Suspected Penile Cancer Referral Form

Suspected Penile Cancer Referral Form

Referrer Details / Patient Details
Name and Position: / Name:
«PATIENT_Forename1»«PATIENT_Surname» / DOB:«PATIENT_Date_of_Birth»
Address:
«PRACTICE_Name»
«PRACTICE_BlockAddress» / Address:
«PATIENT_BlockAddress» / Gender: «PATIENT_Sex»
Hospital No:
NHS No: «PATIENT_Current_NHS_Number»
Tel No:
«PRACTICE_Main_Comm_No» / Telephone Number: «PATIENT_Main_Comm_No» / «PATIENT_Mobile_No»
Number Confirmed
Practice Safe Haven Email:
Practice.email / Has a carer: Yes No / Capacity concerns? (e.g. has dementia/ learning disability)
Decision to Refer Date:
«SYSTEM_Date» / Translator Required: Yes No Language: Lang_spoke / Mobility:
Clinical details
Please detail your conclusions and what needs excluding or attach referral letter.
penile mass or ulcerated lesion, where a sexually transmitted infection has been excluded as a cause (consider)
This includes progressive ulceration or a mass particularly in the glans penis or prepuce, but can involve the skin of the penile shaft. Lumps within the corpora cavernosa not involving the penile skin are usually not cancer but indicate benign Peyronie’s disease, which does not require urgent or fast track referral.
a persistent penile lesion after treatment for a sexually transmitted infection has been completed (consider)
unexplained or persistent symptoms affecting the foreskin or glans (consider).
This does not include simple phimosis, fungal infections and balanitis.
Smoking status:
Smoking#b / WHO Performance Status:
0 -Fully active
1 -Able to carry out light work
2 -Up & about >50% of waking time
3 -Limited to self-care, confined to bed/chair >50%
4 -No self-care, confined to bed/chair 100%
BMI if available:
Weight#fa
Please attach additional clinical issues list from your practice system. Details to include:Current Medication, co-morbidities, significant psychosocial issues, allergies, relevant family history & alcohol status.Please see below.

Medication

active.(t)#fbolh[Repeat Medication]

RxAcute.(3mt)#adif

Problems

Problems.(t)#ab[Known Problems]

Medical History

Priority12.(t)#ab[Significant Medical History P1 and P2]

Allergies

allergy.(t)#aiefg[Known Allergies]

Family History

family_his.(all)(124)

Alcohol Status

Alcohol.(3)#acd

Other

Checklist
The two week wait pathway is a pressured Gloucestershire resource - please continue to help us ensure our patients are seen and investigated in a timely manner. This helps to minimise any anxiety for patients during this uncertain time, to pick up a cancer diagnosis and start treatment earlier, all which improve patient outcomes and experience.
I have informed the patient that their symptoms mean we need to exclude cancer
I have given the patient the 2ww cancer referral information leaflet
I have decided not to inform the patient / give the leaflet (e.g. lack of mental capacity)
If the patient is then unable to attend the 2ww appointment in the next 2 weeks, please delay the referral to a time when they can attend. This allows other patients to be prioritised.
Trust Specific Details
For hospital to completeUBRN:
Received date:

[Suspected Penile Cancer] TWW / Feb 2018 / Cancer CPG / Version 1.0 / Review date Feb 2019Page 1 of 2