Mid Yorkshire Hospitals Trust Suspected Head & Neck Cancer Referral Form
Only refer when patient is available to attend an appointment within the next 14 days
GENERATE a Choose & Book request, insert the Unique Booking Request Number (UBRN) in the space below
OR FAX this form within 24 HOURS to the Fast Track Office on 01924 542746
Telephone enquiries 01924 212507
GP Practice: / Tel:GP Name: / Fax:
Dental Practice: / Tel:
Dental Practitioner: / Fax:
Patient Details
Name / Male / FemaleAddress
Postcode / D O B
Age
Tel:
Mobile
Has patient previously visited this hospital / Yes / Interpreter required? / Yes
Hospital No: (if known) / First Language
NHS No:
Current Medication: (Please ensure a full summary is provided):______
______
Referral Information (please tick appropriate boxes):Symptoms:
Age ≥45 with persistent unexplained hoarseness
Age ≥45 with a persistent unexplained lump in neck / Cancer area suspected:
Mouth
Signs: / How long present? / Larynx
Pain / Hoarseness / ______/ Pharynx
Enlarging mass / Site ______/ Ear
Red patch / Dysphagia / ______/ Salivary
White patch / Dysarthria / ______/ Nose/Post nasal space
Change in pre-existing lesion / Otalgia / ______/ Other ______
Salivary gland mass / Bleeding / ______/ I AM REFERRING THIS PATIENT TO:
Thyroid lump / Risk Factors: / Oral Oncology Clinic
Orbital mass / Smoker/Ex-smoker / ENT Clinic
Any age – unexplained
ulceration in the oral cavity
Lasting > 3 wks / Excess alcohol / Neck lump clinic
Thyroid clinic
*Cervical adenopathy with a significant lymphocytosis should be directed to Haematology via referral form PF4035a (suspected haematology cancer referral form)
Comments/medical history/other reasons for urgent referral (please use Continuation Form if necessary)
Information given to patients 1. Is the patient aware of this cancer referral and been given a leaflet?
Links to Pt Leaflet: - https://www.midyorks.nhs.uk/cancer-information-and-resources
- http://nww.northkirkleesccg.nhs.uk/for-practices/clinical-guidelines-pathways/
2. Is the patient available within the next 14 days?
3. Has the patient given consent for their information to be accessed by
Healthcare professionals involved in their care?
GP/Dental Practitioner Signature: Date:
REFERRAL GUIDELINES FOR SUSPECTED HEAD AND NECK CANCER INCLUDING THYROID CANCER
Refer a patient who presents with symptoms suggestive of head and neck cancer including thyroid cancer as detailed in the NICE guidance below.
Urgent Referral:
Refer urgently patients with:
· An unexplained lump in the neck, of recent onset, or a previously undiagnosed lump that has changed over a period of 3 to 6 weeks
· An unexplained persistent swelling in the parotid or submandibular gland
· An unexplained persistent sore or painful throat
· Unilateral unexplained pain in the head and neck area for more than 4 weeks, associated with otalgia (ear ache) but a normal otoscopy
· Unexplained ulceration of the oral mucosa or mass persisting for more than 3 weeks
· Unexplained red and white patches (including suspected lichen planus) of the oral mucosa that are painful or swollen or bleeding
For patients with persistent symptoms or signs related to the oral cavity in whom a definitive diagnosis of a benign lesion cannot be made, refer or follow up until the symptoms and signs disappear. If the symptoms and signs have not disappeared after 6 weeks, make an urgent referral.
If no Community Dental service is available – consider an urgent for assessment for possible oral cancer by a dentist in people who have either:
· A lump on the lip or in the oral cavity or
· A red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia
If no Community Dental service available refer to Maxillo-facial/Head and neck service if the patient has
· A lump on the lip or in the oral cavity consistent with oral cancer or
· A red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia
· An unexplained thyroid lump ? suspicion of cancer from scan – i.e., scan needs to be done before referral made.
To a Dentist:
Refer urgently to a dental practitioner patients with unexplained tooth mobility persisting for more than 3 weeks.
For a Chest X-Ray:
Refer urgently for chest X-ray patients with hoarseness persisting for more than 3 weeks, particularly smokers aged over 50 years and heavy drinkers.
If there is a positive finding, refer urgently to a team specialising in the management of lung cancer. If there is a negative finding, refer urgently to a team specialising in head and neck cancer.
Non-urgent Referral:
Refer non-urgently a patient with unexplained red and white patches of the oral mucosa that are not painful, swollen or bleeding (including suspected lichen planus).
Investigations:
With the exception of persistent hoarseness, investigations are not recommended as they can delay referral.
THYROID CANCER
Immediate Referral:
Refer immediately patients with symptoms of tracheal compression including stridor due to thyroid swelling.
Urgent Referral:
Refer urgently patients with a thyroid swelling associated with any of the following:
- a solitary nodule increasing in size - a history of neck irradiation
- a family history of endocrine tumour - unexplained hoarseness or voice changes
- cervical lymphadenopathy - very young (pre-pubertal) patient
- patient aged 65 years and older
Investigations:
· Primary care initiation of investigations such as ultrasonography or isotope scanning is not recommended
· Request thyroid function tests in patients with a thyroid swelling without stridor or any of the features listed above. Refer patints with hyper- or hypothyroidism and an associated goiter, non-urgently to an endocrinologist. Patients with goiter and normal thyroid function tests without any of the features listed above should be referred non-urgently.
HEAD & NECK FINAL VERSION May 2016 PF4036