SOUTH EAST LONDON CANCER NETWORK
Breast Referral Proforma
Please tick the box of the hospital clinic you are referring to, tick the relevant symptoms to indicate the urgency
of this referral and fax this form to the relevant Team within 24 hours. Guidelines to help determine urgency are
on the reverse side.
King’s College PRUH site
kch-tr.br-2weekwait@nhs.net
Tel: 01689 866701/65790/65794
Fax: 01689 863 187
King’s College
Fax: 020 3299 4798
Tel: 020 3299 3962
Guy’s & St Thomas’
Fax: 020 7188 0923
Tel: 020 7188 0902
Queen Elizabeth
Fax: 020 8836 4035
Tel: 020 8836
5964/5
Lewisham
Fax: 020 8333 3451
Tel: 020 8333 3450
Queen Mary’s
Fax: 020 8308 9264
Tel: 020 8308 3253
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
Daytime Telephone
Interpreter required?
Y / N
Transport required?
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
Post Code
Fax
SECTION 3 – CLINICAL INFORMATION.
PLEASE CIRCLE REFERRAL URGENCY, TICK THE RELEVANT SYMPTOMS / SCENARIOS AND MARK THE DIAGRAM.
Yes / No I want to make an URGENT (2 WEEK) referral
Suspected malignant lump
Texture change (> 25 yrs)
History of breast cancer
Nipple ulceration / eczema
Recent nipple distortion
Erythema / Skin oedema
Unilateral blood stained or
serous nipple discharge
Male, >50 yrs with unilateral
subareolar lump
Yes / No I want to make a NON-URGENT referral
Lump
Inverted nipple
Skin infiltration/
Peau d’orange
Mobile lump (< 25 yrs )
Breast pain
Other (please specify)
Male, <50 yrs with breast
symptoms
Medical & family history, including previous breast investigations / Additional information
- continue on a separate sheet if required.
Please attach patient computer record summary if available.
SOUTH EAST LONDON CANCER NETWORK
Information to support Breast referrals
Refer urgently patients:
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Any age with a suspected malignant lump.
Aged 25+ with a change in texture of the breast perceived by the woman.
With a history of breast cancer who presents with a further lump or suspicious symptoms.
With unilateral eczematous nipple change that does not respond to topical treatment.
With nipple distortion of recent onset (not retractile nipple).
With spontaneous unilateral blood stained or serous nipple discharge.
With unexplained inflammatory changes (erythema and skin oedema).
Who are male, aged 50 years and older with a unilateral subareolar mass with or without nipple
distortion or associated skin changes.
 Use this proforma to refer urgently (2 Week Wait), ticking the relevant box
Refer non-urgently:
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Women aged less than 25 years with a mobile lump.
Patients with breast pain that is troublesome but with no palpable abnormality, when initial
treatment in primary care fails.
 Use Choose & Book or this proforma (ticking the relevant box) to refer non-urgently
Refer to family history clinic:
Women with no breast symptoms/signs who have a significant maternal or paternal family history of
breast/ovarian cancer:
 One 1st degree relative diagnosed before age 40
 Two relatives (one 1st degree and one 2nd degree, or two 1st degree) diagnosed before an average
age of 60
 Three or more relatives (one must be 1st degree) diagnosed with breast cancer
 Families with both breast and ovarian cancer, or male breast cancer, should also be referred.
 In Lambeth, Southwark and Lewisham phone “Cancer – a family affair?” on 020 7188 1385
 In Bromley refer patients by letter to the Breast CNS at Princess Royal University Hospital
 In Greenwich refer patients by letter to the Breast CNS at Queen Elizabeth Hospital
 In Bexley refer patients by letter to the Breast CNS at Queen Mary’s Sidcup
Investigations in Primary Care:
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In patients presenting with symptoms and / or signs requiring hospital referral, investigation prior to
referral is not recommended.
In particular it is not normally recommended to insert a needle into the breast, or to start treatment
such as Tamoxifen.
Patient information and support:
Consider the information and support needs of patients and the people who care for them while they
are waiting for the referral appointment. Resources for GPs to use are available from the Cancer
Network on 020 7188 7090, or visit our website www.selcn.nhs.uk.
Approved by the South East London Cancer Network in July 2012
For comments or additional copies contact the Network on Tel 020 7188 7090 / Fax 020 7188 7120, or visit our website:
www.selcn.nhs.uk.