Download 2WW Skin Nov 2016

Skin
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
Usual GP
Fax No.
Practice Code
Please use separate children’s proforma for patients under 16

I suspect melanoma/ SCC or BCC fulfilling the criteria for 2 week wait Yes
No

Histological diagnosis of SCC or melanoma (usually unexpected)
Yes
No

I have discussed the possibility of cancer with this patient.
Yes
No
Tick if
2ww Referral if:
Criteria
applies
Suspected Malignant Melanoma
Any changing pigmented lesion which has a score of THREE on the weighted scoring
system below (please fill score chart below)
Suspected invasive squamous cell carcinoma (not intra-epidermal/
Bowen’s)
Rapidly growing non-healing lump that may be crusted, ulcerated, horn-like or bleeding.
Base should be raised
Yes
No
Immunosuppressed?
Yes
No
Suspected basal cell carcinoma that fulfil 2ww criteria
BCC should be referred routinely EXCEPT where delay in treatment would cause significant
impact in the following circumstances:
Suspected BCC on nose or in periorbital region within 5mm of the eye measuring > 3mm
diameter
Yes
No
Lesion greater than 20mm diameter on head and neck?
Yes
No
If answer to both of these is no, this referral will be treated as a ROUTINE referral
A pigmented or non-pigmented skin lesion that suggests nodular
melanoma
Form to be reviewed annually
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Revised: August 2016
Site
Size
(mm)
Duration (wks
or mths)
Suspected Malignant Melanoma Score Chart
Any changing pigmented lesion which has a score of THREE on the weighted scoring system
below:
Major Features:
Tick if
ENTER SCORE 2 IF PRESENT
present
1.Rapid change in size
2.Irregular pigmentation
3.Irregular border
Minor features:
ENTER SCORE 1 IF PRESENT
4.Inflammation
5.Larger than other lesions (diameter >7mm)
6.Oozing/ crusting of lesion
7.Itch or altered sensation
PLEASE ENTER TOTAL SCORE
If score is less than 3, this referral will be treated as a ROUTINE referral unless the following
declaration is completed
Despite a score of less than 3, I strongly suspect melanoma and would like this patient to be see
on the two week wait
Yes
No
N/A
NB Multiple abnormal moles should be referred ROUTINELY if they are of concern
Details of lesion referred
Clinical Information
Medical History
Current Medications
Known Allergies
Form to be reviewed annually
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Revised: August 2016
Family History
Patient anxiety level
Patient information and support needs
Information given to the patient
Other information
WHO performance status: (please tick)
0 – normal activity
1 – restrictive light work
2 – self-care but no work > 50% of working day
3 – limited self-care – confined to bed/chair > 50% of waking day
4 – completely disabled – totally confined to bed/chair
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: Malignant
Benign
Guidance




NB It is not recommended that patients with a suspected melanoma or squamous cell carcinoma have their
lesions biopsied in general practice. They should be referred to a local specialist with the lesion intact.
BENIGN LESIONS WILL NOT BE TREATED IN THE 2 WEEK WAIT CLINIC
Moles and seborrhoeic keratosis that catch or irritate should be referred routinely
Only Basal Cell Carcinomas of the type detailed in this form should be referred on the 2 week wait.
Otherwise they should be referred routinely
Form to be reviewed annually
Page 1 of 4
Revised: August 2016
Summary of the NICE 2015 suspected cancer guidelines
Skin cancers
Malignant melanoma
Refer suspected
cancer pathway


Dermoscopy suggests malignant melanoma.
Suspicious pigmented skin lesion that scores 3 or more from
weighted 7 point checklist:

Major features (score 2 points each):
o Change in size.
o Irregular shape.
o Irregular colour.
o
Minor features (score 1 point each):
o Largest diameter ≥7mm.
o Inflammation.
o Oozing.
o Change in sensation.
Consider cancer
 A pigmented or non-pigmented skin lesion that suggests nodular
pathway referral
melanoma.
Squamous cell carcinoma (SCC)
Consider cancer
 A skin lesion that raises the suspicion of SCC.
pathway referral
No recommendations were made on the use of dermoscopy as there is
very limited and low quality evidence.
Basal cell carcinoma (BCC)
GPs should ONLY excise suspected BCCs in accordance with NICE
guidelines on improving outcomes for people with skin tumours.
Consider routine
 A skin lesion that raises suspicion of BCC.
referral
Only consider
 If delay in removing a suspected BCC may have an unfavourable
suspected cancer
impact, e.g. due to the size or location.
pathway
Form to be reviewed annually
Page 1 of 4
Revised: August 2016