SUSPECTED CANCER REFERRAL FORM: HAEMATOLOGY

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.
IMMEDIATE referral (via A&E)
All ages blood film shows:
Acute leukaemia
Severe pancytopaenia
Chronic Leukaemia with blood film suggesting immediate referral
≤25 years only
Unexplained petechiae (leukaemia)
Hepatosplenomegaly (leukaemia)
Unexplained lymphadenopathy or splenomegaly (lymphoma)
Consider associated symptoms e.g. fever, night sweats, shortness of breath, pruritus, weight loss
URGENT ADMISSION (via A&E or to Acute Oncology)
All ages
Symptoms of metastatic spinal cord compression (MSCC)
For advice please contact Clinical Oncology Registrar On-Call via Royal Surrey switchboard 01483 571122 bleep 71-4490
SUSPECTED MYELOMA
Criteria for an appointment with a specialist within two weeks
Results of protein electrophoresis or a urine Bence-Jones protein suggest myeloma
Consider that an abnormal FBC, hypercalcaemia or acute kidney injury may need an immediate referral
Asymptomatic low level paraproteins compatible with MGUS should be monitored and referral may not be required.
SUSPECTED HODGKIN’S and NON-HODGKIN’S LYMPHOMA (Adults only)
For younger patients, please refer to the ‘Suspected Cancer Referral form’ for Children & Young people
Criteria for an appointment with a specialist within two weeks
Unexplained lymphadenopathy or splenomegaly (consider)
- Consider also any associated symptoms e.g. fever, night sweats, shortness of breath, pruritus, weight loss or alcohol induced lymph node pain
- Direct TWR referral to appropriate surgical team for excisional biopsy of a lymph node is recommended as the preferred way of diagnosing lymphoma, e.g. refer patients with suspicious neck lymphadenopathy using Head and Neck TWR referral form
- The anatomical position of the lymph node may suggest primary spread and therefore referral to different clinical team for excisional biopsy
Investigations
Please ensure the following recent results are available:
Blood test (less than 8 weeks old):
Lymphoma
FBC result ______Date ______Or date of test ______
If also requested:
ESR result ______Date ______Or date of test ______
LFT result ______Date ______Or date of test ______
U&E result ______Date ______Or date of test ______
Bone result ______Date ______Or date of test ______
LDH result ______Date ______Or date of test ______
IGs result ______Date ______Or date of test ______
Myeloma
FBC result ______Date ______Or date of test ______
eGFR result ______Date ______Or date of test ______
U&E result ______Date ______Or date of test ______
Bone profile result ______Date ______Or date of test ______
Serum protein electrophoresis result ______Date ______Or date of test ______
BJP result ______Date ______Or date of test ______
If also requested:
IGs result ______Date ______Or date of test ______
ESR 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
Site-specific information and advice for primary care:
Suspected Leukaemia
Offer a very urgent (within 48 hours) FBC for patients with the following unexplained signs/ symptoms:
Signs/ symptoms / Adults aged >25 years / Children and young people
Pallor / ü / ü
Persistent fatigue / ü / ü
Unexplained fever / ü / ü
Unexplained persistent or recurrent infection / ü / ü
Generalized lymphadenopathy / ü / ü
Unexplained bruising / ü / ü
Unexplained bleeding / ü / ü
Unexplained petechiae / ü
Hepatosplenomegaly / ü
Persistent or unexplained bone pain / ü
Suspected Myeloma
Offer a very urgent (within 48 hours) protein electrophoresis & a BenceJones protein urine test, a FBC, urea and electrolytes, calcium and ESR to:
·  Patients aged 60 or over with a presentation consistent with possible myeloma and
o  Hypercalcaemia or
o  Leukopenia
o  New renal impairment
·  Patients with a presentation consistent with possible myeloma and/or ESR at levels consistent with myeloma
Offer urgently (within 2 weeks) protein electrophoresis & a BenceJones protein urine test, a FBC, urea and electrolytes, calcium and ESR to patients aged 60 or over with:
·  Persistent bone pain (particularly back pain) or
·  Unexplained fracture
Refer adults, children and young people with a blood count or blood film reported as acute leukaemia immediately.

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

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