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Lung
Fast Track Referral – 2 Week Wait
Please refer via the e-Referral Service
Patient Details:
Patient Name
Address
DOB
Home Tel. No.
Mobile Tel. No.
Preferred Tel.
No.
Main Spoken
Language
Transport
needed?
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:
Please use separate children’s proforma for patients under 16
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 can confirm that I have discussed the possibility with the patient that the diagnosis may be cancer
I confirm that I have explained the 2 week wait appointment and process to the patient
PLEASE HAND THE PATIENT A COPY OF THE URGENT REFERRALS PATIENT INFORMATION LEAFLET
(link to leaflet)
Tick if criteria
applies
Ring Chest Physician if patient has:
1. Evidence of superior Vena Caval Obstruction (swelling of face and/or neck with a fixed
elevated JVP)
2. Stridor
Non smoker?
Smoker?
Ex smoker ?
History of COPD?
Mesothelioma?
Order urgent CXR in people aged 40 or over if they have
 2 or more of the following unexplained symptoms and signs
 if they have ever smoked and have 1 or more of the following unexplained
symptoms or signs
 any age with asbestos exposure and 1 or more of the following signs
Symptoms
Chest pain
Shortness of breath
Form to be reviewed annually
Page 1 of 4
Tick if criteria
applies
Revised: August 2016
Cough
Weight Loss
Fatigue
Loss of appetite
Signs
Chest signs consistent with lung cancer or pleural disease
Finger clubbing
Supraclavicular lymphadenopathy or persistent lymphadenopathy
Persistent or recurrent chest infection
Thrombocytosis
NB: UP TO DATE U&E REQUIRED TO ENABLE CT SCAN WITH CONTRAST
Tick if criteria
applies
2ww Referral if:
Chest x-ray findings suggest lung cancer or mesothelioma
Are aged 40 or over with unexplained haemoptysis
Evidence of metastases of a possible lung cancer – state where
Underlying chronic respiratory problems with unexplained changes in existing symptoms
Clinical Information:
Medical History
Current Medications
Known allergies
Family History
Patient anxiety level
Patient information and support needs
Information given to the patient
Other information
Form to be reviewed annually
Page 2 of 4
Revised: August 2016
WHO performance status: (please tick)
0 – normal activity
1 – restrictive light work
2 – Self-care but no work, up >50% of waking day
3 – limited self-care – confined to bed/chair >50% of waking day
4 – completely disabled – totally confined to bed/chair
Patient information & support needs
Please provide details.
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 3 of 4
Revised: August 2016
Summary of the NICE 2015 suspected cancer guidelines
Respiratory cancers
Lung cancer and mesothelioma
Refer via cancer
 CXR findings are suggestive of lung cancer.
pathway
 Aged >40y with unexplained haemoptysis
Offer and urgent
CXR

Aged >40y with the following symptoms that are unexplained (if
smoker/ ex-smoker/ asbestos exposure: 1 symptom is needed, if
never smoked 2 symptoms needed):
o Cough
o Fatigue
o Shortness of breath
o Chest pain
o Weight loss
o Appetite loss
Consider urgent
CXR (within 2w)

Aged >40y with:
o Persistent or recurrent chest infection
o Finger clubbing
o Supraclavicular or persistent cervical lymphadenopathy
o Chest signs consistent with lung cancer or pleural disease
o Thrombocytosis
Form to be reviewed annually
Page 4 of 4
Revised: August 2016