SUSPECTED CANCER REFERRAL FORM: GYNAECOLOGY

(including ovarian, endometrial, cervical, vulval and vaginal)

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.
Cancer type suspected
Ovary Cervix Endometrium Vulva Vagina
Menopausal status
Pre-menopause Post-menopause Hysterectomy
HRT
Yes No
Criteria for an appointment with a specialist within two weeks
Ovarian cancer
(the Further Information & Guidance section advises when to request a CA-125)
Physical examination identifies ascites &/or a pelvic or abdominal mass, which is not obviously uterine fibroids
Ultrasound suggests ovarian cancer
Raised CA125 and USS suggestive of ovarian cancer
(Please attach all findings and results)
Endometrial cancer
Post-menopausal bleeding
USS indicates possible endometrial cancer (any age) (Please attach report)
Refer to NICE guidance below for indications for direct access to USS investigation (PV discharge, visible haematuria etc.)
Cervical
Consider if cervix appears on examination to be consistent with cervical cancer
Vulval
Consider if unexplained vulval lump, ulceration or bleeding
Vaginal
Consider if unexplained palpable mass in or at the entrance to the vagina
Arrange direct access USS for any of the following:
(Note - please also consider urological causes for patient with haematuria)
  • Any age
/ With CA125 ≥35iu/ml
  • ≥55yr
/ With unexplained PV discharge and any of: /
  • First presentation with these symptoms
  • Thrombocytosis
  • Haemauturia

With visible haematuria and any of: /
  • Low Hb
  • Thrombocytosis
  • High blood glucose

Investigations
Please ensure the following recent results are available:
Blood test (less than 8 weeks old):
eGFR result ______Date ______Or date of test ______
CA125 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 includerecent 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
Site-specific information and advice for primary care:
Cervix:
  • Refer any abnormal looking cervix
  • Examine women with abnormal bleeding i.e. post coital bleeding, intermenstrual bleeding,post menopausal bleeding or blood stained discharge to exclude cervical pathology.
  • If recent change in hormonal therapy, e.g. HRT or contraception, refer if bleeding persists after three months or consider stopping hormonal treatment and observing if examination normal.
A smear test is not required before referral, and a previous negative result should not delay referral.
Endometrium:
  • Consider risk factors for endometrial cancer- obesity, tamoxifen, HRT- unnapposed oestrogens.
  • Arrange direct access USS for post menopausal bleeding and refer if endometrial thickness 5 mm or if bleeding recurs.
  • If recent change or initiation of HRT, refer if bleeding persists after three months or consider stopping hormonal treatment and observing if examination normal.
Ovary:
Step One
Arrange an URGENT (within 2 weeks) CA125 and/or ultrasound tests (esp. if ≥ 50yr) if any of the following symptoms are present persistently or frequently
  • Persistent abdominal distention (bloating)

  • Increase urinary urgency &/ or frequency

  • New onset symptoms suggestive of IBS

  • Early satiety &/or loss of appetite

  • Pelvic or abdominal pain

Consider CA125 and/or ultrasound tests at any age if any of the following:
  • Unexplained weight loss

  • Changes in bowel habits

  • Fatigue

Step Two
CA125 / ≥35iu/ml / Arrange USS / Abnormal / Refer 2WW
Normal / Reassess
<35iu/ml / Reassess / Investigate further
Safety Net

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

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