SW LONDON CANCER NETWORK Suspected Skin Cancers Referral Form (Melanoma and Squamous Cell Carcinoma) (NICE 2006)

Urgent Referrals Criteria

(Please tick category) / Date of GP decision to refer: / No. of pages faxed:
SK 1 Any lesion suggestive of skin cancer / / GP DETAILS
SK 2 Any lesion confirmed on biopsy to be cancer /
SK 3 Any lesion suspected to be a melanoma / / GP name and initials: / GP Practice Code:
SK 4 Non-healing lesions larger than 1 cm, with induration and present for over 8 weeks / / Address: / Post Code:
Location/Site of lesion(s):
Hospital
NB: Please tick specialty if relevant. The large majority of suspected melanoma or suspected squamous cell cancers should be referred to dermatology for diagnosis. However, those with obvious cancer may be referred directly to plastic surgery for treatment
Telephone No: / Fax. No:
St. George’s /
/ PATIENT DETAILS
Last Name: / First Name:
Kingston / / Address: / Post Code :
Croydon /

St Helier/Sutton /

Daytime Tel or Mobile: / Gender: /
The Royal Marsden
Queen Mary’s /

o Dermatology
o Plastics
Date of Birth: / Age:
Please note
·  PLC = Pigmented lesion clinic
·  Non-cancerous, benign or cosmetic moles/lesions will not be removed
·  Patients may be asked to undress fully for total skin examination
For written/illustrated guidelines please contact your local dermatologist
Interpreter required? / / Language: / Ethnicity:
Hospital No: / NHS No:
COMMENTS/OTHER REASONS FOR URGENT REFERRAL

SOUTH WEST LONDON CANCER NETWORK

How to make urgent referrals for suspected skin cancers

(melanoma and squamous cell carcinoma)

Please FAX/EMAIL this form to the Cancer Office at the relevant hospital, with or without an accompanying letter. Emails MUST be sent from a NHS.net address. Please ensure that the referral reaches the hospital within 24 hours of the GPs decision to refer date.

Guidelines for urgent referral:

1. Melanoma
·  Pigmented lesions on any part of the body which have one or more of the following features:
Growing in size Changing shape
Irregular outline Changing colour
Mixed colour Ulceration
Inflammation
Note: Melanomas are usually 5mm or greater at the time of diagnosis, but a small number of patients with very early melanoma may have lesions of a smaller diameter.
2. Squamous Cell Carcinoma
·  Slowly growing non-healing lesions with significant induration on palpation with documented expansion over a period of 1-2 months.
·  Positive biopsy.
·  Patients who are therapeutically immunosuppressed after organ transplant have a high incidence of skin cancers, especially squamous cell carcinomas which can be unusually aggressive and metastasize. Transplant patients who develop new or growing cutaneous lesions should be referred under the two week rule.
Note: Cancers tend to be larger (>1cm) than actinic keratoses and have a palpable component deep to the skin surface.
NB Patients with Basal Cell Carcinoma should not be referred using this form.

Epsom and St Helier NHS Trust

Epsom General Hospital

Dorking Road, Epsom

Surrey KT18 7EG

FAX: 020 8296 2741
TEL: 020 8296 2742
/

Epsom and St Helier NHS Trust

St Helier Hospital

Wrythe Lane, Carshalton

Surrey SM5 1AA

FAX: 020 8296 2741
TEL: 020 8296 2742

Croydon Health Services NHS Trust

Croydon University Hospital

London Road, Croydon

Surrey CR7 7YE

FAX: 020 8401 3337
TEL: 020 8401 3986
/

St George’s Healthcare NHS Trust

St George’s Hospital

Blackshaw Road, Tooting

London SW17 0QT

FAX: 020 8725 0778
TEL: 020 8725 1111
EMAIL:

Kingston Hospital NHS Trust

Kingston Hospital

Galsworthy Road

Kingston KT2 7QB

FAX: 020 8934 3306TEL: 020 8934 3305 /

Kingston Hospital NHS Trust

Queen Mary’s Hospital
Roehampton Lane
London SW15 5PN
FAX: 020 8812 7937
TEL: 020 8487 6037/6032

Royal Marsden Foundation NHS Trust

Royal Marsden Hospital

Fulham Road

London SW3 6JJ

FAX: 020 8661 3149TEL: 0800 731 2325
EMAIL:
/

Royal Marsden Foundation NHS Trust

Royal Marsden Hospital

Downs Road

Surrey SM2 5PT

FAX: 020 8661 3149TEL: 0800 731 2325
EMAIL: