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WHHT HAEMATOLOGY SUSPECTED CANCER REFERRAL FORM
Date of Referral: Click here to enter a date.
West Herts Hospitals:
[email protected]
For urgent advice contact the Haematology secretary via switchboard TEL: 01727 897199
PLEASE USE E-REFERRAL.
NOTE: This form is NOT for use for patients aged < 16 years.
NOTE: For guidance on symptoms, please see PAGE 2.
PATIENT DETAILS –Must provide current telephone number.
Last name:
Gender: M ☐ F ☐
NHS No:
Address:
First name:
DOB:
Telephone (Day):
Telephone (Evening):
Mobile No.:
Patient agrees to telephone message being left? Y ☐ N ☐
Transport required? Y ☐
Email:
Interpreter required? Y ☐
Language/Hearing:
Learning difficulties? Y ☐
Mental capacity assessment required? Y ☐
Known safeguarding concerns? Y ☐
Mobility requirements (unable climb on/off bed)?
Y☐
SUSPECTED CANCER
☐ Leukaemia
☐ Lymphoma (HD or NHL)
GP DETAILS
GP name:
Practice Code:
Address:
☐ Myeloma
TEL:
Practice email:
INVESTIGATIONS TO SUPPORT REFERRAL
**MANDATORY**
ALL HAEM CANCERS:
FBC
Renal function/U+E
Lymphoma: Chest X-ray
Myeloma: Urine Bence Jones Protein LFT Bone profile
Protein electrophoresis*
*If paraprotein <15g/l with no symptoms/abnormalities,
discuss with consultant
* If blood film/FBC indicates Leukaemia, bleep on-call Haem
consultant directly. Send form so patient tracked*
PATIENT MEDICAL HISTORY
Existing conditions & Risk factors (inc smoking status):
CLINICAL EXAMINATIONS
Teen & Young Adult (16 – 24 yrs) *STOP REFER TO UCLH**
Use the London Cancer Referral Form
Note: There is a separate Children’s referral form for pts <16 yrs.
– IMMEDIATE ASSESSMENT
☐ Hepatosplenomegaly
– IMMEDIATE ASSESSMENT
☐ Petechiae [2015]
– Call consultant
☐ Lymphadenopathy
– Call consultant
☐ Splenomegaly
Adults (≥25 yrs) – TICK ALL THAT APPLY
☐ Unexplained Lymphadenopathy – Ensure FBC & CXR done
– Ensure FBC & CXR done
☐ Splenomegaly
Attach results suggesting myeloma:
FBC
U+E (renal function)
LFT
Bone profile
Urine Bence Jones Protein
Protein electrophoresis*
*If paraprotein <15g/l with no symptoms/abnormalities, discuss
with consultant
☐ Other primary cancer (specify):
*Spinal cord compression/renal failure: refer medical emergency*
ADDITIONAL INFORMATION
Current medication (attach list and indications):
Y☐
Y☐
Y☐
Y☐
Allergies
Anticoagulants/Antiplatelets
Immunosuppressants
Diabetic
WHO Patient Performance status (see key below)
☐0
☐1
☐2
☐3
☐4
DISCUSSIONS WITH PATIENT PRIOR TO REFERRAL
Cancer needs to be excluded
Patient given referral information leaflet
Date(s) unavailable next 14 days:
Please attach a Patient Summary including:
☐ Referral letter (if applicable)
☐ Investigation
results
☐ PMH
☐ Up-to-date medications list
and indications
If your patient does not meet NICE suspected cancer referral criteria, but you feel they warrant further
investigation, please disclose full details in your referral letter.
☐
☐
WHO PATIENT PERFORMANCE STATUS KEY
0
1
2
3
4
Fully active, able to carry on all pre-disease performance without restriction
Restricted in physically strenuous activity but ambulatory and able to carry out light/sedentary work, e.g. house or school work.
Ambulatory and capable of self-care, but unable to carry out work activities. Up and active > 50% of waking hours.
Capable of only limited self-care. Confined to bed or chair >50% of waking hours.
Completely disabled. Cannot carry out any self-care. Totally confined to bed or chair.
Teenage & Young Adult (16-24)
IF 16 –24 yrs WITH
unexplained
petechiae or
hepatosplenomegaly
[2015]
Adults (≥25 YEARS)
IF 16 –24 yrs WITH ANY:
 pallor
 persistent fatigue
 unexplained fever
 persistent/recurrent infection
 generalised lymphadenopathy
 persistent bone pain
 unexplained bruising
 unexplained bleeding
URGENT: IMMEDIATE
ASSESSMENT
Call consultant + complete
suspected cancer form
≥60 YEARS
IF ≥60 YRS with
persistent bone pain,
particularly back pain or
unexplained fracture
IF ≥60 YRS with hypercalcaemia
or leukopenia and presentation
consistent with myeloma
ALL AGES
Any of the following:
 pallor
 persistent fatigue
 unexplained fever
 persistent/ recurrent infection
 unexplained petechiae
 unexplained bruising
 unexplained bleeding
 hepatosplenomegaly
Full blood count
(WITHIN 48 HRS)
*If blood film/FBC indicates abnormality,
bleep on-call Haem consultant (although
secondary care will get in touch with GP if
film suggests Leukaemia). Send form so
patient is tracked*
Full Blood Count, LFT Bone
Profile, U+E (renal function),
Urine Bence Jones Protein,
Protein electrophoresis*
Generalised or unexplained
lymphadenopathy or splenomegaly.
Consider associated symptoms:
 fever;  night sweats;
 shortness of breath;  pruritus;
 weight loss;  alcohol-induced
lymph node pain [2015]
FBC +consider Chest X-ray
STOP: If FBC suggests NO lymphocytosis,
follow local lymph node pathway.
FBC suggests lymphocytosis:
AGE?
16-24
Call consultant.
Complete form
WITHIN 48 HOURS
>25
REFERRAL WITHIN
14 DAYS
SUSPECTED CANCER REFERRAL
WITHIN 14 DAYS
*If paraprotein <15g/l with no symptoms/abnormalities, discuss with consultant