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Children’s Fast Track Referral – 2 Week Wait Fax to: 0114 2757836 Patient Details: Patient Name Address DOB Home Tel. No. Mobile Tel. No. Preferred Tel. No. Main Spoken Language Transport required? NHS No. Gender Ethnicity Email Address Interpreter needed? Registered GP Details: Practice Name Registered GP Registered GP Address Tel No. Email Date of referral: Usual GP Fax No. Practice Code Time of referral: Dear Colleague I would be grateful for your opinion on the patient named above who presents with clinical findings I consider suspicious of malignancy. I have discussed the possibility of cancer with this patient. Has the patient confirmed that they can be available to attend an appointment within the next two weeks? Yes No Sections deal with: Leukaemia Lymphoma Brain tumour Form to be reviewed annually Neuroblastoma Wilms’ tumour Soft tissue sarcoma Page 1 of 8 Bone tumour Retinoblastoma Thyroid tumour Revised: August 2016 X if chosen Leukaemia (0-16 years) Contact on call consultant One or more of the following symptoms and signs requires investigation with full blood count and blood film: X if X if If full blood chosen chosen count or blood film indicates leukaemia, Pallor Persistent or recurrent infections Contact on call consultant If full blood count Fatigue Generalised lymphadenopathy or blood film do Unexplained Persistent or unexplained bone pain not indicate irritability leukaemia but still high level of suspicion from Unexplained fever Unexplained bleeding, bruising or purpura history 2ww referral Hepatosplenomegaly X if chosen Lymphoma (0-16 years) Contact on call consultant Lymphoma is suspected if one or more of the following are present, particularly in the absence of local infection: X if X if chosen chosen Lymph nodes non-tender, firm Other features of general illor hard health, fever or weight 2ww referral The axillary nodes are involved Lymph nodes greater than (in the absence of local infection 2cm in size or dermatitis) Lymph nodes progressively The supraclavicular nodes are enlarging involved Mediastinal or hilar mass on chest X-ray X if chosen Brain tumour (0-16 years) Reduced level of consciousness Contact on call consultant Any symptoms suggestive of spinal cord compression AGED <2 The development of any of the following symptoms may suggest a CNS tumour: Form to be reviewed annually Page 2 of 8 Revised: August 2016 X if chose n X if chosen AGED >2 X if chosen New onset seizures Extensor attacks Bulging fontanelle Persistent vomiting Abnormal increase in head size Arrest or regression of motor development Altered behaviour Abnormal eye movements Lack of visual following Contact on call consultant 2ww referral Poor feeding/failure to thrive Squint (Referral urgency contingent on other features) The presence of any of the following should prompt urgent or immediate referral: Headache and vomiting causing early morning waking New and persistent headache Contact on call consultant If unable to undertake an adequate neurological examination, 2ww referral New onset seizures with any associate neurological signs. Cranial nerve abnormalities Visual disturbances Gait abnormalities 2ww referral Motor or sensory signs Unexplained deteriorating school performance or developmental milestones Unexplained behavioural and/or mood changes X if chosen Neuroblastoma (all ages) Refer to NICE CG27 Page 92 Infant younger than 1 year with abdominal or thoracic mass Contact on call Child with abdominal mass and either leg weakness and /or unexplained consultant urinary retention as this may be due to cord compression. The presence of the following symptoms and signs requires investigation with full blood count: X if X if chosen chosen If results indicate Persistent or unexplained Unexplained fever anaemia, consider bone pain neuroblastoma Persistent or recurrent upper Pallor 2ww referral respiratory tract infections Fatigue Generalised lymphadenopathy Unexplained irritability Unexplained bruising In children or young people with symptoms that could be explained by neuroblastoma, an abdominal examination and/or urgent abdominal ultrasound should be undertaken and FBC and chest X-ray considered In children or young people with symptoms that could be explained by neuroblastoma, an abdominal examination and/or urgent abdominal ultrasound should be undertaken and FBC and chest X-ray considered Form to be reviewed annually Page 3 of 8 Revised: August 2016 Any mass identified Proptosis Leg weakness (see above) Unexplained urinary retention (see above) Unexplained back pain Wilm’s Tumour (all ages) Refer to NICE CG27 Page 92 X if chosen X if chosen Progressive abdominal distension Contact on call consultant Contact on call consultant Abdominal mass Abdominal examination not possible 2ww referral Haematuria Soft Tissue