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LUNG Suspected Cancer Referral (2 Week Wait Referral) To support NICE guidance 2005 Please FAX within 24 hours to Cancer Pathways department: 020 8928 8836 Section 1 PATIENT INFORMATION (Please complete in BLOCK CAPITALS) Date of Referral Date of Birth NHS number UBRN SURNAME FIRST NAME Miss Mrs Ms Mr Other:_________ / / / / - - Home Tel. M[ ]F [ ] Mobile/Daytime Tel. Address Transport Y N Interpreter Y N Language Ethnicity Post Code Section 2 PRACTICE INFORMATION (Please use practice stamp if available) Referring GP Locum Practice Address Y N Telephone Fax Post Code Section 3 CLINICAL INFORMATION (please TICK all applicable entries) Please enclose print outs of CURRENT medications and PAST MEDICAL HISTORY Criteria for Urgent referral Indications for urgent chest x-ray prior to urgent referral [ ] Smokers or ex-smokers aged > 40 years with [ ] Haemoptysis No. of episodes: _________ persistent haemoptysis Unexplained or persistent ( > 3 weeks): [ ] Chest X-ray suggestive of lung cancer [ ] Chest and/or shoulder pain [ ] Dyspnoea [ ] Normal CXR where there is a high suspicion of lung [ ] Weight loss [ ] Chest signs cancer [ ] Hoarseness [ ] Finger clubbing [ ] History of asbestos exposure and recent onset [ ] Cervical or supraclavicular [ ] Cough of chest pain, shortness of breath or unexplained lymphadenopathy systemic symptoms where a CXR indicates [ ] features suggestive of metastasis from a lung cancer pleural effusion, pleural mass or any suspicious (e.g. secondaries in the brain, bone, liver, skin) lung pathology [ ] Underlying chronic respiratory problems with If Signs of SVCO or Stridor consider unexplained changes in existing symptoms immediate referral N.B. A CHEST X- RAY REPORT MUST BE ATTACHED WHERE INDICATED unless exceptional circumstances apply (please explain): INVESTIGATIONS [ ] CHEST X-RAY PERFORMED Date : / / Done at:___________________ Results/Comments: Medical History and Known Allergies Medication Discussed urgent suspected cancer referral with patient: Y N Discussed with the patient that they may be asked to attend an appropriate investigation prior to or at their first appt: Comments/other reasons for suspecting cancer Hospital use only: (Tick where appropriate) Date Appointment Booked: Target Dates 2ww 62/7 / / / / / / Date of Referral receipt: Database: / Patient confirmed: / A separate letter only need accompany if you feel it necessary Approved by the North East London Cancer Network April 2006 Y N LOCAL CONTACT DETAILS If you wish to discuss any clinical issues concerning this referral please contact: Dr Alistair Reinhardt Dr Mathina Roberts Dr Phillip Raines Dr Simon Quantrill Dr Ali Mohammed Prof Michael Roberts Julia Mcveigh Consultant (Lead Clinician) Consultant Consultant Consultant Consultant Consultant Clinical Nurse Specialist 0208 535 6675 0208 539 5522- Ext 016 0208 535 5469 0208 535 6642 0208 535 5469 0208 535 6782 0208 539 5522- Ext 945 If you wish to discuss any other aspect of this referral please contact the Cancer Pathways Office on 020 8535 6856/ 020 8535 6768 x4348 x4350 CRITERIA FOR URGENT SUSPECTED CANCER REFERRAL1 Please FAX the referral form within 24 hours Refer a patient who presents with symptoms suggestive of lung cancer to a team specialising in the management of lung cancer, depending on local arrangements. Investigations Referral for diagnostic chest X-ray Most patients with intrathoracic tumours have an abnormal x-ray. PLEASE ARRANGE AN X-RAY BEFORE REFERRING. Many patients will present late, or with signs on an x-ray taken for other reasons. Patients will need an urgent chest x ray if they present with any of the symptoms or signs of underlying cancer mentioned in this proforma and guideline, and also if they have any underlying chronic respiratory problems with unexplained changes in existing symptoms. If there are x-ray features of lung cancer including: o slowly resolving consolidation o pleural effusion o pleural mass Then the patient should be referred urgently If the x-ray is normal, but the suspicion of cancer is slight, please speak to a chest physician for more guidance. Please note that a two-week appointment will not be issued and you will be contacted by the Cancer Referral Office unless: a) the x-ray report is faxed together with this form b) x-ray is normal, but high suspicion of lung cancer c) Smokers or ex-smokers aged > 40 years with persistent haemoptysis d) Other circumstances apply ~ specify on proforma Risk factors The following patients have a high risk of developing lung cancer: all current or ex-smokers patients with chronic obstructive pulmonary disease people who have been exposed to asbestos people with a previous history of cancer (especially head and neck) An urgent referral for a chest X-ray or to a specialist can be considered sooner in these patients. Secondaries may also produce: o pain in the ribs, back, arm (brachial neuritis in Pancoast tumour), o headache (with or without vomiting fits and limb weakness), o superior vena caval obstruction. Liver secondaries can produce jaundice or an enlarged liver. Incidence2 In 2000 there were 38,410 new cases of lung cancer diagnosed in the UK. There are about 50 new cases per 100,000 population each year. Lung cancer is the second most commonly diagnosed cancer in the UK and causes more than a fifth of all deaths from cancer. 1 Based on Referral Guidelines for Suspected Cancer (NICE, 2005) Notes in grey refer to the evidence grading used in the NICE guidelines, for more information see www.nice.org.uk/cg027NICEguideline 2 Lung Cancer Factsheet (Cancer Research UK, Jan 2004)