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URGENT SUSPECTED CANCER REFERRAL FORM To: Cancer Office, Croydon University Hospital, London Road, Croydon, CR7 7YE THIS FORM MUST BE FAXED Tel: 020 401 3986 Fax: 020 8401 3337 Hospital No. Date Clinic Appt: Meets 2 week rule? YES/NO Referring Clinician Referrer Name Referring Practice Practice Address Date of Referral Tel Number Fax Number Postcode Patient Details Name Address Postcode Ethnic Origin If Interpreter required what language NHS Number DOB Tel No (Home) Tel No (Work) Mobile Number Gender IMPORTANT INFORMATION PLEASE COMPLETE ALL SECTIONS Suspected Cancer Type Name of preferred specialist Patient awareness Questions Has the patient been made aware of the nature of their referral? Has the patient been supplied with supportive information about the Urgent Suspected Cancer referral process? Have you asked the patient if they will be available to receive an appointment within the next two weeks? Has the patient indicated to you that they would be available to attend an appointment within the next two weeks? Does the patient require a translator? If Yes, please specify language YES YES YES YES YES / NO / NO / NO / NO / NO Clinical details: N.B DO NOT REFER PATIENTS AS URGENT SUSPECTED CANCER UNLESS THEY MEET THE CRITERIA BELOW Date: ~[Today...] Referral Version: V1.0 582768337 NHS Number: ~[NHS Number] Released: 02.02.10 Page 1 of 3 CH Children’s Cancers GY Gynaecological Cancer LG Lung Cancer LG 1 CH 1 Abnormal blood count suggesting further investigation CH 2 Lymphadenopathy, if one or more of the following are present (particularly in the absence of local Infection Lymph nodes are non-tender, firm or hard Lymph nodes are greater than 2 cm in size Lymph nodes are progressively enlarging Other features of general ill health, fever or weight loss Axillary node involvement (in absence of local infection or dermatitis) Supra-clavicular node involvement CH 3 Shortness of breath, in association of the above signs, particularly if not responding to bronchodilators CH 4 Persistent parental anxiety CH 5 Recurrent presentation (3 times or more) with the same symptoms and no diagnosis BN Bone cancer or Sarcoma BN 1 A soft tissue lump with any of the following features: Greater than 5 cm in diameter Deep to facia, fixed or immobile Painful Increasing in size A recurrence after previous excision BN 2 If the patient has HIV disease and Kaposi’s sarcoma is suspected BN 3 An x-ray suggests a bone cancer is a possibility UGI Upper GI Cancer GY 1 Lesions suspicious of cancer on cervix or vagina on speculum examination GY 2 Lesions suspicious of cancer on clinical examination of the vulva GY 3 Palpable abdominal or pelvic mass (not obviously fibroids) GY 4 Suspicious pelvic mass on ultrasound GY 5 Post menopausal bleeding in a woman not on HRT GY 6 Persistent or unexplained post menopausal bleeding in a woman on HRT, after cessation of the HRT for 6 weeks GY7 Post menopausal bleeding in a women taking Tamoxifen GY 8 Persistent intermenstrual bleeding and a negative pelvic examination CR Lower GI Cancer Chest x-ray suggestive/suspicious of lung cancer (including pleural effusion and slowly resolving consolidation). LG 2 Persistent haemoptysis in smokers/ex-smokers over 40 years of age. LG 3 Signs of superior vena caval obstruction (swelling of face/neck with fixed elevation of jugular venous pressure). LG 4Stridor (consider emergency referral). SK CR 1 Patients aged 40+ with rectal bleeding and a change of bowel habit (looser stools) for 6 weeks or more CR 2 Patients 60+ with rectal bleeding for 6 weeks or more, without a change in bowel habit and without anal symptoms CR 3 Patients 60+ with a change of bowel habit (looser stools) for 6 weeks or more without rectal bleeding CR 4 Lower abdominal mass consistent with large bowel involvement CR 5 Palpable rectal mass (intraluminal) at any age CR 6 Men of any age with unexplained iron deficiency anaemia, Hb 11.0 g/dl or less CR 7 Non menstruating women with unexplained iron deficiency anaemia, Hb 10.0 g/dl or less SK 1 SK 2 SK 3 SK 4 CNS HN Brain Tumours Skin Cancers Any lesion suggestive of skin cancer Any lesion confirmed on biopsy to be cancer Any lesion suspected to be a melanoma Non healing lesions larger than 1 cm, with induration and present for over 8 weeks Head and Neck Cancer UGI 1 Patients of any age with dyspepsia AND with any of the following Chronic GI bleeding Dysphagia Progressive unintentional weight loss Persistent vomiting Iron deficiency anaemia Epigastric mass Suspicious barium meal result UGI 2 Patients aged over 55 with unexplained persistent recent onset dyspepsia UGI 3 Dyspepsia that occurs within 5 seconds of having commenced swallowing UGI 4 Unexplained weight loss (and no dyspepsia) UGI 5 Iron deficiency anaemia (and no dyspepsia) UGI 6 Persistent vomiting and weight loss (and no dyspepsia) UGI 7 Patients presenting with Unexplained upper abdominal pain and weight loss (+/- back pain An upper abdominal mass (+/- dyspepsia UGI 8 Obstructive jaundice CNS 1 Patients with CNS symptoms where a brain tumour is suspected. CNS 2 Recent onset headaches with features of raised intra-cranial pressure or other suggestive symptoms. CNS 3 New, qualitatively different, unexplained and progressively severe headaches CNS 4 Suspected recent onset seizures CNS 5 Patients with rapid progression of Sub acute focal neurological deficit Unexplained cognitive deficit, behavioural disturbance, slowness, or a combination of these Personality changes confirmed by a witness, for which there is no reasonable explanation CNS 6 Patients with a past medical history of cancer developing any of the following Recent onset seizure Progressive neurological deficit