Download 2 week wait cancer referral for suspected lung cancer SFHFT

Sherwood Forest Hospitals NHS Foundation Trust
2 week wait referral for suspected lung cancer
Patient surname:
Referring GP:
Patient forename:
Address:
Date of Birth:
Address:
Telephone:
Postcode:
Fax:
NHS No.:
Date of referral:
Gender:
Home Telephone:
Mobile Telephone:
Imaging & Investigations to support referral
Prior to referral patients require:
 A chest x-ray prior to referral, taken with the last 3 months
 Up to date renal function, taken within the last 3 months
Please ensure these are provided if not known or out of date.
Most referrals will generate a CT chest request unless the patient is under 40, or has had appropriate
imaging within 3 months. The patient’s up-to-date renal function is needed to generate this request.
Chest X-ray within last year? 
EGFR: ________
Where performed (if not SFH) __________________________
Creatinine: ________
Date checked: __________
2 week wait referral criteria (at least 1 must be ticked)
 Smokers/ex-smokers aged >40 with persistent haemoptysis (> 1 week)
 Chest X-ray suggestive of lung cancer or mesothelioma
 Normal chest X-ray where there is a high suspicion of lung cancer/mesothelioma
(e.g. smoker, elderly, refractory symptoms, clinical signs consistent with cancer)
 Stridor (please consider admission if severe)
 Superior vena cava obstruction (swelling of face and/or neck, with fixed elevation of jugular venous
pressure – please consider admission if severe)
Clinical reason for referral:
To support potential solitary pulmonary nodule follow-up:
Smoking history (pack years): ________ Family history of lung cancer? Yes / No
Previous cancer (where)? Yes /No _____________________________
Produced: March 2017
Review Due February 2019