Suspected Upper Gastrointestinal Tract Cancer Referral

GP or GDP Details / Patient Details
Name: / Name:
Address: / Address:
Tel No.: / Tel No. (home): / Please check tel. nos
Email: / Tel No. (work):
Decision to Refer Date: / Tel No. (mobile):
NHS No.: / DoB:
Hospital No.: / Gender:
Interpreter Required:
Language: / Mobility:
Please confirm that the patient is aware that this is a suspected cancer referral: - Yes No
Date(s) that patient is unable to attend within the next two weeks:
If patient is not available for the next 2 weeks, and aware of nature of referral, please only refer when able and willing to accept an appointment.

Referral criteria and pathways for Clinic Assessment

Oesophageal Cancer
PLEASE REFER TO THE DIRECT ACCESS GASTROSCOPY SERVICE FOR SUSPECTED CANCER
A barium swallow is more appropriate in cases of suspected oesophageal cancer where the level of dysphagia is above the suprasternal notch.
Direct access barium swallow
All test results will be returned to the referring GP to deal with accordingly with the exception of a confirmed cancer diagnosis which will be automatically added to the Cancer MDT.
Highly suspicious of oesophageal cancer but patient is unfit or unwilling to undergo a gastroscopy.
Reason for referring to clinic rather than direct access gastroscopy
Gall bladder cancer
Ultrasound indicates gall bladder cancer
Liver cancer
Ultrasound indicates liver cancer
Pancreatic cancer
Any patient with jaundice;
CT indicates pancreatic cancer;
ultrasound indicates pancreatic cancer.
Clinical findings
upper abdominal mass consistent with stomach cancer (consider)
Aged 60 and over with weight loss and any of the following:
diarrhoea / abdominal pain / Vomiting / New-onset diabetes
back pain / nausea / Constipation
Clinical History:
Clinical Examination:

Attachments: Letter Medication List Other

Additional Information:
All Isle of Scilly patients may be given a telephone assessment prior to any attendances for diagnostics.
Macmillan rapid referral guidelines:
http://www.macmillan.org.uk/Documents/AboutUs/Health_professionals/PCCL/Rapidreferralguidelines.pdf
Suspected cancer: recognition and referral June 2015 NICE guidance: http://www.nice.org.uk/guidance/ng12