SUSPECTED CANCER REFERRAL FORM: SKIN

(including Melanoma, Squamous Cell Carcinoma, and specific Basal Cell Carcinomas)

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
(Maxillo Facial and Plastics) / Fax: 01483 464848​
Email:
Surrey and Sussex Healthcare NHS Trust / Fax: 01737 231733
Community Outpatients (Dermatology Service) / Fax: 01483 431802
Patient details
SURNAME: / FIRST NAME: / TITLE:
GENDER: / DOB: / NHS NUMBER:
ETHNICITY: / LANGUAGE:
INTERPRETER REQUIRED: / TRANSPORT REQUIRED:
PATIENT ADDRESS: / POSTCODE:
CONTACT DETAILS: HOME: / MOBILE: / EMAIL:
Does this patient have Capacity to Consent for Surgical Procedures? Yes No
If No, is there a Medical Power of Attorney in place? Yes No
Medical Power of Attorney (PoA)
Name: Relationship to pt:
Phone number:
Address: / Next of Kin (If no PoA)
Name: Relationship to pt:
Phone number:
Address:
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.
Suspected Skin Cancer Type
Melanoma
Squamous Cell Carcinoma
Attach any relevant histology reports.
Risk factors
Previous melanoma
Red Hair
Solar keratosis
Excessive or prolonged UV exposure
Family history (of melanoma or pancreatic cancer)
Fair skin (doubles the risk of melanoma)
Multi naevi
Please annotate location of lesion(s):
Criteria for an appointment with a specialist within two weeks:
Malignant Melanoma (Excision in primary care should be avoided.)
SITE of lesion: ______SIZE: ______DURATION: ______
MAJOR (scoring 2 points each)
Change in size
Irregular shape
Irregular colour / MINOR (scoring 1 point each)
Largest diameter ≥7mm
Inflammation
Oozing
Change in sensation / SCORE
Suspicious lesion scoring ≥ 3 on the weighted list
or
if you strongly suspect cancer, any 1 feature
= suspected cancer referral
Consider urgent referral of pigmented or non-pigmented lesion suggestive of nodular melanoma
Dermatoscopy findings suggestive of malignant melanoma. Please describe findings:
Squamous Cell Carcinoma (Excision in primary care should be avoided.)
SITE of lesion: ______SIZE: ______DURATION: ______
Consider urgent referral if lesion is suspicious of a SCC or SCC is possible.
Please indicate if:
Immunosuppression
Non-healing, ulcerated, keratinised or crusted
Lesion at site of trauma and/or sun exposed site
Documented expansion/rapid growth
Significant induration
Basal Cell Carcinoma
SITE of lesion:______SIZE: ______DURATION: ______
ONLY refer BCC urgently using this form if there is concern that delay in assessment may significantly affect the outcome with respect to lesion site e.g eyelids, auditory canal, lip.
(GPs should only excise suspected BCCs in accordance with NICE guidelines on improving outcomes for people with skin tumours.)
Consider referring suspected BCC ONLY for:
Lesions that are suspicious of a BCC and are in an anatomically difficult position e.g. eyelids, auditory canal, lip.
Lesions that are suspicious of a BCC where rapid changes may lead to an unfavourable impact requiring urgent assessment.
Any BCC in an immunosuppressed person that also fulfills the above criteria.
Investigations
Please ensure the following recent results are available:
Blood test (less than 8 weeks old):
eGFR result ______Date ______Or date of test ______
Free text box for additional clinical information/referral letter, including histology (if available):
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.

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

1

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:
Immunosuppression is defined by:
  • organ transplant recipient
  • systemic immune suppressive therapy for inflammatory disease, e.g. arthritis, psoriasis, inflammatory bowel disease
  • haematological disorder affecting immunity
  • recent chemotherapy
Squamous cell carcinomas
Squamous cell carcinomas are usually raised lesions, a number of typical features have been described: often ulcerated keratinised or crusting lesions and growing typically on the head and neck or back of hand. They occur commonly and are higher risk in anyone who is immunocompromised or had a previous organ transplant. Refer all new skin lesions in this group urgently.
Basal cell carcinoma
Features suggestive of a basal cell carcinoma include:
  • An ulcer with raised, rolled edge,
  • Prominent fine blood vessels around the lesion,
  • Nodules, often waxy or pearly in appearance.
Suspected basal cell carcinomas should only be excised in primary care in accordance with the NICE guidance on Improving outcomes for people with skin tumours including melanoma (May 2010). Specific sites of concern are sun-exposed areas such as the scalp, face, hands and arms, particularly in fair-haired patients.

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

1