Download Gynaecology Urgent Suspected Cancer Referral

SOUTH EAST LONDON CANCER NETWORK
Gynaecology Urgent Suspected Cancer Referral
Please tick the box of the hospital clinic you are referring to and fax this form to the relevant Urgent Referral
Team within 24 hours. Guidelines are on the reverse side.
King’s PRUH site
[email protected]
Tel: 01689 866701/65790/65794
Fax: 01689 863187
King’s College
Fax: 020 3299 1515
Tel: 020 3299 1516
Guy’s & St Thomas’
Fax: 020 7188 0923
Tel: 020 7188 0902
Lewisham
Fax: 020 8333 3451
Tel: 020 8333 3450
SECTION 1 – PATIENT INFORMATION. PLEASE COMPLETE IN BLOCK CAPITALS.
SURNAME
Patient visited this hospital before?
Y / N
FIRST NAME
NHS
Hospital
Number
Number
Patient aware the referral is urgent?
Y / N
Gender
M / F
D.O.B.
Address
First language
Post Code
Daytime Telephone
Interpreter required?
Y / N
Transport required?
Y / N
Home Telephone (if different)
/ Mobile No.
SECTION 2 – PRACTICE INFORMATION. USE PRACTICE STAMP IF AVAILABLE.
Referring GP
Date of referral
Practice Address
Telephone
Post Code
Fax
SECTION 3 – CLINICAL INFORMATION. PLEASE TICK THE RELEVANT BOXES.
Cancer type suspected
Ovary
Cervix
Endometrium
Vagina / Vulva
Menopausal status
Premenopausal
Postmenopausal
Hysterectomy
On HRT
Bleeding PV
Intermenstrual
Postcoital
Postmenopausal
Number of episodes
Duration (days / weeks)
Abdominal symptoms
Yes
No
Examination findings
Negative
Abdominal mass
Pelvic mass
Visible cervical lesion
Vulval / vaginal lesion
Bleeding / ulcerated vulval /vaginal lesion
Additional information - Attach patient computer record summary if available. Continue on separate sheet if required.
SOUTH EAST LONDON CANCER NETWORK
Information to support Gynaecology referrals
Refer urgently patients:
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With clinical features suggestive of cervical cancer on examination. A smear test is not required
before referral, and a previous negative result should not delay referral.
With an unexplained vulval lump.
Not on HRT with postmenopausal bleeding.
On HRT with persistent or unexplained postmenopausal bleeding after cessation of HRT for 6
weeks.
Taking tamoxifen with post menopausal bleeding.
With vulval bleeding due to ulceration.
With a palpable abdominal or pelvic mass on examination that is not obviously uterine fibroids or
not of gastrointestinal or urological origin. Obtain Ca125, Ca199 and CEA markers.
Consider an urgent referral for patients with persistent inter-menstrual bleeding and negative pelvic
examination.
 Use this proforma to refer urgently (2 Week Wait)
Investigations in Primary Care:
A full pelvic examination, including speculum examination of the cervix, is recommended for patients
presenting with any of the following:
 alterations in the menstrual cycle
 intermenstrual bleeding
 postcoital bleeding
 postmenopausal bleeding
 vaginal discharge.
Carry out an abdominal palpation, and consider a pelvic examination, in patients with vague, nonspecific, unexplained abdominal symptoms such as
 bloating
 constipation
 abdominal pain
 back pain
 urinary symptoms.
In patients with vulval pruritus or pain, a period of ‘treat, watch and wait’ is reasonable. Active followup is recommended until symptoms resolve or a diagnosis is confirmed. If symptoms persist, the
referral may be urgent or non-urgent, depending on the symptoms and the degree of concern about
cancer.
Non-urgent referrals should be made using Choose & Book or a letter.
Patient information and support:
Consider the information and support needs of patients and the people who care for them while they
are waiting for the referral appointment. Resources for GPs to use are available from the Cancer
Network on 020 7188 7090, or visit our website www.selcn.nhs.uk.
Approved by the South East London Cancer Network in June 2012
For comments or additional copies contact the Network on Tel 020 7188 7090 / Fax 020 7188 7120, or visit our website:
www.selcn.nhs.uk.