SARCOMA SUSPECTED CANCER REFERRAL FORM
Date of GP decision to refer: Click here to enter a date.
No. of pages sent:
ESSEX AND BEDS & HERTS: London Sarcoma Service ask for direct referral – NO ULTRASOUND DELAY
ANGLIA: Addenbrookes and Norfolk & Norwich run a diagnostic service, triaging patients to Birmingham.
It is recommended that GPs refer to the tertiary centre (WITHIN 48 HOURS) following results of X-ray.
NOTE: Do not refer HIV-associated Kaposi’s sarcoma with this form.
PATIENT DETAILS –Must provide current telephone number.
Last name:
Gender: M ☐ F ☐
NHS No:
Address:
First name:
DOB:
Telephone (Day):
Telephone (Evening):
Mobile No.:
Patient agrees to telephone message being left? Y ☐ N ☐
Transport required? Y ☐
Email:
Interpreter required? Y ☐
Language/Hearing:
Learning difficulties? Y ☐
Mental capacity assessment required? Y ☐
Known safeguarding concerns? Y ☐
Mobility requirements (unable climb on/off bed)?
Y☐
SYMPTOMS & CLINICAL EXAMINATIONS
STOP: If suspected bone metastases from an unknown primary,
refer using local cancer of the unknown primary form
X-ray
suggests the possibility of bone sarcoma [2015]
☐
☐ Spontaneous fracture
☐ Bone destruction
☐ Soft tissue swelling
☐ New bone formation
☐ Periosteal elevation
☐ Unexplained bone swelling or pain [2015]
SOFT TISSUE SARCOMA
☐ Ultrasound suggests soft tissue sarcoma [2015] if available
☐ Ultrasound uncertain, but clinical concern [2015] if available
Mass with 1 or more of the following:
☐ >5cm in size
☐ Deep to fascia
☐ Painful
☐ Fixed
☐ Increasing in size [2015]
Please provide more details, if the following:
☐ Other
☐ Recurrence following excision
IF <25 years, call consultant and refer urgently (WITHIN 48 HOURS)
[2015]. Complete and send this form so patient is tracked.
Please attach a Patient Summary including:
☐ Referral letter (if applicable)
☐ Investigation results
GP DETAILS
GP name:
Practice Code:
Address:
TEL:
FAX:
Practice email:
INVESTIGATIONS IN SUPPORT OF REFERRAL
You don’t need to wait for results of tests to refer.
☐ BONE: X-ray
☐ SOFT TISSUE: Ultrasound (if available)
Please attach reports with completed referral form.
Location:
Size:
PATIENT MEDICAL HISTORY (MANDATORY)
Existing conditions & Risk factors (inc smoking status):
Current medication:
Y☐
Y☐
Y☐
Y☐
Allergies
Anticoagulants/Antiplatelets
Immunosuppressants
Diabetic
WHO Patient Performance status (see key below)
☐0
☐1
☐2
☐3
☐4
DISCUSSIONS WITH PATIENT PRIOR TO REFERRAL
Cancer needs to be excluded
Patient given referral information leaflet
Date(s) unavailable next 14 days:
☐ PMH
☐ Up-to date medications list and indications
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.
0
1
2
3
4
WHO PATIENT PERFORMANCE STATUS KEY
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 or 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.
FOR GUIDANCE ON SYMPTOMS & HOSPITAL CONTACT DETAILS, SEE REVERSE OF THIS FORM.
☐
☐
< 25 YEARS
X-ray suggests
possibility of
bone sarcoma
[2015]
QUERY
≥ 25 YEARS
Unexplained
bone swelling
or pain
Unexplained lump
that is increasing
in size [2015]
Unexplained lump
that is increasing
in size [2015]
Unexplained
bone swelling
or pain
V. urgent direct
access X-ray in
48hrs (primary
care must ensure
result is acted on)
Urgent direct
access ultrasound
in 2 wks (primary
care must ensure
result is acted on)
IF AVAILABLE
Urgent direct
access ultrasound
in 2 wks (primary
care must ensure
result is acted on)
IF AVAILABLE
V. urgent direct
access X-ray in
48hrs (primary care
must ensure result
is acted on)
X-ray suggests
possibility of
bone sarcoma
[2015]
QUERY
Ultrasound suggests soft
tissue sarcoma or clinical
concern persists [2015]
IF AVAILABLE
CALL CENTRE: REFER WITHIN 48 HOURS
SUSPECTED CANCER REFERRAL WITHIN 14 DAYS
**There is a separate referral form for patients aged <16 years**
ANGLIA
Diagnostic services (triage to Birmingham)
Addenbrookes
Use e-referral (Choose & Book)
Add-tr.nhsoutpatientreferrals@nhs.net
Tel: 01223 216214
ESSEX and BEDS & HERTS
SOFT TISSUE (ALL SITES)
Royal Marsden Hospital
FAX: 020 8661 3149
TEL: 020 8661 3630
CentralReferralsOffice@rmh.nhs.uk
SOFT TISSUE (Non-limb/trunk, i.e. head & neck, pelvic,
skin, breast, retroperitoneal, urology, abdominal, etc.
University College London Hospital
FAX: 020 3447 9932
TEL: 020 3447 9599
ucl-tr.LondonSarcomaService@nhs.net
Norfolk & Norwich
Use e-referral (Choose & Book)
FAX: 01603 286876
SOFT TISSUE SARCOMA (Limb & Trunk)
Royal National Orthopaedic Hospital
FAX: 020 8909 5709
TEL: 020 8909 5603
mo-tr.LondonSarcomaService@nhs.net
BONE SARCOMA
Royal National Orthopaedic Hospital
FAX: 020 8909 5709
TEL: 020 8909 5603
mo-tr.LondonSarcomaService@nhs.net