SOUTH EAST LONDON CANCER NETWORK

Paediatric Urgent Suspected Cancer Referral

If you suspect a child or young person has cancer, please telephone the paediatrician on call to discuss referral and possible admission. If urgent referral is advised please use this proforma to record the referral information and fax a copy to the relevant hospital clinic for inclusion in the patient notes. A copy can also be given to the patient / family for presentation in the clinic.

King’s College PRUH site


Tel: 01689 866701/65790/65794
Fax: 01689 863 187 /

Queen Elizabeth

Fax: 020 8836 4035
Tel: 020 8836 6000 (bleep 396) /

Guy’s & St Thomas’

Fax: 020 7188 0923
Tel: 020 7188 7188

King’s College

Fax: 020 3299 1515
Tel: 020 3299 1516 /

Lewisham

Fax: 020 8333 3451
Tel: 020 8333 3000 /

Queen Mary’s

Fax: 020 8308 9264
Tel: 020 8302 2678

Section 1 – PATIENT INFORMATION. Please complete in BLOCK CAPITALS.

SURNAME
/
Patient visited this hospital before?
/
Y / N
FIRST NAME
/
NHS number
Gender
/
M / F
/
D.O.B.
/
Patient aware the referral is urgent?
/
Y / N
Address
Post Code
/
First language
Interpreter required?
/
Y / N
Transport required?
/
Y / N

Daytime Telephone

/

Home Telephone (if different)

/ Mobile No.

Section 2 – PRACTICE INFORMATION. Use practice stamp if available.

Referring GP

/

Date of referral

Practice Address

Post Code
/

Telephone

Fax

Section 3 – CLINICAL INFORMATION. Please tick the relevant boxes.

Cancer suspected / Signs & Symptoms / Clinical findings
Leukaemia
Lymphoma
Brain / CNS
Neuroblastoma
Wilm’s tumour
Soft tissue
Bone
Retinoblastoma
Other (please specify): / Bone / back / rest pain
Behavioural changes / learning difficulties
Fatigue, lethargy
Fever
Haematuria / urinary retention
Headache / vomiting / ataxia / squint
Local swelling
Motor / sensory signs
Shortness of breath
Weight loss
Amount Over period
Other (please specify): / Abnormal blood count
Anaemia
Abdominal mass
Hepatomegaly
Lymphadenopathy
Neurological signs
Petechiae / Purpura
Soft tissue mass
Splenomegaly
Other (please specify):
Additional comments - including medical history and medication. Continue on separate sheet if required.
Name of paediatrician consulted:
Date:

** Discuss referral with a paediatrician first. If urgent referral is advised, fax this proforma to the relevant clinic and give a copy to the parents / patient to take to their appointment. **

SOUTH EAST LONDON CANCER NETWORK

Information to support Paediatric referrals

Refer urgently children or young people with:

  • Fatigueorshortness of breath in a previously healthy child combined with one or more of the following:
  • lymphadenopathy
  • hepatosplenomegaly
  • clinical evidence of anaemia or petechiae
  • Bone pain and / or swelling if:
  • diffuse or persistent
  • X-ray indicative of cancer.
  • Lymphadenopathy which has one or more of the following characteristics:
  • Non tender / firm / hard
  • unresolved after a course of antibiotics
  • associated with signs of generalised ill health, fever and/or weight loss
  • involves axillary or supraclavicular nodes
  • Headache of recent origin with one or more of the following features:
  • increasing frequency or severity (e.g. causing nocturnal awakening)
  • associated with behavioural change or deterioration in school performance
  • associated with neurological signs or symptoms of raised intracranial pressure
  • Soft tissue mass which has one or more of the following characteristics:
  • size > 2 cms
  • shows rapid or progressive growth
  • fixed or deep to fascia
  • associated with regional lymph node enlargement
  • non-tender
  • Haematuria
  • Full blood count indicative of leukaemia
  • With symptoms suggestive of neuroblastoma (proptosis, unexplained back pain, leg weakness, unexplained urinary retention).
Consider referral when children present several times with no clear diagnosis (investigations should also be carried out). Take into account parental insight and knowledge when considering a referral.
Phone paediatrician to discuss referral, and use this proforma to refer urgently (2 Week Wait)

Refer immediately (acute admission) children or young people with:

  • Either unexplained petechiae, or hepatosplenomegaly.
  • Either hepatosplenomegaly, or mediastinal or hilar mass on chest X-ray.
  • With a reduced level of consciousness.
  • Headache and vomiting that cause early morning waking or occur on waking as these are classical signs of raised intracranial pressure.
  • With any neurological symptoms and signs (new-onset seizures, cranial nerve abnormalities, visual disturbances, gait abnormalities, motor or sensory signs, unexplained deteriorating school performance or developmental milestones, unexplained behavioural and/or mood changes).
Children aged younger than 2 years with new-onset seizures, bulging fontanelle, extensor attacks or persistent vomiting should be referred immediately.
Send to A&E or phone paediatrician to arrange admission

Refer non-urgently:

Consider referral when a child or young person presents with persistent back pain (an examination is needed and a full blood count and blood film). Persistent parental anxiety is sufficient reason for referral, even where a benign cause is considered most likely. Take into account parental insight and knowledge when considering urgent referral.

Approved by the South East London Cancer Network in November 2006.

For comments, additional copies, further information on the referral guidelines or patient information resources for GPs to use contact the Network on Tel 020 7188 7090 / Fax 020 7188 7120, or visit our website: .

Referral pathway for suspected paediatric cancer