Sarcoma (all ages) An unexplained mass at almost any site that has one or more of the following features: X if X if chosen chosen Associated with regional lymph node Deep to the fascia 2ww referral enlargement Non-tender Size >2 cm in diameter Progressively enlarging A soft tissue mass in an unusual location: X if chosen Proptosis Persistent unexplained unilateral nasal obstruction with or without discharge and/or bleeding X if chosen X if chosen Scrotal swelling Consider Sarcoma Bloodstained vaginal discharge Aurul polyps/discharge Urinary retention Bone Sarcoma (all ages) Persistent localised bone pain and/or swelling Rest pain, back pain or unexplained limp X-ray suggestive of osteosarcoma Form to be reviewed annually Page 4 of 8 X-ray required Discuss with paediatric orthopedic surgeon or paediatrician, and/or X-ray 2ww referral Revised: August 2016 X if chosen Retinoblastoma (mostly under 2 years) 2ww referral to paediatric ophalmologist White papillary reflex (leukocoria) X if chosen X as applicable New squint or change in visual acuity X if chosen Suspicion of cancer Discrete Lump with Thyroid Pre-pubertal and adolescents with new thyroid mass X chosen 2ww referral to paediatric ophalmologist Skin Cancer 2ww referral to Paediatric Endocrinologist X as applicable Rapidly changing skin lesion 2ww referral to dermatology Changing pigmented skin lesion 2ww referral to dermatology Clinical Information Medical History Current Medications Known Allergies Family history Patient anxiety level Form to be reviewed annually Page 5 of 8 Revised: August 2016 Patient information and support needs Information given to the patient Other information WHO performance status: (please tick) 0 – normal activity 1 – restrictive light work 2 – self-care but no work > 50% of working day 3 – limited self-care – confined to bed/chair > 50% of waking day 4 – completely disabled – totally confined to bed/chair To be completed by the Data Team Date of decision to refer Date of appointment Date of earliest offered appointment (if different to above) Specify reason if not seen at earliest offered appointment Periods of unavailability Booking number (UBRN) Final Diagnosis: Form to be reviewed annually Malignant Benign Page 6 of 8 Revised: August 2016 Summary of the NICE 2015 suspected cancer guidelines Childhood cancers Leukaemia Refer for immediate specialist assessment Offer FBC within 48h Lymphoma: Non Hodgkin Consider very urgent referral (for appointment within 48 hours) Brain Tumour Consider very urgent referral Unexplained petechiae or hepatosplenomegaly (may indicate severe marrow suppression therefore a medical emergency). Children and young people with any of the following: o Pallor o Persistent fatigue o Unexplained fever o Unexplained persistent infection o Generalised lymphadenopathy o Persistent or unexplained bone pain o Unexplained bruising o Unexplained bleeding Unexplained lymphadenopathy or splenomegaly. Take into account any associated symptoms, particularly fever, night seats, SOB (from mediastinal mass), pruritus or weight loss. Children and young people with newly abnormal cerebellar or other central neurological function. Neuroblastoma Most occur in children <5y. Consider specialist assessment within 48h Children with a palpable abdominal mass or unexplained enlarged abdominal organ. Wilm’s Tumour Consider specialist assessment within 48h Soft Tissue Sarcoma Consider a very urgent direct access ultrasound scan within 48 hours Consider a very urgent referral within 48h Bone Sarcoma Consider a very urgent Form to be reviewed annually Usually children 1-3y. Embryonal tumour of the kidney. Children with a palpable abdominal mass or unexplained enlarged abdominal organ or unexplained visible haematuria. Children and young people with an unexplained lump that is increasing in size. Children and young people if they have ultrasound scan findings that are suggestive of soft tissue sarcoma or if ultrasound findings are uncertain and clinical concern persists. Children and young people if an X-ray suggests the Page 7 of 8 Revised: August 2016 referral within 48h Consider a very urgent direct access X-ray within 48h Retinoblastoma Consider urgent referral (within 2w) for ophthalmological assessment Discrete Lump with Thyroid possibility of bone sarcoma. Children and young people with unexplained bone swelling or pain. Children with an absent red reflex. Skin cancer Non- site specific symptoms in children Consider referral for children If there parent/carer has persistent concern or anxiety about the child’s symptoms even if most likely to have a benign cause. Take into account insight and knowledge of parents/carers when considering referral. N.B. The positive predictive value of parental concern has not been studied. Form to be reviewed annually Page 8 of 8 Revised: August 2016