Suspected Urology Cancer Referral Form

GP or GDP Details / Patient Details
Name: / Name:
Address: / Address:
Tel No.: / Tel No. (home): / Please check tel. nos
Email: / Tel No. (work):
Decision to Refer Date: / Tel No. (mobile):
NHS No.: / DoB:
Hospital No.: / Gender:
Translator Required:
Language: / Mobility:
Please confirm that the patient is aware that this is a suspected cancer referral: - Yes No
Date(s) that patient is unable to attend within the next two weeks:
If patient is not available for the next 2 weeks, and aware of nature of referral, please only refer when able and willing to accept an appointment.
The above details are required before we can begin booking appointments
GPs maydecide not to refer patientsmeeting these criteria viathis pathway.If referring via another pathway,please state the reason for this decision in the urgent/routine referral.

Referral criteria

Prostate cancer (Please complete PSA for all referrals)
Prostate feels malignant on digital rectal examination.
PSA level are above the age-specific reference range, after exclusion of UTI. / Age Specific Reference ranges
40-49yrs / ≥ 2.5 ug/ml / 60-69yrs / ≥ 4 ug/ml
50-59yrs / ≥ 3 ug/ml / 70 or over / ≥ 5 ug/ml
Bladder and Renal cancer (Please ensure EGFR testing has been performed within the last 6 weeks)
Aged 45 and over and have:
unexplained visible haematuria without urinary tract infection or
visible haematuria that persists or recurs after successful treatment of urinary tract infection, or
Aged 60 and over and have unexplained non-visible haematuria, persistent for > 2 weeks, and either dysuria or a raised white cell count on a blood test
Imaging suspicious of renal cancer
Imaging suspicious of bladder cancer
Testicular cancer
Non-painful enlargement or change in shape or texture of the testis.
Imaging suspicious of testicular cancer
Penile cancer
Penile mass or ulcerated lesion,
Unexplained or persistent symptoms affecting the foreskin or glans such as unusual foul smelling discharge, bleeding, phimosis or swollen lymph nodes in groin area.
Clinical History:
Clinical Examination:

Please attach additional clinical details to include:

Significant medical history
Co-morbidities
Current medication
Any other relevant information inc allergies

Attachments: Letter Medication List Other

Additional Information:
All Isle of Scilly patients may be given a telephone assessment prior to any attendances for diagnostics.
Macmillan rapid referral guidelines:
http://www.macmillan.org.uk/Documents/AboutUs/Health_professionals/PCCL/Rapidreferralguidelines.pdf
Suspected cancer: recognition and referral June 2015 NICE guidance: http://www.nice.org.uk/guidance/ng12
Clinic Pathways
Prostate, testicular and penile cancer referrals are booked for outpatient clinic review with a Consultant Urologist.
Bladder and renal cancer referrals are booked into the one-stop haematuria clinic where an ultrasound and cystoscopy will be performed.