SOUTH EAST LONDON CANCER NETWORK

Breast Referral Proforma

Please tick the box of the hospital clinic you are referring to, tick the relevant symptoms to indicate the urgency of this referral and fax this form to the relevant Team within 24 hours. Guidelines to help determine urgency are on the reverse side.

King’s College PRUH site


Tel: 01689 866701/65790/65794
Fax: 01689 863 187 /

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 4798
Tel: 020 3299 3962 /

Lewisham

Fax: 020 8333 3451
Tel: 020 8333 3450 /

Queen Mary’s

Fax: 020 8308 9264
Tel: 020 8308 3253

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 circle referral urgency, tick the relevant symptoms / scenarios and mark the diagram.

/

Yes / No I want to make an urgent (2 Week) referral

Suspected malignant lump
Texture change (> 25 yrs)
History of breast cancer
Nipple ulceration / eczema
Recent nipple distortion / Erythema / Skin oedema
Unilateral blood stained or serous nipple discharge
Male, >50 yrs with unilateral subareolar lump
Yes / No I want to make a non-urgent referral

Mobile lump (< 25 yrs )

Breast pain
Other (please specify) /

Male, <50 yrs with breast symptoms

Medical & family history, including previous breast investigations / Additional information

- continue on a separate sheet if required.

Please attach patient computer record summary if available.

SOUTH EAST LONDON CANCER NETWORK

Information to support Breast referrals

Refer urgently patients:

·  Any age with a suspected malignant lump.
·  Aged 25+ with a change in texture of the breast perceived by the woman.
·  With a history of breast cancer who presents with a further lump or suspicious symptoms.
·  With unilateral eczematous nipple change that does not respond to topical treatment.
·  With nipple distortion of recent onset (not retractile nipple).
·  With spontaneous unilateral blood stained or serous nipple discharge.
·  With unexplained inflammatory changes (erythema and skin oedema).
·  Who are male, aged 50 years and older with a unilateral subareolar mass with or without nipple distortion or associated skin changes.
Ä Use this proforma to refer urgently (2 Week Wait), ticking the relevant box

Refer non-urgently:

·  Women aged less than 25 years with a mobile lump.
·  Patients with breast pain that is troublesome but with no palpable abnormality, when initial treatment in primary care fails.
Ä Use Choose & Book or this proforma (ticking the relevant box) to refer non-urgently

Refer to family history clinic:

Women with no breast symptoms/signs who have a significant maternal or paternal family history of breast/ovarian cancer:
·  One 1st degree relative diagnosed before age 40
·  Two relatives (one 1st degree and one 2nd degree, or two 1st degree) diagnosed before an average age of 60
·  Three or more relatives (one must be 1st degree) diagnosed with breast cancer
·  Families with both breast and ovarian cancer, or male breast cancer, should also be referred.
Ä In Lambeth, Southwark and Lewisham phone “Cancer – a family affair?” on 020 7188 1385
Ä In Bromley refer patients by letter to the Breast CNS at Princess Royal University Hospital
Ä In Greenwich refer patients by letter to the Breast CNS at Queen Elizabeth Hospital
Ä In Bexley refer patients by letter to the Breast CNS at Queen Mary’s Sidcup

Investigations in Primary Care:

·  In patients presenting with symptoms and / or signs requiring hospital referral, investigation prior to referral is not recommended.
·  In particular it is not normally recommended to insert a needle into the breast, or to start treatment such as Tamoxifen.

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. Resources for GPs to use are available from the Cancer Network on 020 7188 7090, or visit our website www.selcn.nhs.uk.

Approved by the South East London Cancer Network in July 2012

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