St Helens & Knowsley Hospitals NHS Trust

SUSPECTED GYNAECOLOGICAL CANCER – REFERRAL FORM

To make an URGENT REFERRAL, Fax to: 0151 430 1629

Telephone Contact No.: 0151 430 1234

REFERRER’S DETAILS

Referring GP

/ GP Code:
Registered GP
GP Address & postcode
GP Tel. No.
GP Fax. No.
Date seen by GP: / Decision to refer date:
PATIENT DETAILS

Title & Surname

/ Forename(s)
D.O.B. / AGE: / Gender: Male Female

Address

Postcode /

*Tel. No. (day)

/

Mobile Tel.

*Tel. No. (evening) / NHS No. / Hospital No.
* N.B. It is essential that you provide a current contact telephone number for the patient so that the Trust can contact the patient within 24-hours to arrange a convenient appointment.
CULTURAL, MOBILITY, IMPAIRMENT ISSUES
What is the patient’s preferred first language? ………………………………………………..
Does the patient require Translation or Interpretation Services? YES NO ………………………………………
Please list any hearing or visual impairments requiring specialist help (Sign language, Braille, Loop Induction systems) ………………………………………………………………………………………………………
Is Disabled Access Required? YES NO Is transport required? YES NO
Ethnic Origin: ……………………………………….. Religion: ………………………………………………………
Is the patient from overseas? YES NO Is the patient a temporary visitor? YES NO
REFERRAL INFORMATION (referral guidelines are provided below / attached to proforma)
Cancer type suspected: Ovary Cervix Endometrium Vulva Vagina
Menopausal Status: Pre Post Hysterectomy HRT:YES NO
Referral Criteria:
  • Clinically suspicious features of the cervix on examination. A smear test is not required before referral and a previous negative result should not delay referral.
  • Post-menopausal bleeding and not on HRT
  • Persistent unexplained post-menopausal bleeding after having stopped HRT for 6 weeks.
  • Postmenopausal bleeding while taking tamoxifen.
  • Unexplained vulval lump.
  • Vulval bleeding due to ulceration.
  • Ultrasound suspicious of Ca ovary
  • Palpable abdominal mass or pelvic mass, not uterine fibroids, not of gastrointestinal or urological origin. Consider an urgent ultrasound scan - if this is not available, make an urgent referral
  • Persistent intermenstrual bleeding and a negative pelvic examination
  • Vulval pruritusor pain. Refer urgently if symptoms persist and there is a high suspicion of cancer.
/
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No

Clinical Finding:
  • Abdominal Examination: Mass
  • Speculum Examination: Cervix Normal
  • Speculum Examination: Cervical Lesion
  • Speculum Examination: Cervix Suspicious
  • Vaginal Lesion:
  • Vulval Lesion:
  • Bimanual Examination: Normal
  • Bimanual Examination: Enlarged Uterus
  • Bimanual Examination: Mass
/ Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Any additional information
e.g. Investigations ordered:
  • USS/Ultrasound
  • Other

Is the patient aware of the reason & urgency for referral & aware that they will be seen within 2 weeks?YES NO

Referral Criteria: NICE – Clinical Guideline 27 (issued June, 2005)

Urgent referral = the patient is seen within the national target for urgent referrals = currently 2 weeks

Refer urgently patients:

  • 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
  • Not on hormone replacement therapy with postmenopausal bleeding
  • On hormone replacement therapy with persistent or unexplained postmenopausal bleeding after cessation of hormone replacement therapy for 6 weeks
  • Taking tamoxifen with postmenopausal bleeding
  • With an unexplained vulval lump
  • With vulval bleeding due to ulceration

Consider urgent referral for patients with persistent intermenstrual bleeding and negative pelvic examination.

Refer urgently for an ultrasound scan patients:

  • With a palpable abdominal or pelvic mass on examination that is not obviously uterine fibroids or not of gastrointestinal or urological origin. If the scan is suggestive of cancer, an urgent referral should be made. If urgent ultrasound is not available, an urgent referral should be made.

Investigations:

  • A full pelvic examination, including speculum examinationof 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
  • Ovarian cancer is difficult to diagnose. In patients with vague, non-specific, unexplained abdominal symptoms such as:
  • bloating
  • constipation
  • abdominal pain
  • back pain
  • urinary symptoms

carry out an abdominal examination. Also consider a pelvic examination.

  • In patients with vulval pruritus or pain, a period of ‘treat, watch and wait’ is reasonable. Active follow-up 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.

Definitions

‘Urgent’: the patient is seen within the national target for urgent referrals (currently 2 weeks)

‘Persistent’ as used in the recommendations in this guideline refers to the continuation of specified symptoms and/or signs beyond a period that would normally be associated with self-limiting problems. The precise period will vary depending on the severity of symptoms and associated features, as assessed by the healthcare professional. In many cases, the upper limit the professional will permit symptoms and/or signs to persist before initiating referral will be 4– 6 weeks.

‘Unexplained’ refers to a symptom(s) and/or sign(s) that has not led to a diagnosis being made by the primary care professional after initial assessment of the history, examination and primary care investigations (if any).

An algorithm1 summarising the principal recommendations on how to proceed when a patient presents with gynaecological symptoms.

  1. National Institute for Health and Clinical Excellence: Referral guidelines for suspected cancer - Clinical Guideline 27 (issued June, 2005)