SOUTH WEST LONDON CANCER NETWORK: Lung Cancer Referral Form

SOUTH WEST LONDON CANCER NETWORK Generic Referral Form for all Suspected Cancers (NICE 2006)

Please ensure that the referral reaches the hospital within 24 hours of the GP decision to refer

Suspected Cancer Type:
………………..………..………………………………..
How to Make Urgent Referrals / Date of GP decision to refer: / No of pages faxed:
Epsom General Hospital

Dorking Road, Epsom

Surrey KT18 7EG

FAX: 020 8296 2741

TEL: 020 8296 2742
Croydon University Hospital

London Road Croydon

Surrey CR7 7YE

FAX: 020 8401 3337

TEL: 020 8401 3986

Kingston Hospital

Galsworthy Road

Kingston KT2 7QB

FAX: 020 8934 3306TEL: 020 8934 3305

Royal Marsden

Downs Road Sutton Surrey SM2 5PT

FAX: 020 8661 3149
TEL: 0800 731 2325
/ St Helier Hospital

Wrythe Lane, Carshalton

Surrey SM5 1AA

FAX: 020 8296 2741

TEL: 020 8296 2742
St George’s Hospital

Blackshaw Road Tooting

London SW17 0QT

FAX: 020 8725 0778
020 8725 3466 for
breast
TEL: 020 8725 1111
cancerreferraloffice@ stgeorges.nhs.uk
Queen Mary’s Hospital
Roehampton Lane
London SW15 5PN
FAX: 020 8812 7937
TEL: 020 8487 6037/6032

Royal Marsden Hospital

Fulham Road London SW3 6JJ

FAX: 020 8661 3149
TEL: 0800 731 2325
/ GP DETAILS
GP Name Initials:
Address:
Telephone No: / GP Practice Code:
Post Code:
Fax No:
PATIENT DETAILS
Last Name:
Address:
Daytime Tel or Mobile:
Date of Birth:
Interpreter Required? Y / N
Hospital No: / First Name:
Post Code:
Gender: M q F q
Age:
Language: Ethnicity:
NHS No:

COMMENTS/OTHER REASONS FOR URGENT REFERRAL

Urgent Referral Code(s) (see list of criteria attached): …………….

List of Criteria for Urgent Referral for all Suspected Cancers

NB: Please insert the appropriate code in the box provided on the generic referral form

CH Children’s Cancers
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
/ GY Gynaecological 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
GY 7 Post menopausal bleeding in a women taking Tamoxifen
GY 8 Persistent intermenstrual bleeding and a negative pelvic
examination / LG Lung Cancer
LG 1 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 4 Stridor (consider emergency referral).
LGI Lower GI Cancer
LGI 1 Patients aged 40+ with rectal bleeding and a change of
bowel habit (looser stools) for 6 weeks or more
LGI 2 Patients 60+ with rectal bleeding for 6 weeks or more,
without a change in bowel habit and without anal
symptoms
LGI 3 Patients 60+ with a change of bowel habit (looser stools)
for 6 weeks or more without rectal bleeding
LGI 4 Lower abdominal mass consistent with large bowel
involvement
LGI 5 Palpable rectal mass (intraluminal) at any age
LGI 6 Men of any age with unexplained iron deficiency
anaemia, Hb 11.0 g/dl or less
LGI 7 Non menstruating women with unexplained iron
deficiency anaemia, Hb 10.0 g/dl or less
/ SK Skin Cancers
SK 1 Any lesion suggestive of skin cancer
SK 2 Any lesion confirmed on biopsy to be cancer
SK 3 Any lesion suspected to be a melanoma
SK 4 Non healing lesions larger than 1 cm, with
induration and present for over 8 weeks
BN Bone cancer or Sarcoma
Please use specific London and South East England referral form
All bone referrals must be sent to the Royal National Orthopaedic Hospital
All soft tissue referrals must be sent to Royal Marsden or UCLH or the Royal National Orthopaedic Hospital
UGI Upper GI 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
UGI 9 Dysphagia / CNS Brain Tumours
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 Head and Neck Cancer
HN 1 Any patient with persistent symptoms or signs related
of 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 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 / UR Urological Cancer
UR 1 Clinically malignant prostate on rectal examination. PSA
result to be sent with referral
UR 2 Raised or rising age specific PSA with or without lower
urinary tract symptoms
UR 3 Macroscopic haematuria in male or female patients of
any age
UR 4 Microscopic haematuria in male or female patients over
50 years of age
UR 5 Recurrent or persistent UTI and haematuria in male or
female patients over 40 years of age
UR 6 Palpable renal mass or solid renal mass on radiological
imaging
UR 7 swelling or mass in the body of the testis
UR 8 Symptoms or signs of penile cancer / BR ; 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 Spontaneous unilateral bloody nipple discharge
BR 7 Men aged 0ver 50 with a breast mass