Persistent headaches New mental or cognitive changes New neurological signs HN 1 Any patient with persistent symptoms or signs related to the oral cavity, which does not resolve within weeks should be referred urgently – unless clearly benign. NH 2 Patients with unexplained red and white patches (including suspected lichen planus) of the oral mucosa that are Painful or Swollen or Bleeding HN 3 Unexplained oral ulceration or mass of 3 weeks duration or more need urgent referral. HN 4 Hoarseness of more than 3 weeks (with normal chest x-ray) HN 5 Persistent, unexplained parotid or submandibular gland swellings HN 6 Persistent, unexplained sore or painful throat HN 7 Unilateral head or neck pain for more than 4 weeks, with ear ache (but normal otoscopy). HN 8 Thyroid swelling with any of the following Solitary nodule increasing in size History of neck radiation Family History of an endocrine tumour Unexplained hoarseness or voice changes Cervical lymphadenopathy Pre-pubertal patients Patients aged 65+ H UR BR Haematological Cancer H 1 Patients with a blood count or blood film reported as acute leukaemia H 2 Patients with persistent unexplained splenomegaly H 3 Patients with the following additional features of lymphadenopathy Persistence for 6 weeks or more Lymph nodes growing in size Lymph nodes greater than 2 cm inn size Widespread nature Associated splenomegaly Night sweats Weight loss Date: ~[Today...] Referral Version: V1.0 582768337 Urological Cancer UR1 Clinically malignant prostate on rectal examination (PSA done at time of referral) UR 2Asymptomatic men with raised or rising age specific PSA UR 3 Symptomatic patients with high PSA UR 4 Male or female patients of any age with painless macroscopic haematuria. UR 5 Patients aged >40 with recurrent or persistent UTI associated with haematuria UR 6 Patients aged <50 with microscopic haematuria AND no proteinuria and NORMAL serum creatinine. UR 7 Patients aged >50 with unexplained microscopic haematuria UR 8 Any patient presenting with symptoms or signs of penile cancer Breast Cancer BR 1 Age over 30 with a discrete lump which persists after her next period BR 2 Discrete lump in a menopausal women BR 3 In women under 30 ONLY IF A lump which enlarges A lump suspicious of cancer (fixed or hard) Other major reasons for concern BR 4 New lump or suspicious symptoms in a person previously diagnosed with breast cancer BR 5 Unilateral eczematous skin or nipple change resistant to treatment BR 6 Spotananeous unilateral bloody nipple discharge BR 7 Men aged 0ver 50 with a breast mass NHS Number: ~[NHS Number] Released: 02.02.10 Page 2 of 3 Why have I been referred urgently to the hospital? The urgent 2 week wait referral system What you can expect What you need to do This information sheet is to help you understand your referral to hospital. It is important to remember that being given an urgent referral to a specialist does not necessarily mean that you have cancer. Why have I been referred to hospital? Your General Practitioner (GP) has asked for you to have an urgent hospital appointment within two weeks. Depending on your symptoms this appointment may be to attend an outpatient clinic, to have a diagnostic test or a combination of the two. The “two week” appointment system was introduced so that a specialist would see any patient with symptoms that might indicate cancer as quickly as possible. Does this mean I have cancer? No it doesn’t. The majority of patients referred under the “two week” appointment system do not have cancer but a simple, or benign, condition. So why has my GP referred me? GPs diagnose and treat many illnesses themselves; however, they occasionally need to arrange for you to see a specialist hospital doctor. This could be for a number of reasons, such as: Your symptoms need further investigation, The treatment already prescribed has not been effective. Investigations your GP arranged have shown some abnormal results. To be sure it is not a serious disease. There are national guidelines for your GP to use to make a decision about whether to refer you for an appointment within two weeks. What do I need to do now? Make sure that you GP surgery have your correct address and telephone number (including a mobile phone number, if possible). The hospital will try to contact you by telephone to arrange an appointment so the correct contact telephone number is very important. If they are not able to make telephone contact, an appointment letter will be sent in the post. Contact your GP surgery if you have not been contacted by the hospital within one week of the appointment with your GP. Let the hospital know immediately if you are unable to attend your appointment so that the appointment can be offered to someone else. It is important that you arrange an alternative date and time when cancelling this appointment. At the end of your first appointment the hospital staff will give you more information about what will happen next. Please feel free to take someone with you to the appointment, you may find this helpful. Do not feel that you have to be alone. Further Information You can get more information about the “two week” appointment system and other information from these websites: www.cancerbackup.org.uk Free-phone helpline on 0808 800 1234 (Mon.Fri 9am.8pm). The helpline number is also free from these mobile phone networks: 3, O2, Orange, T-Mobile, Virgin, Vodafone when calls are made from the UK. NHS Direct: www.nhsdirect.nhs.uk 0845 4647 NICE (Referral for Suspected Cancer): http://www.nice.org.uk/Guidance/CG27/PublicInfo/pdf/English South West London Cancer Network www.swlcn.nhs.uk Date: ~[Today...] Referral Version: V1.0 582768337 NHS Number: ~[NHS Number] Released: 02.02.10 Page 3 of 3