ARDEN CANCER NETWORK
TWO WEEK REFERRAL SERVICES - HAEMATOLOGY
Indications for an urgent referral for a suspected new malignancy are:
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FBC with a film report suggesting acute leukaemia or chronic myeloid leukaemia (please
attach FBC report).
Lymphadenopathy (> 1cm ) persisting for 6 weeks, or increasing in size especially if > 2cm
Hepatosplenomegaly with an abnormal FBC.
Bone pain associated with anaemia and a raised ESR (or plasma viscosity) or renal
impairment.
Bone x-rays reported as being suggestive of myeloma.
An abnormal FBC AND a constellation of 3 or more of the following symptoms: fatigue,
night sweats, weight loss, itching, breathlessness, fever, bruising, recurrent infections, bone
pain. (A chest x-ray and urine culture should be considered at the time of referral in
these cases).
Pre-investigations required of GP: FBC, U&Es, CXR. If not done, arrange at time of referral.
NOTE1: Blood test results indicative of acute leukaemia requiring immediate attention will be
reviewed by the haematologist within the hospital laboratory. The GP will then be
contacted and arrangements made for admission.
NOTE2: Patients with spinal cord compression or acute renal failure: admit.
NOTE3: Chronic lymphocytic leukaemia: refer routinely unless previously discussed with
haematologist. If patient is well and HB and platelets are normal and WBC < 50X10[9]
/Litre then GP can monitor patient with 6 monthly FBCs.
GEORGE ELIOT HOSPITAL (GEH), NUNEATON FAX REFERRAL TO: 02476 865670
Clinical advice may be obtained from:
Consultant:
Dr M Narayanan
024 7686 5033
Out of hours:
Doctor on call for Haematology through GEH Switchboard
02476351351
ST CROSS HOSPITAL, RUGBY
FAX REFERRAL TO: 024 7684 4185
Clinical advice may be obtained from:
Consultants:
Dr A Cader
01788 545190
Out of hours: Doctor on call for Haematology through Walsgrave switchboard
UNIVERSITY HOSPITALS COVENTRY AND WARWICKSHIRE NHS TRUST, COVENTRY
FAX REFERRAL TO: 024 76968520
Clinical advice may be obtained from:
Consultants:
Dr B. Harrison
024 7653 8866
Dr N. Jackson
024 7653 5108
Dr O. Chapman
024 7653 8612
Dr J. Mills
024 7653 5954
Out of hours: Doctor on call for Haematology through Walsgrave switchboard 024 76 602020
WARWICK HOSPITAL, WARWICK
FAX REFERRAL TO: 01926 482665
Clinical advice may be obtained from:
Consultants:
Dr P. Rose
01926 495321 ext 4209/4214
Dr A. Borg
01926 495321 ext 4498/4214
Out of hours: Doctor on call for Haematology through Warwick switchboard0
Revised APRIL 2006: NOTE THIS NEW FORM MUST BE USED FROM 1.7.06 ONWARDS
[GEH Fax: 02476865670 / UHCW Fax: 02476968520 / WARWICK Fax: 01926482665]
Patient aware of
reason for referral
NHS
Yes
ARDEN CANCER NETWORK TWO WEEK WAIT REFERRAL SERVICE
This referral is made on the basis that the referring doctor consider that the patient
has clinical indications of a new malignancy
HAEMATOLOGY
REASON FOR REFERRAL

TICK
FBC with film report suggesting acute leukaemia or chronic myeloid
leukaemia
(Please attach FBC report)

Hepatosplenomegaly, with an abnormal FBC

Bone x-rays suggestive of myeloma

Lymphadenopathy > 1cm for 6 weeks or increasing in size and for > 2 cm

Bone pain with anaemia and a  ESR/plasma viscosity or renal impairment
An abnormal FBC AND a constellation of 3 or more of the following:
(Suggest perform chest x-ray and infection screen (e.g. urine culture) at the time of referral)
Fatigue
Itching
Recurrent infections
Night sweats
Breathlessness
Fever
Weight loss
Bone pain
Bruising
Additional history/comments (including medications and / or any recent investigations)
Interpreter required YES/NO: If YES which language?_____________________________
Patient Details
GP Details
Surname:
Name:
Forename:
Address:
Address:
Postcode:
Postcode:
Practice Code:
Hospital No:
GP Code:
NHS No:
Phone:
Date of Birth:
Fax No:
How can we communicate time and date of this urgent
appointment to the patient?
Date of decision to refer:
Phone (day time contact number):
Evening contact number:
For Hospital use only
Criteria for referral met: Y/N
Further investigations for suspicion of cancer: Y/N
Discharge back to GP: Y/N
Further investigations NOT suspicious of cancer: Y/N
Time and date received …………………………………………… Date of appointment ………………………………..
Signed …………………………………………….. Printed ………………………………. Date ………………………….
Comments: ……………………………………………………………………………………………………………………
Revised APRIL 2006: NOTE THIS NEW FORM MUST BE USED FROM 1.7.06 ONWARDS
[GEH Fax: 02476865670 / UHCW Fax: 02476968520 / WARWICK Fax: 01926482665]
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