Download Breast Suspected Cancer Referral

HAEMATOLOGY Suspected Cancer Referral
(2 Week Wait Referral)
To support NICE guidance 2005
Please FAX within 24 hours to Cancer Pathways department: 020 8928 8836
Section 1 PATIENT INFORMATION (Please complete in BLOCK CAPITALS)
Date of Referral
Date of Birth
NHS number
UBRN
SURNAME
FIRST NAME
Miss Mrs Ms Mr
Other:_________
/
/
/
/
-
-
Home Tel.
M[ ]F [ ]
Mobile/Daytime Tel.
Address
Transport Y
N
Interpreter Y
N
Language
Ethnicity
Post Code
Section 2 PRACTICE INFORMATION (Please use practice stamp if available)
Referring GP
Locum
Practice Address
Y
N
Telephone
Fax
Post Code
Section 3 CLINICAL INFORMATION (please TICK all applicable entries)
Please enclose print outs of CURRENT medications and PAST MEDICAL HISTORY
[ ] UNEXPLAINED
One or more of
[ ] SIGNIFICANT
BLOOD COUNT or
PERSISTENT
LYMPHADENOPATHY [ ] BONE PAIN / X-RAY
BLOOD FILM
SPLENOMEGALY
suggestive
of
MYELOMA
IF persisting for > 6 weeks
suggestive of ACUTE
[ ] HYPERCALCAEMIA
without evidence of
or > 2 cm or widespread
LEUKAEMIA or
[ ] RENAL IMPAIRMENT
chronic
liver disease
or with splenomegaly or
CHRONIC MYELOID
[ ] ANAEMIA
Please detail:
with B symptoms
LEUKAEMIA
[ ] SPINAL CORD
DISCUSS
IMMEDIATELY BY
TELEPHONE WITH
DUTY HAEMATOLOGY
CONSULTANT OR SpR
WBC
[
Hb
[
Platelets
[
Neutrophils
[
Lymphocytes [
Investigations:
]
]
]
]
]
COMPRESSION
(If < 1cm, unlikely to be
significant)
With
2 or MORE of the following
symptoms, particularly if
[ ] SERUM PARAPROTEIN severe or associated with
abnormal FBC
[ ] URINARY BJP
[ ] IMMUNE PARESIS
[ ] Abdominal pain
[ ] Bone pain
[ ] Bruising/Bleeding
Renal failure or spinal
[ ] Fatigue
cord compression in
[ ] Fever
suspected myeloma ~
[ ] Itching ~ generalised
[ ] Night sweats ~drenching
DISCUSS IMMEDIATELY
[ ] Pain on drinking alcohol
BY TELEPHONE WITH DUTY
[ ] Recurrent infections
HAEMATOLOGY
[ ] Stomatitis/Mouth ulcers
CONSULTANT OR SpR
[ ] Weight loss
One or more of
Size [
] cm
Site(s) (please list)
Before referring, please
ensure glandular fever
test is negative if patient
<30 years and localised
infections treated. Also
consider HIV infection.
Medical History, Known Allergies and Medication
Discussed urgent suspected cancer referral with patient:
Comments/other reasons for suspecting cancer
Y
N
Hospital use only: (Tick where appropriate)
Date Appointment Booked:
Target Dates
2ww
62/7
/
/
/
/
/
/
Date of Referral receipt:
Database:

/
Patient confirmed:
/

A separate letter only need accompany if you feel it necessary
Approved by the North East London Cancer Network April 2006
LOCAL CONTACT DETAILS
If you wish to discuss any clinical issues concerning this referral please contact:
Dr Naim Akhtar
Karen Bennett
Consultant Haematology (Lead Clinician)
0208 535 6687
Clinical Nurse Specialist
0208 539 5522- Bleep 343
If you wish to discuss any other aspect of this referral please contact the Cancer Pathways
Office on 020 8535 6856/ 020 8535 6768 x4348 x4350
CRITERIA FOR URGENT SUSPECTED CANCER REFERRAL1
Please FAX the referral form within 24 hours



Refer a patient who presents with symptoms suggesting haematological cancer to a team
specializing in the management of haematological cancer, depending on local arrangements.
Be aware that haematological cancers can present with a variety of symptoms that may have a
number of different clinical explanations.
Combinations of the following symptoms and signs warrant full examination, further investigation
(including a blood count and film) and possible referral:
- fatigue
- breathlessness
- drenching night sweats
- bruising
- fever
- bleeding
- weight loss
- recurrent infections
- generalised itching
- bone pain
The urgency of referral depends on the symptom severity and findings of
alcohol-induced pain
abdominal pain
lymphadenopathy
splenomegaly
investigations.
For immediate referral above please telephone duty Haematology Consultant or
SpR via switchboard
Investigations
In patients with:



persistent unexplained fatigue carry out a FBC, blood film and ESR, plasma viscosity or C-reactive
protein (according to local policy). Repeat at least once if the patient’s condition remains unexplained
and does not improve
unexplained lymphadenopathy carry out a FBC, blood film and ESR, plasma viscosity or C-reactive
protein. Consider glandular fever test if age <30 and consider a course of antibiotics if
lymphadenopathy localized.
any of the following additional features of lymphadenopathy:
- persistence for 6 weeks or more
- lymph nodes increasing in size
- lymph nodes greater than 2 cm in size
- widespread nature
- associated splenomegaly, night sweats or weight loss
investigate further and/or refer


unexplained bruising, bleeding and purpura or symptoms suggesting anaemia, carry out FBC, blood
film, clotting screen and ESR, plasma viscosity or C-reactive protein (according to local policy)
persistent and unexplained bone pain, carry out FBC and X-ray, urea and electrolytes, liver and bone
profile, PSA test (in males) and ESR, plasma viscosity or C-reactive protein (according to local policy).
1 Based on Referral Guidelines for Suspected Cancer (NICE, 2005).. Notes in grey refer to the evidence grading used
in the NICE guidelines, for more information see www.nice.org.uk/cg027NICEguideline