SOUTH EAST LONDON CANCER NETWORK

Lung Urgent Suspected Cancer Referral

Please tick the box of the hospital clinic you are referring to and fax this form to the relevant Urgent Referral Team within 24 hours. Guidelines are on the reverse side.

King’s College PRUH site


Tel: 01689 866701/65790/65794
Fax: 01689 863187 /

Queen Elizabeth

Fax: 020 8836 4035
Tel: 020 8836 5964/5 /

Guy’s & St Thomas’

Fax: 020 7188 0923
Tel: 020 7188 0902

King’s College

Fax: 020 3299 1515
Tel: 020 3299 1516 /

Lewisham

Fax: 020 8333 3451
Tel: 020 8333 3450 /

Queen Mary’s

Fax: 020 8308 9264
Tel: 020 8308 3230

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

SURNAME
/
Patient visited this hospital before?
/
Y / N
FIRST NAME
/
NHS
Number
/
Hospital
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.

Symptoms

Haemoptysis

None
Once
Persistent / Chest and / or shoulder pain
Dyspnoea
Hoarseness / Weight loss
Amount
Over period / Cough
Changes in underlying chronic respiratory problems

History

/

Clinical Examination

Current / ex-smoker
Asbestos exposure
COPD / Prior cancer diagnosis
Type
Date Diagnosed / Chest signs
Signs of SVCO
Signs of metastases / Finger clubbing
Cervical LNS

Chest X-ray Results

/

Additional Information

Continue on separate sheet, and attach patient

computer record summary if available.

SOUTH EAST LONDON CANCER NETWORK

Information to support Lung referrals

Refer urgently patients with:

  • Persistent haemoptysis in smokers or ex-smokers aged 40 years and older.
  • A chest X-ray suggestive of lung cancer (including pleural effusion and slowly resolving consolidation).
  • A normal chest X-ray where there is a high clinical suspicion of lung cancer.
  • A history of asbestos exposure and recent onset of chest pain, shortness of breath or unexplained systemic symptoms where a chest X-ray indicates pleural effusion, pleural mass or any suspicious lung pathology.
Use this proforma to refer urgently (2 Week Wait)

Refer urgently* for a chest X-ray patients with:

* the report should be returned within 5 working days
  • Haemoptysis.
  • Unexplained or persistent (>3 wks)
  • Chest and/or shoulder pain
  • Dyspnoea
  • Weight loss
  • Chest signs
  • Hoarseness
  • Finger clubbing
  • Cervical or supraclavicular lymphadenopathy
  • Cough
  • Features suggestive of metastasis from a lung cancer (e.g. brain, bone, liver, skin).
  • Underlying COPD with unexplained changes in existing symptoms.
  • Chest pain, breathlessness in a patient known to have asbestos exposure.
Follow local procedures for urgent chest X-rays

Refer immediately (acute admission) patients with:

  • Signs of superior vena caval obstruction (swelling of the face/neck with fixed elevation of jugular venous pressure).
  • Stridor.
Refer to hospital immediately by phone / A&E

Risk factors:

  • All current or ex-smokers.
  • Patients with COPD.
  • 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 (for example, if signs and symptoms have lasted less than 3 weeks).

Patient information and support:

Consider the information and support needs of patients and the people who care for them while they are waiting for the referral appointment.

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

For comments or additional copies contact the Network on Tel 020 7188 7090 / Fax 020 7188 7120, or visit our website: .