SUSPECTED CANCER REFERRAL FORM: SARCOMA (ADULTS)

Date of decision
to refer: / Date referral received at Trust:
Please see Guidance for referral pathways
SUSPECTED SARCOMA (Limb and Trunk) / SUSPECTED SARCOMA (Limb, Trunk and Spine)
SOFT TISSUE SARCOMA / SOFT TISSUE SARCOMA
BONE SARCOMA
Royal Marsden Hospital
Fax: 020 8661 3149
Tel: 020 8661 3630
Email: / Royal National Orthopaedic Hospital (RNOH)
Fax: 020 8909 5709
Tel: 020 8909 5603
Email:
Patient details
SURNAME: / FIRST NAME: / TITLE:
GENDER: / DOB: / NHS NUMBER:
ETHNICITY: / LANGUAGE:
INTERPRETER REQUIRED: / TRANSPORT REQUIRED:
PATIENT ADDRESS: / POSTCODE:
CONTACT DETAILS: HOME: / MOBILE: / EMAIL:
GP practice details
USUAL GP NAME:
PRACTICE NAME:
PRACTICE ADDRESS: / PRACTICE CODE:
DIRECT LINE TO THE PRACTICE (BYPASS):
MAIN: / FAX: / EMAIL:
Referring clinician:
Patient engagement and availability
I confirm the following:
I have discussed the possibility that the diagnosis may be cancer
I have provided the patient with a suspected cancer referral leaflet
I have informed the patient that the appointment will be within the next two weeks & attendance is advised
Please note any dates the patient is NOT available for an appointment in the next 2 weeks.
Patient’s WHO performance status
Grade / Explanation of activity
0 / Fully active, able to carry on all pre-disease performance without restriction.
1 / Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work.
2 / Ambulatory and capable of all selfcare but unable to carry out any work activities. Up and about more than 50% of waking hours.
3 / Capable of only limited selfcare, confined to bed or chair more than 50% of waking hours
4 / Completely disabled. Cannot carry on any selfcare. Totally confined to bed or chair.
REASON FOR SUSPECTED CANCER REFERRAL
SUSPECTED SOFT TISSUE SARCOMA / SUSPECTED PRIMARY BONE SARCOMA
Specific body site: / Specific body site:
Refer the patient to Marsden or RNOH with a soft tissue mass which has one or more of the following features: / Refer the patient to RNOH with an x-ray that is suspicious and showing the following features:
Increasing in size / Spontaneous fracture
Deep to fascia / Bone destruction
Painful / New bone formation
Fixed/immobile / Periosteal elevation
> 5cm in size / Normal or equivocal x-ray but high clinical suspicion of bone sarcoma
Imaging that suggests soft tissue sarcoma / Bone swelling or tenderness
Other (please specify): / Bone pain (including night pain and pain not responding to simple analgesia)
Recurrence following excision (please specify):
Normal or equivocal ultrasound but high clinical suspicion of sarcoma
This patient has had a previous sarcoma (Please state when and where treated).
Investigations
Please ensure the following recent results are available:
Blood test (less than 8 weeks old):
eGFR Result______Date ______Or date of test ______
Please attach any relevant imaging and histology reports
Free text box for additional clinical information/referral letter:
If this case has been discussed with the secondary care clinical team, please specify with whom, when and advice given:
Please use this area to autopopulate a patient summary: to includerecent consultations, current diagnoses; past medical history; recent investigations; recent blood test results; medication; any other fields which might be helpful to secondary care.
Further information and guidance
Useful websites:
CRUK main / CRUK learning / e-CDS
Macmillan / Macmillan learning / Genetics and Family History
Map of Medicine / NICE / Q-Cancer
Site-specific information and advice for primary care:
  • Refer Children and Young Adults to your Local Trust using the “Suspected Cancer Referral Form: Children and Young People”
  • Refer Adult patients with suspected sarcoma to your Local Trust for imaging.
The guidance for requesting direct access for imaging is as follows:
Suspected spontaneousfracture / X-Ray / via A&E
Unexplained lump increasing in size / USS / ≤2wk
Bone Swelling or Bone Pain / X-ray / routine
  • Refer patients requiring biopsies to a Sarcoma diagnostic clinics held either at the Royal Marsden (Soft Tissue Sarcoma) or Royal National Orthopaedic Hospital (Bone Sarcoma and Soft Tissue Sarcoma)
  • Refer patients with Kaposi Sarcoma (HIV associated) via the local GUM services.

Final agreed by CCGs across St Luke’s Cancer Alliance March 2017

1