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SUSPECTED CANCER REFERRAL FORM: HAEMATOLOGYDate of decision to refer:Date referral received at Trust: Trust name(s)Email for referral FORMTEXT ?????Ashford and St. Peter’s NHS Foundation TrustFax: 0800 9234668Email: twrasph@ FORMTEXT ?????Frimley Health NHS Foundation TrustFax: 01276 604506 FORMTEXT ?????Royal Surrey County Hospital NHS Foundation TrustFax: 01483 464848?Email: rsc-tr.TWWAppts@ FORMTEXT ?????Surrey and Sussex Healthcare NHS TrustFax: 01737 231733Patient detailsSURNAME: FIRST NAME: TITLE: GENDER:DOB:NHS NUMBER:ETHNICITY:LANGUAGE: INTERPRETER REQUIRED: TRANSPORT REQUIRED:PATIENT ADDRESS:POSTCODE: CONTACT DETAILS: HOME: MOBILE:EMAIL:GP practice detailsUSUAL GP NAME: PRACTICE NAME: PRACTICE ADDRESS: PRACTICE CODE:DIRECT LINE TO THE PRACTICE (BYPASS):MAIN:FAX: EMAIL: Referring clinician: Patient engagement and availabilityI confirm the following: FORMTEXT ????? I have discussed the possibility that the diagnosis may be cancer FORMTEXT ????? I have provided the patient with a suspected cancer referral leaflet FORMTEXT ????? I have informed the patient that the appointment will be within the next two weeks & attendance is advisedPlease note any dates the patient is NOT available for an appointment in the next 2 weeks.Patient’s WHO performance statusGradeExplanation of activity FORMTEXT ?????0Fully active, able to carry on all pre-disease performance without restriction. FORMTEXT ?????1Restricted 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. FORMTEXT ?????2Ambulatory and capable of all selfcare but unable to carry out any work activities. Up and about more than 50% of waking hours. FORMTEXT ?????3Capable of only limited selfcare, confined to bed or chair more than 50% of waking hours. FORMTEXT ?????4Completely disabled. Cannot carry on any selfcare. Totally confined to bed or chair.IMMEDIATE referral (via A&E)All ages blood film shows: FORMTEXT ????? Acute leukaemia FORMTEXT ????? Severe pancytopaenia FORMTEXT ????? Chronic Leukaemia with blood film suggesting immediate referral ≤25 years only FORMTEXT ????? Unexplained petechiae (leukaemia) FORMTEXT ????? Hepatosplenomegaly (leukaemia) FORMTEXT ????? Unexplained lymphadenopathy or splenomegaly (lymphoma)Consider associated symptoms e.g. fever, night sweats, shortness of breath, pruritus, weight lossURGENT ADMISSION (via A&E or to Acute Oncology)All ages FORMTEXT ????? Symptoms of metastatic spinal cord compression (MSCC) For advice please contact Clinical Oncology Registrar On-Call via Royal Surrey switchboard 01483 571122 bleep 71-4490SUSPECTED MYELOMACriteria for an appointment with a specialist within two weeks FORMTEXT ????? Results of protein electrophoresis or a urine Bence-Jones protein suggest myelomaConsider that an abnormal FBC, hypercalcaemia or acute kidney injury may need an immediate referralAsymptomatic 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 peopleCriteria for an appointment with a specialist within two weeks FORMTEXT ????? 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 biopsyInvestigationsPlease ensure the following recent results are available:Blood test (less than 8 weeks old):Lymphoma FORMTEXT ????? FBC result _________________ Date ____________ Or date of test ________If also requested: FORMTEXT ????? ESR result _________________ Date ____________ Or date of test ________ FORMTEXT ????? LFT result _________________ Date ____________ Or date of test ________ FORMTEXT ????? U&E result _________________ Date ____________ Or date of test ________ FORMTEXT ????? Bone result _________________ Date ____________ Or date of test ________ FORMTEXT ????? LDH result _________________ Date ____________ Or date of test ________ FORMTEXT ????? IGs result _________________ Date ____________ Or date of test ________ Myeloma FORMTEXT ????? FBC result _________________ Date ____________ Or date of test ________ FORMTEXT ????? eGFR result _________________ Date ____________ Or date of test ________ FORMTEXT ????? U&E result _________________ Date ____________ Or date of test ________ FORMTEXT ????? Bone profile result _____________ Date ____________ Or date of test ________ FORMTEXT ????? Serum protein electrophoresis result _______ Date _______ Or date of test ______ FORMTEXT ????? BJP result _________________ Date ____________ Or date of test ________If also requested: FORMTEXT ????? IGs result _________________ Date ____________ Or date of test ________ FORMTEXT ????? 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 guidanceUseful websites:CRUK mainCRUK learninge-CDSMacmillanMacmillan learningGenetics and Family HistoryMap of MedicineNICEQ-CancerSite-specific information and advice for primary care: Suspected LeukaemiaOffer a very urgent (within 48 hours) FBC for patients with the following unexplained signs/ symptoms:Signs/ symptomsAdults aged >25 yearsChildren and young peoplePallorPersistent fatigueUnexplained feverUnexplained persistent or recurrent infectionGeneralized lymphadenopathyUnexplained bruisingUnexplained bleedingUnexplained petechiaeHepatosplenomegalyPersistent or unexplained bone pain Suspected MyelomaOffer 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 andHypercalcaemia orLeukopeniaNew renal impairmentPatients 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) orUnexplained fractureRefer adults, children and young people with a blood count or blood film reported as acute leukaemia immediately. ................
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