NHS CONFIDENTIAL (OFFICIAL – SENSITIVE: PERSONAL)

URGENT REFERRAL FOR SUSPECTED HEAD AND NECK CANCER

INCLUDING THYROID CANCER

INADEQUATELY COMPLETED FORMS AND UNJUSTIFIABLE REQUESTS WILL BE RETURNED TO THE REFERRER

PATIENT DETAILS: / REFERRAL DATE: Short date letter merged
SURNAME: / DOB: / PRACTICE:
Practice code:
REFERRING GP:
FIRST NAME: / AGE:
NHS NUMBER: / GENDER:
ADDRESS:
PHONE:
Home:
Mobile:
Work: / UK RESIDENT? YES☐NO ☐ / CATEGORY: NHS ☐ PP ☐
CONSENT: Patient has given verbal consent for Consultant to access GP records: YES ☐ NO ☐
INTERPRETER REQUIRED?(if yes, state language)YES ☐NO ☐
Has the patient been informed that they are being referred for the suspicion of cancer under the two-week rule, that they will be seen within two weeks and that there will be limited flexibility of clinic appointments due to the short time target? / YES ☐NO ☐
Has the patient been given a 2 week referral information leaflet explaining the risk of cancer? / YES ☐NO ☐
LARYNGEAL CANCER(NICE GUIDANCE) REFERRAL CRITERIA:
Consider referring patients aged 45 and over with:
☐persistent unexplained hoarseness or
☐an unexplained lump in the neck
Local ENT recommendations - please consider urgent referral for the following symptoms:
  • unexplained persistent sore or painful throat
  • persistent dysphagia for more than 3 weeks
  • unexplained unilateral pain in the head and neck area for more than 4 weeks, associated with otalgia but a normal otoscopy
  • hoarseness persisting for more than 3 weeks with a negative chest x-ray, particularly smokers aged older than 50 and heavy drinkers(please tick the appropriate box above for a 2WW referral if high level of suspicion)
  • stridor
  • lump in the neck of recent onset, or a previously undiagnosed lump that has changed over a period of 3 to 6 weeks(please tick the appropriate box above for a 2WW referral if high level of suspicion)
  • unexplained persistent swelling in the parotid or submandibular or clavicular regions
  • unilateral nasal obstruction, particularly when associated with purulent discharge
  • unexplained significant weight loss, with any of the above

Title

DOB: NHS No:Page 1 of 22WW –Head and Neck v3.1June 2016

Sender – GP Practice (Printed 02/11/2018); Receiver –UHMB

NHS CONFIDENTIAL (OFFICIAL – SENSITIVE: PERSONAL)

ORAL CANCER(NICE GUIDANCE) REFERRAL CRITERIA:
Consider referring patientswith:
☐an unexplained ulceration in the oral cavity lasting more than 3 weeks
☐a persistent unexplained lump in the neck
☐a lump on the lip or in the oral cavity consistent with oral cancer
☐a red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia
Local ORAL SURGERY recommendations - please consider urgent referral for the following symptom:
  • unexplained tooth mobility for more than 3 weeks

THYROID CANCER(NICE GUIDANCE) REFERRAL CRITERIA:
Consider referring patients with:
☐an unexplained thyroid lump
If there are any concerns and the patient does not fit the above criteria, please use ‘ENT Advice and Guidance’
FURTHER INFORMATION:
Comments / other clinical information and any additional needs, including investigative results:

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DOB: NHS No:Page 1 of 22WW –Head and Neck v3.1June 2016

Sender – GP Practice (Printed 02/11/2018); Receiver –UHMB

NHS CONFIDENTIAL (OFFICIAL – SENSITIVE: PERSONAL)

Title

DOB: NHS No:Page 1 of 22WW –Head and Neck v3.1June 2016

Sender – GP Practice (Printed 02/11/2018); Receiver –UHMB

NHS CONFIDENTIAL (OFFICIAL – SENSITIVE: PERSONAL)

SEND REQUEST TO: / Email: / Tel:
University Hospitals of Morecambe Bay Trust / / 0845 055 9990

Title

DOB: NHS No:Page 1 of 22WW –Head and Neck v3.1June 2016

Sender – GP Practice (Printed 02/11/2018); Receiver –UHMB

NHS CONFIDENTIAL (OFFICIAL – SENSITIVE: PERSONAL)

DELETE WHERE APPROPRIATE:

Problems

Medication

Allergies

Family History

OTHER RELEVANT INFORMATION:
Latest Alcohol Consumption:
Latest Smoking Status:
Latest BMI:

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DOB: NHS No:Page 1 of 22WW –Head and Neck v3.1June 2016

Sender – GP Practice (Printed 02/11/2018); Receiver –UHMB