SUSPECTED CANCER REFERRAL FORM: LOWER GI

(Including colorectal and anal)

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.
COLORECTAL CANCER
Criteria for an appointment with a specialist within two weeks
Guidance: Always consider the possibility of an ovarian cancer in women over 50 where there is a change in bowel habit (perform VE, request CA125 etc. as per the agreed pathway which reflects NICE guidelines)
Abnormal lower GI investigations (colonoscopy/flexible sigmoidoscopy) suggestive of cancer (please give full clinical details in the ‘additional clinical information’ box below)
Any age with suspicious abdominal or rectal mass
Any age with unexplained anal mass or ulceration
≥ 40 years with unexplained abdominal pain and weight loss
≥ 40 years with unexplained iron deficiency anaemia
≤ 50 years with rectal bleeding with any of the following unexplained symptoms:
Abdominal pain
Change in bowel habit
Weight loss
Iron deficiency anaemia (please attach results)
≥ 50 years with unexplained rectal bleeding
≥ 50 years with unexplained abdominal pain or weight loss
≥ 50 years with unexplained change in bowel habit
≥ 60 years with unexplained anaemia even in the absence of iron deficiency (please attach results)
Investigations
Please ensure the following recent results are available:
Blood test (less than 8 weeks old):
eGFR Result______Date ______Or date of test ______
Hb Result______Date ______Or date of test ______
MCV Result______Date ______Or date of test ______
Ferritin Result______Date ______Or date of test ______
Date of last colonoscopy ______
Date of last OGD ______
Information required to assess fitness for further investigations
Is that patient fit for bowel prep at home? YES NO
Is the patient fit for day case sigmoidoscopy? YES NO
Is the patient taking iron? YES NO
Is the patient anticoagulated? YES NO
(please ensure this is specified in the medication list)
Is the patient diabetic? YES NO
Is the patient on hypertensive medication? YES NO
Please ensure that any recent blood tests are included.
Frailty Assessment Score:
0 / Very Fit – robust, fully active, energetic and motivated and exercise regularly.
1 / Well –no active disease symptoms but are less fit than category 0 occasionally exercise (Able to carry out light work)
2 / Managing Well –medical problems are well controlled, but are not regularly active beyond routine walking. (Up & about 80% of waking time)
3 / Vulnerable – While not dependent on others for daily help, symptoms limit activities (tired during the day).
4 / Mildly Frail –often have more evident slowing, and need help in high order IADLs (progressively impairs light work).
5 / Moderately Frail –need help with all outside and household activities including self-care.
6 / Severely Frail – Completely dependent for personal care, (physical or cognitive), but stable and not at high risk of dying within 6 months. (Confined to bed/chair 50%)
7 / Very Severely Frail – Completely dependent, approaching the end of life. Typically, they could not recover even from a minor illness. (No self-care, confined to bed/chair 100%)
8 / Terminally Ill - Approaching the end of life. This category applies to people with a life expectancy <6 months, who are not otherwise evidently frail.
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:
  1.  Note: As FOBts are not currently available in our area and you are concerned about your patient but they do not appear to ‘fit’ the referral criteria, please contact your local specialist for further advice
  1. Remember to use the following to decide which patients to refer urgently:
  • Abdominal pain is now an important symptom
  • The threshold for an iron deficiency anaemia has been removed
  • Any change in bowel habit is relevant

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

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