Download NHSC_ Urgent Suspected Cancer Generic

URGENT SUSPECTED CANCER REFERRAL FORM
To:
Cancer Registry,
Mayday University Hospital,
London Road,
Croydon, CR7 7YE
THIS FORM MUST BE FAXED
Tel:
020 401 3986
Fax:
020 8401 3337
Hospital No.
Date Clinic Appt:
Meets 2 week rule? YES/NO
Referring Clinician
Referrer Name
Referring Practice
Practice Address
Date of Referral
Tel Number
Fax Number
Postcode
Patient Details
Name
Address
Postcode
Ethnic Origin
If Interpreter required what language
NHS Number
DOB
Tel No (Home)
Tel No (Work)
Mobile Number
Gender
IMPORTANT INFORMATION PLEASE COMPLETE ALL SECTIONS
Suspected Cancer Type
Name of preferred specialist
Patient awareness Questions
Has the patient been made aware of the nature of their referral?
Has the patient been supplied with supportive information about the Urgent Suspected Cancer referral process?
Have you asked the patient if they will be available to receive an appointment within the next two weeks?
Has the patient indicated to you that they would be available to attend an appointment within the next two weeks?
Does the patient require a translator? If Yes, please specify language
YES
YES
YES
YES
YES
/ NO
/ NO
/ NO
/ NO
/ NO
Clinical details:
N.B
DO NOT REFER PATIENTS AS URGENT SUSPECTED CANCER UNLESS THEY MEET THE CRITERIA BELOW
Date: ~[Today...]
Referral Version: V1.0
234830334
NHS Number: ~[NHS Number]
Released: 02.02.10
Page 1 of 3
CH
Children’s Cancers
GY
Gynaecological Cancer
LG
Lung Cancer
LG 1
CH 1 Abnormal blood count suggesting further investigation
CH 2 Lymphadenopathy, if one or more of the following are
present (particularly in the absence of local
Infection
Lymph nodes are non-tender, firm or hard
Lymph nodes are greater than 2 cm in size
Lymph nodes are progressively enlarging
Other features of general ill health, fever or weight
loss
Axillary node involvement (in absence of local
infection or dermatitis)
Supra-clavicular node involvement
CH 3 Shortness of breath, in association of the above signs,
particularly if not responding to bronchodilators
CH 4 Persistent parental anxiety
CH 5 Recurrent presentation (3 times or more) with the
same symptoms and no diagnosis
BN
Bone cancer or Sarcoma
BN 1 A soft tissue lump with any of the following features:
Greater than 5 cm in diameter
Deep to facia, fixed or immobile
Painful
Increasing in size
A recurrence after previous excision
BN 2 If the patient has HIV disease and Kaposi’s sarcoma
is suspected
BN 3 An x-ray suggests a bone cancer is a possibility
UGI
Upper GI Cancer
GY 1 Lesions suspicious of cancer on cervix or vagina on speculum
examination
GY 2 Lesions suspicious of cancer on clinical examination of the
vulva
GY 3 Palpable abdominal or pelvic mass (not obviously fibroids)
GY 4 Suspicious pelvic mass on ultrasound
GY 5 Post menopausal bleeding in a woman not on HRT
GY 6 Persistent or unexplained post menopausal bleeding in a
woman on HRT, after cessation of the HRT for 6 weeks
GY7 Post menopausal bleeding in a women taking Tamoxifen
GY 8 Persistent intermenstrual bleeding and a negative pelvic
examination
CR
Lower GI Cancer
Chest x-ray suggestive/suspicious of lung cancer
(including pleural effusion and slowly resolving
consolidation).
LG 2 Persistent haemoptysis in smokers/ex-smokers over 40
years of age.
LG 3 Signs of superior vena caval obstruction (swelling of
face/neck with fixed elevation of jugular venous
pressure).
LG 4Stridor (consider emergency referral).
