Suspected Cancer Referral Form: Brain and Cns

SUSPECTED CANCER REFERRAL FORM: BRAIN AND CNS

Date of decision
to refer: / Date referral received at Trust:
Trust name(s) / Email for referral
Ashford and St. Peter’s NHS Foundation Trust / Fax: 0800 9234668
Email:
Frimley Health NHS Foundation Trust / Fax: 01276 604506
Royal Surrey County Hospital NHS Foundation Trust / Fax: 01483 464848
Email:
Surrey and Sussex Healthcare NHS Trust / Fax: 01737 231733
Patient details
SURNAME: / FIRST NAME: / TITLE:
GENDER: / DOB: / NHS NUMBER:
ETHNICITY: / LANGUAGE:
INTERPRETER REQUIRED: / TRANSPORT REQUIRED:
PATIENT ADDRESS: / POSTCODE:
CONTACT DETAILS: HOME: / MOBILE: / EMAIL:
GP practice details
USUAL GP NAME:
PRACTICE NAME:
PRACTICE ADDRESS: / PRACTICE CODE:
DIRECT LINE TO THE PRACTICE (BYPASS):
MAIN: / FAX: / EMAIL:
Referring clinician:
Patient engagement and availability
I confirm the following:
I have discussed the possibility that the diagnosis may be cancer
I have provided the patient with a suspected cancer referral leaflet
I have informed the patient that the appointment will be within the next two weeks & attendance is advised
Please note any dates the patient is NOT available for an appointment in the next 2 weeks.
Patient’s WHO performance status
Grade / Explanation of activity
0 / Fully active, able to carry on all pre-disease performance without restriction.
1 / Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work.
2 / Ambulatory and capable of all selfcare but unable to carry out any work activities. Up and about more than 50% of waking hours.
3 / Capable of only limited selfcare, confined to bed or chair more than 50% of waking hours.
4 / Completely disabled. Cannot carry on any selfcare. Totally confined to bed or chair.
REFERRAL FOR DIRECT ACCESS INVESTIGATIONS, WHERE AVAILABLE
GPs should arrange urgent brain MRI (or brain CT if MRI is contraindicated), to be performed within 2 weeks, for patients presenting with symptoms which raise suspicion of brain cancer.
See Suspected Cancer Referral Guide – Brain & CNS for symptoms and referral pathway
REASON FOR SUSPECTED CANCER REFERRAL
Abnormal brain MRI/CT scan suggestive of cancer
Progressive, sub-acute loss of central neurological function
See Suspected Cancer Referral Guide – Brain & CNS for symptoms
Referral is due to CLINICAL CONCERNS that do not meet referral criteria.
(The GP MUST give full clinical details in the ‘additional clinical information’ box at time of referral)
Referral is due to GP not having direct access to urgent Brain MRI/CT and patient is presenting with symptoms which raise suspicion of brain cancer
(The GP MUST give full clinical details in the ‘additional clinical information’ box at time of referral)
Investigations
Please ensure the following recent results are available:
Blood test (less than 8 weeks old):
eGFR result ______Date ______Or date of test ______
Additional imaging studies (in past 3 months):
Imaging studies result ______Date ______Or date of test ______
Free text box for additional clinical information/referral letter:
If this case has been discussed with the secondary care clinical team, please specify with whom, when and advice given:
Please use this area to autopopulate a patient summary: to include recent consultations, current diagnoses; past medical history; recent investigations; recent blood test results; medication; any other fields which might be helpful to secondary care.
Further information and guidance
Useful websites:
CRUK main / CRUK learning / e-CDS
Macmillan / Macmillan learning / Genetics and Family History
Map of Medicine / NICE / Q-Cancer
Useful resources:
1. NICE: Suspected cancer: recognition and referral, NG12 (2015) http://www.nice.org.uk/guidance/ng12
2. HeadSmart – Be Brain Tumour Aware http://www.headsmart.org.uk/home/
3. Royal College of Radiologists – iRefer: Appropriate use of CT/MRI in headache http://nww.irefer.nhs.uk/adult/#Tpc180
Site-specific information and advice for primary care:
· Approximately 10% of patients may be unsuitable for, or unable to tolerate an MRI brain scan, e.g. patients with pacemakers in-situ or those with severe claustrophobia. In these patients a CT scan may be more appropriate, taking potential radiation exposure in to consideration.
· A ‘normal’ scan
A normal investigation does not preclude the need for ongoing follow up, monitoring and further investigation. Furthermore, a seemingly ‘normal’ MRI scan may provide false reassurance in patients who have neurological pathology that MRI scanning is unable to detect.
· Incidental findings
A small percentage of MRI scans may yield abnormalities in otherwise healthy individuals. This may impact on these patients in a number of ways including further investigation and the potential impact on health insurance premiums.
As incidental findings are not an infrequent result of MRI scanning, patients should have prior counselling and information to make them aware of the potential for such findings as a consequence of their investigation.
· No definition of ‘progressive sub-acute loss of central neurological function’ has been provided for this update, but the 2005 NICE guidance for suspected cancer includes signs or symptoms that may cause concern, including: progressive neurological deficit, new-onset seizures, headaches, mental changes, cranial nerve palsy.
· Headaches of recent onset accompanied by features suggestive of raised intracranial pressure, e.g. vomiting, drowsiness, posture-related headache, pulse-synchronous tinnitus, or other focal or non-focal neurological symptoms, such as blackout or change in personality or memory.
· Consider urgent referral in patients with rapid progression of: sub-acute focal neurological deficit; unexplained cognitive impairment, behavioural disturbance or slowness, or a combination of these; personality changes confirmed by a witness and for which there is no reasonable explanation even in the absence of the other symptoms or signs of a brain tumour.

Final agreed by CCGs across St Luke’s Cancer Alliance March 2017