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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 Page 1 of 4 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 Page 1 of 4 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