SK
CR 1 Patients aged 40+ with rectal bleeding and a change of bowel
habit (looser stools) for 6 weeks or more
CR 2 Patients 60+ with rectal bleeding for 6 weeks or more, without
a change in bowel habit and without anal symptoms
CR 3 Patients 60+ with a change of bowel habit (looser stools) for 6
weeks or more without rectal bleeding
CR 4 Lower abdominal mass consistent with large bowel
involvement
CR 5 Palpable rectal mass (intraluminal) at any age
CR 6 Men of any age with unexplained iron deficiency anaemia, Hb
11.0 g/dl or less
CR 7 Non menstruating women with unexplained iron deficiency
anaemia, Hb 10.0 g/dl or less
SK 1
SK 2
SK 3
SK 4
CNS
HN
Brain Tumours
Skin Cancers
Any lesion suggestive of skin cancer
Any lesion confirmed on biopsy to be cancer
Any lesion suspected to be a melanoma
Non healing lesions larger than 1 cm, with
induration and present for over 8 weeks
Head and Neck Cancer
UGI 1 Patients of any age with dyspepsia AND with any of the
following
Chronic GI bleeding
Dysphagia
Progressive unintentional weight loss
Persistent vomiting
Iron deficiency anaemia
Epigastric mass
Suspicious barium meal result
UGI 2 Patients aged over 55 with unexplained persistent
recent onset dyspepsia
UGI 3 Dyspepsia that occurs within 5 seconds of having
commenced swallowing
UGI 4 Unexplained weight loss (and no dyspepsia)
UGI 5 Iron deficiency anaemia (and no dyspepsia)
UGI 6 Persistent vomiting and weight loss (and no dyspepsia)
UGI 7 Patients presenting with
Unexplained upper abdominal pain and weight loss
(+/- back pain
An upper abdominal mass (+/- dyspepsia
UGI 8 Obstructive jaundice
CNS 1 Patients with CNS symptoms where a brain tumour is
suspected.
CNS 2 Recent onset headaches with features of raised intra-cranial
pressure or other suggestive symptoms.
CNS 3 New, qualitatively different, unexplained and progressively
severe headaches
CNS 4 Suspected recent onset seizures
CNS 5 Patients with rapid progression of
Sub acute focal neurological deficit
Unexplained cognitive deficit, behavioural
disturbance, slowness, or a combination of these
Personality changes confirmed by a witness, for which
there is no reasonable explanation
CNS 6 Patients with a past medical history of cancer developing any
of the following
Recent onset seizure
Progressive neurological deficit
Persistent headaches
New mental or cognitive changes
New neurological signs
HN 1 Any patient with persistent symptoms or signs related to
the oral cavity, which does not resolve within weeks should
be referred urgently – unless clearly benign.
NH 2 Patients with unexplained red and white patches (including
suspected lichen planus) of the oral mucosa that are
Painful
or
Swollen
or
Bleeding
HN 3 Unexplained oral ulceration or mass of 3 weeks duration or
more need urgent referral.
HN 4 Hoarseness of more than 3 weeks (with normal chest x-ray)
HN 5 Persistent, unexplained parotid or submandibular gland
swellings
HN 6 Persistent, unexplained sore or painful throat
HN 7 Unilateral head or neck pain for more than 4 weeks, with
ear ache (but normal otoscopy).
HN 8 Thyroid swelling with any of the following
Solitary nodule increasing in size
History of neck radiation
Family History of an endocrine tumour
Unexplained hoarseness or voice changes
Cervical lymphadenopathy
Pre-pubertal patients
Patients aged 65+
H
UR
BR
Haematological Cancer
H 1 Patients with a blood count or blood film reported as acute
leukaemia
H 2 Patients with persistent unexplained splenomegaly
H 3 Patients with the following additional features of
lymphadenopathy
Persistence for 6 weeks or more
Lymph nodes growing in size
Lymph nodes greater than 2 cm inn size
Widespread nature
Associated splenomegaly
Night sweats
Weight loss
Date: ~[Today...]
