-hour contact number for specialist advice, along with guidance on symptom recognition and when to seek help.”
Why: A structured assessment by someone trained to use it is what makes advice over the phone safe.
“Best practice dictates that only staff who have successfully completed formal telephone triage training to assess treatment and disease related symptoms and are deemed competent should perform triage duties.”
Why: Immunotherapy side effects can start months or years after the last dose.
“CAUTION! Please note patients who are receiving or have received IMMUNE CHECK POINT INHIBITORS may present with treatment related problems at anytime during treatment or even months to years after treatment has been completed.”
UK Oncology Nursing Society (UKONS), hosted by the UK Acute Oncology Society 2025
Why: A shared grading scale means every nurse reaches the same decision for the same symptom.
“Practitioners are advised to refer to the latest version of NCI-CTCAE common toxicity criteria to assess the severity of the problem and seek further clinical advice regarding management.”
UK Oncology Nursing Society (UKONS), hosted by the UK Acute Oncology Society 2025
Why: Infection with a low white cell count can kill within hours, and a normal temperature does not rule it out.
“IF TEMPERATURE 37.5˚C OR ABOVE OR BELOW 36.0˚C OR GENERALLY UNWELL - URGENT ASSESSMENT AND CLINICAL REVIEW - FOLLOW NEUTROPENIA PATHWAY.”
UK Oncology Nursing Society (UKONS), hosted by the UK Acute Oncology Society 2025
Why: These can hide a fever while an infection is developing.
“ALERT - patients who have taken analgesia or steroids or who may be dehydrated may not present with an abnormal temperature but may still have an infection and be at risk of sepsis - if in doubt do a count.”
UK Oncology Nursing Society (UKONS), hosted by the UK Acute Oncology Society 2025
Why: Chest pain during treatment can be a heart problem, a clot in the lung or a drug reaction.
“STOP oral and intravenous Systemic Anti-Cancer Treatment (SACT) until reviewed by oncology or haematology team.”
UK Oncology Nursing Society (UKONS), hosted by the UK Acute Oncology Society 2025
Why: These are emergencies that can first be described over the phone as an ordinary symptom.
“Back pain consider metastatic spinal cord compression (MSCC).”
UK Oncology Nursing Society (UKONS), hosted by the UK Acute Oncology Society 2025
Why: Several moderate problems together can add up to someone who is seriously unwell.
“Red = arrange for a face to face assessment as soon as possible”
UK Oncology Nursing Society (UKONS), hosted by the UK Acute Oncology Society 2025
Why: The next nurse or doctor needs to know what was said and advised.
“A robust local system for documenting helpline activity is essential for audit, continuity of care, and service improvement.”
How care is usually carried out, read from the guidelines and standards cited. Your own team's protocol and their judgement come first; this page is for understanding it, not for doing it yourself.
In the UK the UKONS Triage Assessment Tool, version 3, is the national standard in practice: 90% of providers use it and a further 9 use versions based on it (UKAOS 2025). Its rules are a symptom-by-symptom 0 to 4 grade with a colour, one amber for review within 24 hours, two ambers escalating to red, and red for face-to-face assessment as soon as possible, with fever at 37.5 °C or more (or below 36 °C) on treatment always triggering the neutropenia pathway. The UKAOS 2025 review, written with UKONS, is the current UK statement on how the service around the tool should run (trained and competency-assessed staff, 24-hour access, records and audit). It is not a graded guideline: the tool is an expert consensus instrument, and its outcomes have been described in service evaluations rather than tested in a trial. The strongest trial evidence for structured symptom reporting comes from patient-reported outcome monitoring (Basch 2016: fewer emergency visits and better quality of life), which complements rather than replaces the phone line.
UK Oncology Nursing Society (UKONS), hosted by the UK Acute Oncology Society 2025 · UK Acute Oncology Society (UKAOS) with UKONS and UKSB 2025 · Supportive Care in Cancer 2023 · Journal of Clinical Oncology 2016
Where it differs: Out of hours, calls go to NHS24, where a trained non-clinical handler asks the UKONS questions and routes the caller; in hours a trained oncology nurse triages. The UKAOS review found 41 UK providers relied on non-clinical staff to answer first.
Evidence: NHS Tayside service review of 8385 calls, 2016 to 2020: 35% advice only, 41% review, 24% review and admission; 85% handled by oncology alone. A descriptive single-centre review without a comparison group.
BMJ Open Quality 2021 · UK Acute Oncology Society (UKAOS) with UKONS and UKSB 2025
Where it differs: Symptom-specific practice guides for nurses giving remote support (17 after the 2020 update, with a guide for difficulty swallowing added in 2026), with assessment, triage, medicines and self-care sections, CTCAE grades added in 2020, and a requirement to review three or more self-care strategies.
Evidence: Built from systematic reviews of guidelines (86 new sources in 2020; 175 in the 2026 update) and validated by Canadian oncology nurses. Read only as abstracts.
Canadian Oncology Nursing Journal 2020 · Canadian Oncology Nursing Journal 2026
Where it differs: Patients report symptoms in an app each day; answers are mapped to green, amber or red, and red tells the patient to ring the 24-hour line. Alerts are grouped into episodes for clinician review in weekday working hours only.
Evidence: A 10-week single-centre service evaluation of 32 patients: 91.7% of check-ins completed, median 47 minutes to first response for in-hours red alerts, no safety signal found. Not a trial.
Patients on cancer treatment who report their symptoms every week through an app or phone line, with nurses acting on alerts, feel better and go to the emergency department less. Two early trials also found longer survival, but the largest trial, designed to test survival, found no difference. The quality-of-life benefit is reason enough to make it routine and paid for.
| Recommendation | Grade, as printed | Source |
|---|---|---|
| One amber: review within 24 hours “1 Amber = review within 24 hours” | not graded (expert consensus tool) | UK Oncology Nursing Society (UKONS), hosted by the UK Acute Oncology Society 2025 |
| Two or more ambers: escalate to red “2 or more amber = escalate to red” | not graded (expert consensus tool) | UK Oncology Nursing Society (UKONS), hosted by the UK Acute Oncology Society 2025 |
| Use of a national triage tool supports standard competency, training and data “The use of a national triage tool would support the development of standard competency, training and education programmes, and support the collection of detailed presentation data using a universal toxicity grading standard.” | recommendation (service review; not graded) | UK Acute Oncology Society (UKAOS) with UKONS and UKSB 2025 |
Shares Superior vena cava obstruction, Metastatic spinal cord compression: recognition, MSCC coordinator, MRI, dexamethasone, radiotherapy and surgery and the tags protocol, acute-oncology, oncological-emergency.
Shares Suspected febrile neutropenia (neutropenic sepsis): the first hour, Febrile neutropenia and the tags protocol, acute-oncology, oncological-emergency.
Shares the tags protocol, acute-oncology, oncological-emergency.
Shares the tags protocol, acute-oncology, oncological-emergency.
Shares the tags protocol, acute-oncology, oncological-emergency.
Shares the tags protocol, acute-oncology, oncological-emergency.
Shares the tags protocol, acute-oncology, oncological-emergency.
Shares the tags protocol, acute-oncology, oncological-emergency.