SOUTH EAST LONDON CANCER NETWORK
Upper GI 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
Fax: 01689 863187
King’s College
Fax: 020 3299 1515
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 3258/3088
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
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.
Dysphagia
Worsening dyspepsia
Age > 55 years, unexplained and
persistent (4-6 weeks) recent-onset
dyspepsia
Symptoms
Persistent vomiting
Frequency / description
Unexplained upper ab pain
and weight loss +/- back pain
Clinical Examination & Results - attach relevant reports
Epigastric /
Suspicious barium
abdominal mass
meal result
Hepatomegaly
Iron deficiency
Obstructive jaundice anaemia
Hb =
Ultrasound scan? Y / N
Ferritin =
Chronic GI bleeding
Progressive unintentional
weight loss
How much
over
Risk Factors
Barrett’s oesophagus
Known dysplasia,
atrophic gastritis or
Peptic ulcer surgery
intestinal metaplasia
> 20 years ago
History
Previous investigation of upper GI tract
Additional information
Location
Diagnosis
Continue on separate sheet, and attach patient
computer record summary if available.
SOUTH EAST LONDON CANCER NETWORK
Information to support Upper GI referrals
Refer urgently patients:
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Dysphagia
Unexplained upper abdominal pain and weight loss, with or without back pain
Upper abdominal mass with or without dyspepsia
Obstructive jaundice (depending on clinical state)
Patients of any age with dyspepsia and any of the following
o Chronic gastrointestinal bleeding
o Progressive unintentional weight loss
o Persistent vomiting
o Iron deficiency anaemia
o Epigastric mass
o Suspicious barium meal result
Patients aged 55 years and older with unexplained and persistent recent-onset dyspepsia
alone.
Consider an urgent referral for patients presenting with:
 Persistent vomiting and weight loss in the absence of dyspepsia
 Unexplained weight loss or iron deficiency anaemia in the absence of dyspepsia
 Unexplained worsening of dyspepsia and
o Barrett’s oesophagus
o Known dysplasia, atrophic gastritis or intestinal metaplasia
o Peptic ulcer surgery over 20 years ago.
 Use this proforma to refer urgently (2 Week Wait)
Investigations in Primary Care:
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When referring, a full blood count may assist specialist assessment in the outpatient clinic.
This should be carried out in accordance with local arrangements.
For all patients with new-onset dyspepsia, consider a full blood count to detect iron
deficiency anaemia.
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.