Referral Version: V1.0
234830334
Urological Cancer
UR1 Clinically malignant prostate on rectal examination (PSA done
at time of referral)
UR 2Asymptomatic men with raised or rising age specific PSA
UR 3 Symptomatic patients with high PSA
UR 4 Male or female patients of any age with painless macroscopic
haematuria.
UR 5 Patients aged >40 with recurrent or persistent UTI associated
with haematuria
UR 6 Patients aged <50 with microscopic haematuria AND no
proteinuria and NORMAL serum creatinine.
UR 7 Patients aged >50 with unexplained microscopic haematuria
UR 8 Any patient presenting with symptoms or signs of penile cancer
Breast Cancer
BR 1 Age over 30 with a discrete lump which persists after her
next period
BR 2 Discrete lump in a menopausal women
BR 3 In women under 30 ONLY IF
A lump which enlarges
A lump suspicious of cancer (fixed or hard)
Other major reasons for concern
BR 4 New lump or suspicious symptoms in a person previously
diagnosed with breast cancer
BR 5 Unilateral eczematous skin or nipple change resistant to
treatment
BR 6 Spotananeous unilateral bloody nipple discharge
BR 7 Men aged 0ver 50 with a breast mass
NHS Number: ~[NHS Number]
Released: 02.02.10
Page 2 of 3
Why have I been referred urgently to the hospital?
The urgent 2 week wait referral system


What you can expect
What you need to do
This information sheet is to help you understand your referral to hospital. It is important to remember that being given
an urgent referral to a specialist does not necessarily mean that you have cancer.
Why have I been referred to hospital?
Your General Practitioner (GP) has asked for you to have an urgent hospital appointment within two weeks. Depending
on your symptoms this appointment may be to attend an outpatient clinic, to have a diagnostic test or a combination of
the two. The “two week” appointment system was introduced so that a specialist would see any patient with symptoms
that might indicate cancer as quickly as possible.
Does this mean I have cancer?
No it doesn’t. The majority of patients referred under the “two week” appointment system do not have cancer but a
simple, or benign, condition.
So why has my GP referred me?
GPs diagnose and treat many illnesses themselves; however, they occasionally need to arrange for you to see a
specialist hospital doctor. This could be for a number of reasons, such as:
 Your symptoms need further investigation,
 The treatment already prescribed has not been effective.
 Investigations your GP arranged have shown some abnormal results.
 To be sure it is not a serious disease.
There are national guidelines for your GP to use to make a decision about whether to refer you for an appointment
within two weeks.
What do I need to do now?
 Make sure that you GP surgery have your correct address and telephone number (including a mobile phone
number, if possible).
 The hospital will try to contact you by telephone to arrange an appointment so the correct contact telephone
number is very important. If they are not able to make telephone contact, an appointment letter will be sent in
the post.
 Contact your GP surgery if you have not been contacted by the hospital within one week of the appointment
with your GP.
 Let the hospital know immediately if you are unable to attend your appointment so that the appointment can be
offered to someone else. It is important that you arrange an alternative date and time when cancelling this
appointment.
 At the end of your first appointment the hospital staff will give you more information about what will happen
next.
 Please feel free to take someone with you to the appointment, you may find this helpful. Do not feel that you
have to be alone.
Further Information
You can get more information about the “two week” appointment system and other information from these websites:
 www.cancerbackup.org.uk
Free-phone helpline on 0808 800 1234 (Mon.Fri 9am.8pm).
The helpline number is also free from these mobile phone networks: 3, O2, Orange,
T-Mobile, Virgin, Vodafone when calls are made from the UK.
 NHS Direct: www.nhsdirect.nhs.uk 0845 4647

NICE (Referral for Suspected Cancer): http://www.nice.org.uk/Guidance/CG27/PublicInfo/pdf/English

South West London Cancer Network www.swlcn.nhs.uk
Date: ~[Today...]
Referral Version: V1.0
234830334
NHS Number: ~[NHS Number]
Released: 02.02.10
Page 3 of 3