SOUTH EAST LONDON CANCER NETWORK Paediatric Urgent Suspected Cancer Referral If you suspect a child or young person has cancer, please telephone the paediatrician on call to discuss referral and possible admission. If urgent referral is advised please use this proforma to record the referral information and email a copy to the relevant hospital clinic for inclusion in the patient notes. A copy can also be given to the patient / family for presentation in the clinic. Princess Royal kch-tr.br-2weekwait@nhs.net Tel: 01689 865676 King’s College Hospital kch-tr.CancerData@nhs.net Tel: 020 3299 1516 Queen Elizabeth Fax: 020 8836 4035 Tel: 020 8836 5964/5 Guy’s & St Thomas’ Fax: 020 7188 0923 Tel: 020 7188 0902 Lewisham Fax: 020 8333 3451 Tel: 020 8333 3450 Queen Mary’s Fax: 020 8308 9264 Tel: 020 8308 3230 SECTION 1 – PATIENT INFORMATION. PLEASE COMPLETE IN BLOCK CAPITALS. SURNAME Patient visited this hospital before? FIRST NAME NHS number Gender Address M / F D.O.B. Post Code Daytime Telephone Y / N Patient aware the referral is urgent? First language Y / N Interpreter required? Transport required? Y / N Y / N Home Telephone (if different) / Mobile No. SECTION 2 – PRACTICE INFORMATION. USE PRACTICE STAMP IF AVAILABLE. Referring GP Date of referral Practice Address Telephone Fax Post Code SECTION 3 – CLINICAL INFORMATION. PLEASE TICK THE RELEVANT BOXES. Cancer suspected Leukaemia Signs & Symptoms Bone / back / rest pain Behavioural changes / learning difficulties Fatigue, lethargy Fever Haematuria / urinary retention Headache / vomiting / ataxia / squint Local swelling Motor / sensory signs Shortness of breath Weight loss Lymphoma Brain / CNS Neuroblastoma Wilm’s tumour Soft tissue Bone Retinoblastoma Other (please specify): Amount Over period Other (please specify): Clinical findings Abnormal blood count Anaemia Abdominal mass Hepatomegaly Lymphadenopathy Neurological signs Petechiae / Purpura Soft tissue mass Splenomegaly Other (please specify): Additional comments - including medical history and medication. Continue on separate sheet if required. Name of paediatrician consulted: Date: ** Discuss referral with a paediatrician first. If urgent referral is advised, email this proforma to the relevant clinic and give a copy to the parents / patient to take to their appointment. ** SOUTH EAST LONDON CANCER NETWORK Information to support Paediatric referrals Refer urgently children or young people with: Fatigue or shortness of breath in a previously healthy child combined with one or more of the following: o lymphadenopathy o hepatosplenomegaly o clinical evidence of anaemia or petechiae Bone pain and / or swelling if: o diffuse or persistent o X-ray indicative of cancer. Lymphadenopathy which has one or more of the following characteristics: o Non tender / firm / hard o unresolved after a course of antibiotics o associated with signs of generalised ill health, fever and/or weight loss o involves axillary or supraclavicular nodes Headache of recent origin with one or more of the following features: o increasing frequency or severity (e.g. causing nocturnal awakening) o associated with behavioural change or deterioration in school performance o associated with neurological signs or symptoms of raised intracranial pressure Soft tissue mass which has one or more of the following characteristics: o size > 2 cms o shows rapid or progressive growth o fixed or deep to fascia o associated with regional lymph node enlargement o non-tender Haematuria Full blood count indicative of leukaemia With symptoms suggestive of neuroblastoma (proptosis, unexplained back pain, leg weakness, unexplained urinary retention). Consider referral when children present several times with no clear diagnosis (investigations should also be carried out). Take into account parental insight and knowledge when considering a referral. Phone paediatrician to discuss referral, and use this proforma to refer urgently (2 Week Wait) Refer immediately (acute admission) children or young people with: Either unexplained petechiae, or hepatosplenomegaly. Either hepatosplenomegaly, or mediastinal or hilar mass on chest X-ray. With a reduced level of consciousness. Headache and vomiting that cause early morning waking or occur on waking as these are classical signs of raised intracranial pressure. With any neurological symptoms and signs (new-onset seizures, cranial nerve abnormalities, visual disturbances, gait abnormalities, motor or sensory signs, unexplained deteriorating school performance or developmental milestones, unexplained behavioural and/or mood changes). Children aged younger than 2 years with new-onset seizures, bulging fontanelle, extensor attacks or persistent vomiting should be referred immediately. Send to A&E or phone paediatrician to arrange admission Refer non-urgently: Consider referral when a child or young person presents with persistent back pain (an examination is needed and a full blood count and blood film). Persistent parental anxiety is sufficient reason for referral, even where a benign cause is considered most likely. Take into account parental insight and knowledge when considering urgent referral. Approved by the South East London Cancer Network in November 2006. For comments, additional copies, or patient information resources please visit http://www.londoncanceralliance.nhs.uk Referral pathway for suspected paediatric cancer Child / young person examined by GP GP suspects cancer and phones on-call paediatrician Paediatrician advises on clinical urgency Immediate Inappropriate Immediate admission arranged, GP records referral information in letter Urgent Urgent referral / clinic appointment arranged, GP completes and emails referral form GP treats / monitors the patient in primary care Non-urgent GP refers patient to appropriate clinic via email or Choose & Book