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Suspected Haematological Malignancies 2ww Referral Form
For Choose and Book referrals, attach this template to a referral in Choose and Book within 24 hours of
creating the request - an appointment must be made for the patient before they leave the practice.
Please X the corresponding box for the hospital the referral is being made to and fax/send within 24 hours.
Barnet
Chase Farm
BHRUT
Barts & London
Fax: 020 8375 1977
Fax: 020 8375 1977
Fax: 01708 435 074/
Fax: 020 3594 3278
Tel: 020 8370 9079
Tel: 020 8370 9079
01708 435 367
Tel: 020 7767 3333
Tel: 01708 435 065
Homerton
Newham
North Middlesex
PAH
Fax: 020 8510 7832
Fax: 020 7363 8818
Fax: 020 8887 2663/4
Fax: 01279 827 171
Tel: 020 8510 5099
Tel: 020 7363 8817
Tel: 020 8887 2662
Tel: 01279 827 550
Royal Free
UCLH
Whipps Cross
Whittington
Fax: 020 7433 2950
Fax: 020 3447 9932
Fax: 020 8928 8836
Fax: 020 7288 5621/3793
Tel: 020 7433 2969
Tel: 020 3447 9599
Tel: 020 8535 6856
Tel: 020 7288 3070
PATIENT DETAILS (Please complete in block
capitals)
GP DETAILS (Please complete in block capitals)
Forename:
Surname:
Address:
Date referral sent:
Name of referrer:
Address:
Post code:
Date of Birth:
/
/
Sex: M
F
NHS Number:
Has the patient previously visited the hospital?
Y
N
Hospital Number:
Post code:
Interpreter required: Y
N
Phone number:
Language:
Fax number:
IMPORTANT:
To be able to contact the patient within 48 hours of referral (day and evening)
please provide patients preferred contact phone details
Home:
Mobile:
Work:
REFERRAL INFORMATION (Mandatory)
Malignancy
Leukaemia
Hodgkins or Non Hodgkins
suspected:
Lymphoma
If acute leukaemia suspected on blood test telephone haematology immediately
Myeloma
If spinal cord compression suspected refer immediately for investigation
Symptoms:
Examination
Findings:
Night Sweats
Itching
Bruising/
Bleeding
Recurrent
infections
Back pain with
‘Red Flags’
Persistent bone pain
Unexplained LN >1cm for 6
weeks
Or Unexplained LN >2cm
Weight loss
Breathlessness
Other
Unexplained
splenomegaly
Renal failure
suspected
Other
Results of Investigations
Hb
WBC
Plat
ESR
WHICH HOSPITAL LABORATORY:
Creatinine
Calcium
Albumin
Bilirubin
If myeloma suspected:
Serum protein
electrophoresis
MSU for Bence
Jones Protein
Radiology as appropriate
Family History of cancer including age of their diagnosis:
Other relevant information (free text):
e.g. location of LNs
I confirm that I have discussed the possibility with the patient that the diagnosis may be cancer
PLEASE INCLUDE WITH THIS PROFORMA PAST MEDICAL HISTORY, MEDICATIONS AND
RESULTS AND YOUR REFERRAL LETTER IF APPROPRIATE
London Cancer 2ww Haematology referral form
Page 1 of 3
Haematological cancers
Patient presents with
Combinations of the
following:
 drenching night sweats
 persistent unexplained
fever
 weight loss
 generalised itching
 breathlessness
 bruising
 bleeding
 recurrent infections
 bone pain
 alcohol-induced LN pain
 abdominal pain
 lymphadenopathy
 splenomegaly.
Full clinical examination,
investigate with FBC and
blood film, ESR/CRP
 Unexplained
lymphadenopathy– >1cm
for 6 weeks
 Or unexplained LN>2cm
 Persistent unexplained
fatigue or symptoms of
anaemia (iron deficiency
anaemia excluded)
 Unexplained bleeding,
bruising, purpura
 Persistent unexplained
splenomegaly
Following features of
lymphadenopathy:
 persistence for 6
weeks or more
 lymph nodes
increasing size
 lymph nodes > 2 cm
 widespread nature
 associated
splenomegaly, night
sweats or weight
loss.
 Persistent unexplained
skeletal pain
RED FLAG FEATURES?


