UPPER GI SUSPECTED CANCER REFERRAL FORM
Date of GP decision to refer: Click here to enter a date.
No. of pages sent:
IF CHOOSE & BOOK IS UNAVAILABLE, COMPLETE FORM AND EMAIL/FAX TO THE REFERRAL TEAM WITHIN 24 HRS.
If your patient does not meet NICE suspected cancer referral criteria, but you feel they warrant further
investigation, please disclose full details in your referral letter.
PATIENT DETAILS –Must provide current telephone number
Last name:
First name:
Gender: M ☐ F ☐
DOB:
BMI (assists diagnostics):
NHS No:
Address:
Email:
Telephone (Day):
Telephone (Evening):
Mobile No.:
Patient agrees to telephone message being left?
Transport required? Y ☐
Interpreter required? Y ☐ Language/Hearing:
Learning difficulties? Y ☐
Known safeguarding concerns? Y ☐
Mental capacity assessment required? Y ☐
Mobility requirements (unable climb on/off bed)?
TEL:
FAX:
Practice email:
INVESTIGATIONS IN SUPPORT OF REFERRAL
Most patients will go straight to diagnostics. Please include:
Y☐N☐
☐ Hb
☐ Platelets ☐ Ferritin ☐ Renal function
Jaundice LFT: ☐ Bilirubin ☐ Alt ☐Alk Phos
PATIENT MEDICAL HISTORY
Risk factors
☐ Barrett’s oesophagus ☐Others (specify Additional Info)
Existing conditions & smoking status:
Y☐
SYMPTOMS & CLINICAL EXAMINATIONS
☐
☐
GP DETAILS
GP name:
Practice Code:
Address:
PANCREATIC: IF ≥40 yrs WITH jaundice [2015]
STOMACH: Upper abdominal mass [2015]
The following tests may be requested by primary care clinicians who
do NOT have direct access – only in EXCEPTIONAL CIRCUMSTANCES.
Cancer teams will direct patients onto the 2WW pathway, IF TEST
RESULTS ARE POSITIVE. Otherwise primary care must act on results.
☐ Mass suggests enlarged gall bladder [2015] 2WW ultrasound
☐ Mass consistent with enlarged liver [2015] 2WW ultrasound
☐ Pancreatic: ≥60yrs with weight loss +ANY: 2WW CT/Ultrasound
☐diarrhoea ☐back pain ☐abdominal pain
☐nausea
☐vomiting ☐constipation ☐new-onset diabetes [2015]
OESOPHAGEAL/STOMACH
2WW ENDOSCOPY
☐ IF ≥55 yrs with dysphagia
☐ IF ≥55 yrs with weight loss with ANY of: 2WW ENDOSCOPY
☐upper abdominal pain
☐ reflux ☐ dyspepsia [2015]
Tests may be requested where primary care DON’T have direct access.
☐ IF ≥55 yrs with nausea OR vomiting and ANY of: ENDOSCOPY
☐weight loss ☐reflux ☐dyspepsia ☐upper ab’nal pain [2015]
☐ IF ≥55 yrs Upper abdominal pain & low Hb levels ENDOSCOPY
(MUST INCLUDE BLOOD TESTS TO SUPPORT REFERRAL)
☐ IF ≥55 yrs with raised platelet count with ANY: ENDOSCOPY
☐ nausea ☐ vomiting ☐ weight loss ☐ reflux ☐ dyspepsia
(MUST INCLUDE BLOOD TESTS TO SUPPORT REFERRAL)
ENDOSCOPY
☐ Haematemesis [2015] (All ages)
ENDOSCOPY
☐ IF ≥55 yrs with treatment-resistant dyspepsia
Current medication (include list & indications):
Y☐
Y☐
Y☐
Y☐
Allergies
Anticoagulants/Antiplatelets
Immunosuppressants
Diabetic
WHO Patient Performance status (MANDATORY)
☐0
☐1
☐2
☐3
☐4
ADDITIONAL INFORMATION
DISCUSSIONS WITH PATIENT PRIOR TO REFERRAL
Cancer needs to be excluded
Patient given referral information leaflet
Date(s) unavailable next 14 days:
☐
☐
Please attach a Patient Summary including:
☐ Referral letter (if applicable)
☐ Investigation results
☐ PMH
☐ Up-to date medications list and indications
WHO PATIENT PERFORMANCE KEY
0
1
2
3
4
Fully active, able to carry on all pre-disease performance without restriction
Restricted in physically strenuous activity but ambulatory and able to carry out light/sedentary work, e.g. house/ office work.
