LOWER GI Suspected Cancer Referral
(2 Week Wait Referral)
To support NICE guidance 2005
Please FAX within 24 hours to Cancer Pathways department on: 020 8928 8836
Section 1 PATIENT INFORMATION (Please complete in BLOCK CAPITALS)
Date of Referral
Date of Birth
NHS number
UBRN
SURNAME
FIRST NAME
Miss Mrs Ms Mr
Other:_________
/
/
/
/
-
-
Home Tel.
M[ ]F [ ]
Mobile/Daytime Tel.
Address
Transport Y
N
Interpreter Y
N
Language
Ethnicity
Post Code
Section 2 PRACTICE INFORMATION (Please use practice stamp if available)
Referring GP
Locum
Practice Address
Y
N
Telephone
Fax
Post Code
Section 3 CLINICAL INFORMATION (please TICK all applicable entries)
Please enclose print outs of CURRENT medications and PAST MEDICAL HISTORY
All ages
[ ] Definite, palpable, right sided, abdominal
mass
[ ] Definite, palpable, rectal (not pelvic) mass
[ ] Unexplained iron deficiency anaemia
AND:
[ ] Male with a Hb of < 11g/dl
[ ] Non menstruating female with a Hb
of < 10g/dl
Over 40 years
[ ] Rectal bleeding WITH a change of bowel habit towards
looser stools &/or increased frequency 6 wks
Medical History, Known Allergies
All Medication
DIABETIC: YES/NO
WARFARIN:
YES/NO
CLOPIDROGREL: YES/NO
Over 60 years
[ ] Rectal bleeding persisting 6wks WITHOUT a change in bowel
habit or anal symptoms (e.g. soreness, discomfort, itching, prolapse, pain)
[ ] Change in bowel habit to looser stools &/or more frequent stools
persisting 6 wks WITHOUT rectal bleeding
Mandatory Investigations
[ ] PR examination
[ ] Abdo examination
Findings:
[ ] FBC: Hb:____ MCV ___ Date: __ /__/__
Family History incl. relative and age at diagnosis
Fitness Rating (ECOG) Please circle approp. no.:
0 Fully active
3 Able to carry out limited self-care,
1 Unable to do strenuous activities
mainly confined to bed or chair
2 Able to walk and self-care
4 Completely confined to bed or chair
Discussed urgent suspected cancer referral with patient:
Y
N
Your patient may go straight to a diagnostic test, for example, Colonoscopy, Flexi sigmoidoscopy, CT abdo pelvis.
 In your opinion would this patient be suitable to go straight to a diagnostic test?
Yes / No
 Have you told the patient they may go straight to a diagnostic test?
Yes / No
Comments/other reasons for urgent referral:
Hospital use only: (Tick where appropriate)
Date Appointment Booked:
Target Dates
2ww
62/7
/
/
/
/
/
/
Date of Referral receipt:
Database:

/
Patient confirmed:
/

A separate letter only need accompany if you feel it necessary
To be Approved by the North East London Cancer Network April 2006
LOCAL CONTACT DETAILS
If you wish to discuss any clinical issues concerning this referral please contact:
Mr Michael Machesney
Mr Pasquale Giordano
Kitty Aristides
Consultant Colorectal Surgeon
Consultant Colorectal Surgeon
Lower GI Nurse Specialist
020 8535 6066
020 8535 6656
0208 539 5522
-Bleep 676
If you wish to discuss any other aspect of this referral please contact the Cancer Pathways
Office on 020 8535 6856/ 020 8535 6768 x4348 x4350
CRITERIA FOR URGENT SUSPECTED CANCER REFERRAL1
Please FAX the referral form within 24 hours
Refer a patient who presents with symptoms suggestive of colorectal or anal cancer to
a team specialising in the management of lower gastrointestinal cancer, depending on
local arrangements.
Investigations




Always carry out a digital rectal examination in patients with unexplained
symptoms related to the lower gastrointestinal tract.
Where symptoms are equivocal a full blood count may help in identifying the
possibility of colorectal cancer by demonstrating iron deficiency anaemia, which
should then determine if a referral should be made and its urgency.
When referring, a full blood count will assist specialist assessment in the
outpatient clinic.
When referring, no examinations or investigations other than abdominal and
rectal examination and FBC are recommended as this may delay referral
Risk factors
Offer patients with ulcerative colitis or a history of ulcerative colitis a follow-up plan
agreed with a specialist in an effort to detect colorectal cancer in this high-risk group.
Low Risk Criteria
Patients of all ages with the following symptoms and no abdominal or rectal mass
are at very low risk of colorectal cancer and should therefore not be referred under
the two-week system:




Rectal bleeding WITH anal symptoms, e.g. soreness, discomfort, itching,
lumps, prolapse and pain
Rectal bleeding with an obvious external cause for bleeding on simple
examination of the perineum, e.g. anal fissure, thrombosed or prolapsed pile
and rectal prolapse
Transient changes in bowel habit, particularly to harder stools and/or
decreased frequency of defecation
Abdominal pain as a single symptom WITHOUT other higher risk
age/symptom/sign profiles, an abdominal mass, an iron deficiency anaemia or
intestinal obstruction
If your patient fits these “low risk” criteria, please do not use this form
Refer the patient by means of a routine referral letter
Fitness rating or ECOG
The ECOG (Eastern Cooperative Oncology Group) performance score:
0 = fully active, the same as before suspicion of cancer
1 = unable to do strenuous activities but still able to do tasks such as light
housework or office work
2 = able to walk and carry out self-care (e.g. eating, dressing), but not able to work
3 = only able to carry out limited self-care, mainly confined to bed or chair
4 = completely confined to bed or chair and not able to carry out self-care
1 Based on Referral Guidelines for Suspected Cancer (NICE, 2005) Notes in grey refer to the evidence
grading used in the NICE guidelines, for more information see
www.nice.org.uk/cg027NICEguideline)
2 In this guideline, unexplained is defined as ‘a symptom(s) and/or sign(s) that has not led to a diagnosis
being made by the primary care professional after initial assessment of the history, examination and
primary care investigations (if any)’. In the context of this recommendation, unexplained means a
patient whose anaemia is considered on the basis of a history and examination in primary care not to
be related to other sources of blood loss (for example, ingestion of NSAIDs) or blood dyscrasia.