SOUTH EAST LONDON CANCER NETWORK
Colorectal Urgent Suspected Cancer Referral
Please tick the box of the hospital clinic you are referring
to and fax this form to the relevant Urgent Referral Team
within 24 hours. Guidelines are on the reverse side.
DATE OF REFERRAL
King’s College PRUH site
kch-tr.br-2weekwait@nhs.net
Tel: 01689 866701/65790/65794
Fax: 01689 863187
Queen Elizabeth
Fax: 020 8836 4035
Tel: 020 8836 5964/5
Guy’s & St Thomas’
Fax: 020 7188 0923
Tel: 020 7188 0902
King’s College
Fax: 020 3299 1515
Tel: 020 3299 1516
Lewisham
Fax: 020 8333 3451
Tel: 020 8333 3450
Queen Mary’s
Fax: 020 8308 9264
Tel: 020 8308 3018/3088
Section 1 – PATIENT INFORMATION. Please complete in BLOCK CAPITALS.
SURNAME
Patient visited this hospital before?
Y / N
FIRST NAME
NHS
Hospital
Number
Number
Patient aware the referral is urgent?
Y / N
Gender
M / F
D.O.B.
Address
First language
Post Code
Mobile Telephone
Interpreter required?
Y / N
Transport required?
Y / N
Home Telephone (if different)
Section 2 – PRACTICE INFORMATION. Please use practice stamp if available.
Referring GP
GP Email Address
Practice Address
Telephone
Fax
Post Code
Section 3 – CLINICAL INFORMATION. Please tick the relevant box.
 Aged 40+, reporting rectal bleeding with a change
 Aged 60+ with rectal bleeding persisting 6 weeks or
of bowel habit towards looser stools and /or increased
stool frequency persisting 6 weeks or more
more without anal symptoms (itching, discomfort,
soreness, lump, prolapse and pain)
 Aged 60+, with a change in bowel habit to looser
 Of any age with a palpable rectal mass
stools and/or more frequent stools persisting 6 weeks
or more
(intraluminal and not pelvic)
 Unexplained iron deficiency anaemia and
 Of any age with a right lower abdominal mass
haemoglobin:
 11g/100mL or less (men of any age)
 10g/100mL or less (non-menstruating
women).
consistent with involvement of the large bowel
Essential blood Results
Hb:
Ferritin:
U + E’s/eGFR:
Past Medical History - Attach patient computer record summary.
Medication: Please circle if patient is on any of these medications.
Hypoglycaemics
Insulin,
Warfarin,
Clopidogrel,
Dipyridamole
Asprin
SOUTH EAST LONDON CANCER NETWORK
Information to support Colorectal referrals
Refer urgently patients:
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Aged 40+ reporting rectal bleeding with a change of bowel habit towards looser stools and / or
increased stool frequency persisting 6 weeks or more.
Aged 60+ with rectal bleeding persisting for 6 weeks or more without anal symptoms.
Aged 60+, with a change in bowel habit to looser stools and/or more frequent stools persisting for
6 weeks or more.
Of any age with a right lower abdominal mass consistent with involvement of the large bowel.
Of any age with a palpable rectal mass (intraluminal and not pelvic).
With unexplained iron deficiency anaemia and a haemoglobin of 11g/100mL or below (men) and a
haemoglobin of 10g/100mL or below (non-menstruating women). Please check ferritin but do not
delay referral.
 Use this proforma to refer urgently (2 Week Wait)
Investigations in Primary Care:
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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 please ensure that the patient has a recent haemoglobin and U + E’s/eGFR as
required by NPSA alert “Reducing risk of harm from oral bowel cleansing solutions”. For further
information see: http://www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=59869&p=2
Faecal occult bloods and tumour markers (e.g. CEA) in symptomatic patients are of little diagnostic
value.
Low risk symptoms:
It is recommended in patients having a normal abdominal and rectal examination and haemoglobin
estimation that the following symptoms be used to identify patients at very low risk of bowel cancer:
 Rectal bleeding with anal symptoms (itching, discomfort, soreness, lump, prolapse and pain).
 Transient changes in bowel habit, particularly to harder stools and/or decreased frequency of
defaecation .
 Abdominal pain as a single symptom without other high-risk symptoms and signs, an iron
deficiency anaemia, or intestinal obstruction.
 Weight loss in the absence of higher risk symptoms unless rapid and profound.
Patients with these symptoms can be initially safely managed in primary care by careful "treat, watchand-wait" strategies and reviewed after 3 months. However, if symptoms persist or recur when off all
treatment and
 Remain low risk – refer routinely to clinic using Choose & Book or a letter.
 Remain in the low risk category but are worrying / severe – refer to clinic using Choose & Book or
a letter, requesting an appointment as soon as possible.
 Change to higher risk – refer urgently to clinic using this proforma.
Risk factors:
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Offer patients with ulcerative colitis a follow-up plan agreed with a specialist in an effort to detect
colorectal cancer in this high-risk group
There is insufficient evidence to suggest that a positive family history of colorectal cancer can be
used to assist in the decision about referral of a symptomatic patient.
Version 3 November 2014
For comments, additional copies, or patient information resources for GPs to use contact the Network on Tel 020 7188 7090 /
Fax 020 7188 7120, or visit our website: www.selcn.nhs.uk.