Mid Yorkshire Hospitals Trust Suspected Lower GI 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:

Patient Details

Name / Male / Female
Address
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: ______

______

Referral Information (please tick appropriate boxes). Please indicate under which group of symptoms you are referring your patient:

Colorectal Cancer

Aged 40 and over with unexplained weight loss and

abdominal pain

Aged 50 and over with unexplained rectal bleeding
Aged 60 and over with:
-  Iron-deficiency anaemia
-  Changes in their bowel habit
Tests show occult blood in their faeces
Of any age:
Rectal or abdominal mass
Aged under 50:
Rectal bleeding and any of the following unexplained symptoms or findings:
-  Abdominal pain
-  Change in bowel habit
-  Weight loss
-  Iron-deficiency anaemia / Offer testing for occult blood in faeces to assess for colorectal cancer in adults without rectal bleeding who (please see instructions below):
Are aged 50 and over with unexplained:
-  Abdominal pain
-  Weight loss
Are aged under 60 with:
-  Changes in their bowel habit
-  Iron-deficiency anaemia
Are aged 60 and over and have anaemia even in the
absence of iron-deficiency
PLEASE NOTE: Currently Mid Yorkshire Hospitals Trust does not provide FOB testing. You may consider a Fast Track Referral after appropriate clinical assessment.
Anal Cancer
Of any age:
Unexplained anal mass or unexplained anal ulceration

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 Signature: Date:

REFERRAL GUIDELINES FOR SUSPECTED LOWER GI CANCER

In a patient with equivocal symptoms who is not unduly anxious, it is reasonable to ‘treat, watch and wait’.

Urgent Referral: Refer urgently patients:

Colorectal Cancer

Aged 40 and over with unexplained weight loss and abdominal pain

Aged 50 and over with unexplained rectal bleeding

Aged 60 and over with:

-  Iron-deficiency anaemia

-  Changes in their bowel habit

Tests show occult blood in their faeces

Of any age:

Rectal or abdominal mass

Aged under 50:

Rectal bleeding and any of the following unexplained symptoms or findings:

-  Abdominal pain

-  Change in bowel habit

-  Weight loss

-  Iron-deficiency anaemia

Offer testing for occult blood in faeces to assess for colorectal cancer in adults without rectal bleeding who:

Are aged 50 and over with unexplained:

-  Abdominal pain

-  Weight loss

Are aged under 60 with:

-  Changes in their bowel habit

-  Iron-deficiency anaemia

Are aged 60 and over and have anaemia even in the absence of iron-deficiency

PLEASE NOTE: Currently Mid Yorkshire Hospitals Trust does not provide FOB testing – you may consider using a Fast Track Referral

Anal Cancer

Of any age:

Unexplained anal mass or unexplained anal ulceration

Risk Factors:

Offer patients with ulcerative colitis or a history of ulcerative colitis a follow-up plan agreed with a specialist in an effort to detect colorectal cancer in this high-risk group.

There is insufficient evidence to suggest that a positive family history of colorectal cancer can be used to assist in the decision about referral of a symptomatic patient.

Investigations:

·  Always carry out a digital rectal examination in patients with unexplained symptoms relating to the lower gastrointestinal tract.

·  Where symptoms are equivocal a full body count may help in identifying the possibility of colorectal cancer by demonstrating iron deficiency anaemia, which should then determine if a referral should be made and its urgency.

·  When referring, a full blood count may assist specialist assessment in the outpatient clinic.

·  When referring, no examinations or investigations other than abdominal and rectal examination and full blood count are recommended as this may delay referral.

·  Consider testing for occult blood in faeces to assess in adults without rectal bleeding who:

-  Aged >50 yrs with unexplained, abdominal pain or weight loss, or

-  Aged <60 with changes in bowel habit or iron-deficiency anaemia**, or

-  Aged >60 yrs and have anaemia even in absence of iron deficiency

** Level of iron-deficiency anaemia is not stated in NICE guidance

*Creutzfeldt-Jakob Disease:

The CJD/CJDv risk assessment form should be completed for all patients undergoing endoscopy procedures and the outcome documented on the fast track referral form.

LOWER GI May 2016 FINAL VERSION PF4037a