Ambulatory and capable of self-care, but unable to carry out work activities. Up and active > 50% of waking hours.
Capable of only limited self-care. Confined to bed or chair >50% of waking hours.
Completely disabled. Cannot carry out any self-care. Totally confined to bed or chair.
ALL AGES
STOMACH: Upper
abdominal mass
[2015] (All ages)
≥ 40 YEARS
PANCREATIC: IF
≥ 40 yrs with
Jaundice [2015]
≥55 YEARS
ANY OF THESE SYMPTOMS:
OESOPHAGEAL/
STOMACH:
haematemesis
[2015] (All ages)
OESOPHAGEAL/ STOMACH:
IF ≥55yrs upper abdominal
pain with low haemoglobin
levels
OESOPHAGEAL/ STOMACH:
IF ≥55yrs with raised
platelet count with any:
nausea/ vomiting/ weight
loss/ reflux/ dyspepsia/
upper abdominal pain
ACTION: Urgent direct access
Upper GI endoscopy WITHIN
14 DAYS (primary care must
ensure result acted on)
Anglia
Addenbrookes
Add-tr.nhsoutpatientreferrals@nhs.net
TEL: 01223 586930
Bedford Hospital
FAX: 01234 792133
Hinchingbrooke
TEL: 01480 847557
hch-tr.cancerMDT@nhs.net
Ipswich Hospital
FAX: 01473 704120
James Paget
FAX: 01493 453325
QEH, King’s Lynn
FAX: 01553 613473
Norfolk & Norwich
FAX: 01603 286876
Peterborough & Stamford
FAX: 01733 678562
2wwreferrals@pbh-tr.nhs.uk
West Suffolk Hospital
wsh-tr.RapidAccess@nhs.net
ACTION: Non-urgent
direct access Upper GI
endoscopy (primary care
must act on result)
OESOPHAGEAL/ STOMACH:
IF ≥55yrs with nausea OR
vomiting with any of: weight
loss/ reflux / dyspepsia/
upper abdominal pain [2015]
ACTION: Urgent direct access CT
scan WITHIN 14 DAYS (primary
care must ensure result acted on)
SUSPECTED CANCER REFERRAL
WITHIN 14 DAYS
≥ 60 YEARS
ACTION: Urgent direct
access ultrasound scan
WITHIN 14 DAYS (primary
care ensure result acted on)
Beds & Herts
East & North Herts
FAX: 01438 284503
If you have not received acknowledgement
within 48hrs (Mon-Fri) contact the 2WW
supervisor on 01438 285206
OESOPHAGEAL/
STOMACH: IF ≥55yr
with treatment
resistant dyspepsia
PANCREATIC: Weight loss AND
any of: diarrhoea/ back pain/
abdominal pain/ nausea/
vomiting/ constipation/ newonset diabetes [2015] ≥ 60 YRS
OESOPHAGEAL/ STOMACH: IF
≥55yrs with weight loss and any of
the following: upper abdominal
pain/ reflux/ dyspepsia [2015]
OESOPHAGEAL/ STOMACH: IF
≥55yrs with dysphagia [2015]
LIVER: abdominal
mass consistent with
an enlarged liver
[2015] (All ages)
GALL BLADDER:
abdominal mass
consistent with an
enlarged gall bladder
[2015] (All ages)
Essex
Basildon & Thurrock
FAX: 01268 598066
cancer.2wwreferrals@btuh.nhs.uk
Colchester Hospital University FT
twoweek.waitreferral@nhs.net
Luton & Dunstable
FAX: 01582 497910
FAX: 01582 497911
West Herts Hospitals
TEL: 01727 897199
Wherts-tr.twwreferrals@nhs.net
Mid Essex Hospitals FT
FAX: 012455 16751
Southend University Hospital FT
FAX: 01702 508174