Age >50 or <20 years
Constitutional symptoms
(malaise, weight loss)
Thoracic pain
Pain worsening at night
or when supine
Severe or progressive
sensory alteration or leg
weakness
Bladder or bowel
dysfunction




Full clinical examination;
investigate with FBC and
blood film, ESR/CRP
+/_ Clotting screen
Full clinical examination,
investigate with FBC and
blood film, ESR/CRP
Full clinical examination;
investigate FBC, U&E, liver
and bone profile, serum
protein electrophoresis and
MSU for BJP, ESR/CRP.
Consider X-ray
FBC/Blood film suggestive
of acute leukaemia
N
Y
N
2 WW
Y
IMMEDIATE
REFERRAL
Possible spinal cord
compression or renal
failure suspected of being
caused by myeloma
IMMEDIATE
REFERRAL
Do:
Remain vigilant for red flag symptoms indicating a malignant cause for bone pain. Consider myeloma in these cases.

Safety net patients with lymphadenopathy. Explain that they should return if the LNs grow, persist for over 6 weeks or are
associated with other symptoms (fever, night sweats, weight loss, pain in LNs after drinking alcohol).

Include all relevant clinical information on the 2ww form. If blood tests are not available at time of referral, indicate the
laboratory where tests were done.

If in doubt about whether to refer, consider phoning for advice; use the contact list opposite.
Don’t
×
If suspecting myeloma, don’t be reassured by a normal serum protein electrophoresis; 1 in 3 patients with myeloma have
normal serum electrophoresis but positive urine BJP.
Be Specific:

When referring via two week wait, be specific about when the patient should have heard from the hospital and what to do if
they have not.

Try to inform the patient that the purpose of the 2ww referral is to exclude serious conditions such as cancer.
London Cancer 2ww Haematology referral form
Page 2 of 3
If you wish to discuss clinical issues relating to the two week wait referral please contact:
Barnet Hospital
Chase Farm Hospital
Barking, Havering and Redbridge University
Hospitals NHS Trust
Barts and the London Hospital
Tel: 020 8216 4383
Louise Edwards (CNS) via Chase Farm Hospital Day
Clinic – 020 8375 2066
Tel: 020 8375 1457
Cancer Referrals Office
Tel: 01708 435065
Bodley Scott Day Unit;
Tel: 020 3465 6780/6789
Out-of hours: bleep the On Call Haematology Oncology
Specialist Registrar or Consultant
Homerton University Hospital NHS Foundation
Trust
Tel: 07909 002 671 (24 hours)
Secretaries’ Office: 020 8510 7325
Dr Roger Amos; Consultant Haematologist
Tel: 020 8510 7900
Josie Robinson, Secretary to above
Tel: 020 8510 7309/
Fax: 020 8510 7555
Newham University Hospital
North Middlesex University Hospital NHS Trust
Princess Alexandra Hospital NHS Trust
Royal Free London NHS Foundation Trust
University College London NHS Foundation Trust
Whipps Cross University Hospital
Dr Pavel Kotoucek – Consultant Haematologist
via Jackie (Secretary to Dr Kotouchek)
Tel: 020 7363 3413
Dr Thuraisamy Kumaran and Dr Neil Rabin; Consultant
Haematologists
Tel: 020 8887 2471
Fast Track Office
Tel: 01279 827 550
Dr Kate Cwynarski; Consultant Haematologist
Tel: 020 7317 7514
Fran Penny, CNS
Tel: 0207 7940500 ext 33477 or bleep 1102
Dr Kirit Ardeshna; Consultant Haematologist, via
secretary Melissa Crozier
Tel: 020 3447 9443
Dr Naim Akhtar; Consultant Haematologist
Lorraine Limburn Secretary:
Tel: 020 8539 5522 x 4547
London Cancer 2ww Haematology referral form
Page 3 of 3