SOUTH EAST LONDON CANCER NETWORK
Lung 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.
King’s College PRUH site
Kch-tr.br-2weekwait@nhs.net
Tel: 01689 866701/65790/65794
Queen Elizabeth
Fax: 020 8836 4035
Tel: 020 8836 5964/5
Guy’s & St Thomas’
Fax: 020 7188 0923
Tel: 020 7188 0902
Fax: 01689 863187
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 3230
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
Fax
Post Code
SECTION 3 – CLINICAL INFORMATION. PLEASE TICK THE RELEVANT BOXES.
Symptoms
Haemoptysis
Chest and / or
None
shoulder pain
Once
Dyspnoea
Persistent
Hoarseness
History
Current / ex-smoker
Asbestos exposure
COPD
Prior cancer
diagnosis
Type
Date Diagnosed
Weight loss
Amount
Cough
Changes in
Over period
underlying chronic
respiratory problems
Clinical Examination
Chest signs
Finger clubbing
Signs of SVCO
Cervical LNS
Signs of metastases
Chest X-ray Results
Additional Information
Continue on separate sheet, and attach patient
computer record summary if available.
SOUTH EAST LONDON CANCER NETWORK
Information to support Lung referrals
Refer urgently patients with:

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
Persistent haemoptysis in smokers or ex-smokers aged 40 years and older.
A chest X-ray suggestive of lung cancer (including pleural effusion and slowly resolving
consolidation).
A normal chest X-ray where there is a high clinical suspicion of lung cancer.
A history of asbestos exposure and recent onset of chest pain, shortness of breath or unexplained
systemic symptoms where a chest X-ray indicates pleural effusion, pleural mass or any suspicious
lung pathology.
 Use this proforma to refer urgently (2 Week Wait)
Refer urgently* for a chest X-ray patients with:
* the report should be returned within 5 working days


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Haemoptysis.
Unexplained or persistent (>3 wks)
o Chest and/or shoulder pain
o Dyspnoea
o Weight loss
o Chest signs
o Hoarseness
o Finger clubbing
o Cervical or supraclavicular lymphadenopathy
o Cough
o Features suggestive of metastasis from a lung cancer (e.g. brain, bone, liver, skin).
Underlying COPD with unexplained changes in existing symptoms.
Chest pain, breathlessness in a patient known to have asbestos exposure.
 Follow local procedures for urgent chest X-rays
Refer immediately (acute admission) patients with:


Signs of superior vena caval obstruction (swelling of the face/neck with fixed elevation of jugular
venous pressure).
Stridor.
 Refer to hospital immediately by phone / A&E
Risk factors:


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All current or ex-smokers.
Patients with COPD.
People who have been exposed to asbestos.
People with a previous history of cancer (especially head and neck).
An urgent referral for a chest X-ray or to a specialist can be considered sooner in these patients (for
example, if signs and symptoms have lasted less than 3 weeks).
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.
Approved by the South East London Cancer Network in November 2006.
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.