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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