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:
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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:
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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