UPPER GI

Suspected Cancer Referral

(2 Week Wait Referral)

Please FAX within 24 hours to Cancer Referrals Office:

Section 1 PATIENT INFORMATION(Please complete in BLOCK CAPITALS)
SURNAME / Date of Referral / /
Date of Birth / /
FIRST NAME / NHS number
UBRN - -
Miss Mrs Ms Mr / Home Tel. / Mobile/Daytime Tel.
Address
Post Code / Transport Y N / Interpreter Y N
Language
Has the patient consented to be contacted forthe appointment? Y N
Section 2 PRACTICE INFORMATION (Please use practice stamp if available)
Referring GP / Locum Y N
Practice Address
Post Code / Telephone

Fax

Section 3 CLINICAL INFORMATION (please TICK all applicable entries)
Gastroscopy ~ symptoms for urgent referral
With or withoutdyspepsia and:Dyspepsia and:
[ ] Dysphagia[ ] Chronic gastrointestinal bleeding
[ ] Epigastric mass[ ] Iron deficiency anaemia
[ ] Persistent vomitingand weight loss[ ] Suspicious barium meal result/CT/USS
[ ] Progressive unintentional weight loss[ ] Aged > 55 yrs with unexplained persistent,recent onset*
Consider in worsening dyspepsia and: * Recent onset means NEW and not a recurrence of previous dyspepsia
[ ] Barrett’s oesophagusPersistent defined as longer than expected(usually6 weeks)
[ ] Peptic ulcer surgery > 20 yearsUnexplained after history/GP investigations
[ ] Known dysplasia, atrophic gastritis,
intestinal metaplasia
OUT-PATIENTS~ symptoms for urgent Upper GI referral
[ ] Jaundice (urgent USS if possible)[ ] Upper abdominal mass
PLEASE ENCLOSE PRINTOUTS OF CURRENT MEDICATIONS and PAST MEDICAL HISTORY
Significant Medical History, Known Allergies
DIABETIC: YES/NO / All Medication
WARFARIN: YES / NO / Investigations
FBC: YES/NO Date: ___/___
Hb:
  • Discussed urgent suspected cancer referral with patient?YN
  • Have you told the patient that they will have agastroscopy? YN

Comments/other reasons for urgent referral
Hospital use only: (Tick where appropriate)
Date Appointment Booked:
/ Date of Referral receipt: / /
Target Dates 2ww / / Database:  Patient confirmed: 
62/7 / /

LOCAL CONTACT DETAILS

CRITERIA1 FOR URGENT SUSPECTED CANCER REFERRAL

Please FAX the referral form within 24 hours

Refer a patient who presents with symptoms suggestive of upper GI cancer to a team specialising in the management of upper GI cancer, depending on local arrangements.

Helicobacter pyloristatus should not affect the decision to refer for suspected cancer.

Note that for patients 55 years, referral for endoscopy is not necessary in the absence of alarm symptoms. Patients being referred urgently for endoscopy should ideally be free from acid suppression medication, including proton pump inhibitors or H2 receptor agonists, for a minimum of 2 weeks.

Investigations
  • When referring, a full blood count may assist specialist assessment in the outpatient clinic. This should be carried out in accordance with local arrangements
  • For all patients with new-onset dyspepsia, consider a full blood count to detect iron deficiency anaemia.

1 Based on Referral Guidelines for Suspected Cancer (NICE, 2005)Notes in grey refer to the evidence grading

used in the NICE guidelines, for more information see

2 “unexplained” is defined as ‘a symptom(s) and/or sign(s) that has not led to a diagnosis being made by the

primary care professional after initial assessment of the history, examination and primary care investigations (if

any)’. In the context of this recommendation, the primary care professional should confirm that the dyspepsia is

new rather than a recurrent episode and exclude common precipitants of dyspepsia such as ingestion of NSAIDs.