LCA UROLOGY URGENT SUSPECTED CANCER REFERRAL FORM
Date of GP decision to refer:
/
/20
No. pages faxed:
PLEASE COMPLETE THIS FORM AND FAX TO THE RELEVANT URGENT REFERRAL TEAM WITHIN 24 HOURS
PATIENT DETAILS – please provide multiple contact details
Last name:
First name:
Gender: M / F
Address:
GP DETAILS
GP name and initials:
Practice code:
Address:
Telephone No (daytime):
Telephone No:
Fax No:
Telephone No (evening):
Practice email address:
Mobile no:
INVESTIGATIONS REQUIRED FOR REFERRAL
Email:
DOB:
Interpreter: Y / N
Language:
Ethnicity:
NHS No:
PSA (required for urgent referrals criteria 1 & 2)
First PSA:
Second PSA :
MSU (required for urgent referrals criteria 1 – 5):
Urgent referrals criteria (tick category)
1.
Clinically malignant prostate on rectal examination. PSA result
to be sent with referral
2.
Raised age related PSA (50-60 >3, 60-69 >4, 70+ >6.5, 85+ >20)
on 2 occasions 4 weeks apart, unless the prostate feels
Creatinine level (request at time of referral required for
all urgent referral criteria)*:
*Please tick if creatinine result to follow:
malignant or the PSA is over 20 when immediate referral
appropriate
3.
Visible haematuria in adults >18 years old
4.
Non visible haematuria greater than a trace on dipstick in adults
> 50 years old
5.
Symptoms of UTI with persistent sterile pyuria >60 years old
6.
Palpable renal mass, or renal lesion which is suspicious for
malignancy identified clinically or radiologically
7.
Testicular lump which appears to be intratesticular or solid
suspicious of cancer
8.
Raised/suspicious penile lesion or phimosis with discharge
and/or palpable/hard area beneath prepuce
Other information or symptoms:
PATIENT MEDICAL HISTORY
Current medication**:
Existing conditions*:
**Otherwise please fax current medication list and medical
history
DISCUSSIONS WITH PATIENT PRIOR TO REFERRAL
1. Has the patient been told it is a suspected cancer
referral?
2. Has the patient been given the urgent referral
leaflet?
3. Have you told the patient where they are being
referred to?
4. Have you told the patient they need to be seen
within 14 days?
1
CLINICAL GUIDELINES AND HOSPITAL CONTACT DETAILS ARE ON THE REVERSE OF THIS FORM
LCA TRUST CONTACT DETAILS FOR URGENT UROLOGICAL CANCER REFERRALS
Chelsea and Westminster
NHS Foundation Trust
Fax: 020 3315 8814
Tel: 020 3315 2679
Croydon Health Services NHS
Trust
Fax:
020 8401 3337
Tel:
020 8401 3986
Epsom and St Helier NHS
Trust
Fax: 020 8296 2741
Tel: 020 8296 2742
Guy’s & St Thomas’
Fax: 020 7188 0923
Tel: 020 7188 0902
Hillingdon Hospital NHS Trust
Fax: 01895 279807
Tel: 01895 279698
Alternate Fax: 01895 279890
Imperial College Healthcare
NHS Trust
Fax: 020 3312 1580
Tel: 020 3312 1527
North West London
Hospitals NHS Trust
Fax: 020 8235 4188
Tel: 020 8235 4293
Princess Royal
Fax: 01689 863187
Tel: 01689 865676
Kingston Hospital NHS
Foundation Trust
Fax:
020 8934 3306
Tel:
020 8934 3305
khn-tr.2WW@nhs.net
Lewisham and Greenwich
University Hospitals NHS
Trust (Queen Elizabeth’s)
Fax: 020 8836 4035
Tel: 020 8836 5964/5
King’s College Hospital NHS
Foundation Trust
Fax: 020 3299 1515
Tel: 020 3299 1516
kch-tr.cancerdata@nhs.net
St George’s Healthcare NHS
Trust
Fax: 020 8725 0778
Tel: 020 8725 1111
E-Mail:
cancerreferraloffice@stgeorg
es.nhs.uk
The Royal Marsden NHS
Foundation Trust
Fax: 020 8661 3149
Tel: 0800 731 2325
Email: rmhtr.referrals@nhs.net
West Middlesex University
Hospital NHS Trust
Fax: 020 8321 5157
Tel: 020 8321 6776
CLINICAL GUIDANCE FOR URGENT UROLOGICAL CANCER REFERRALS
Patients with any of the following symptoms should be referred urgently using this proforma:

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Painless visible haematuria in adults
Recurrent (>3 episodes in 6 months) or persistent (on-going despite minimum of 2 weeks antibiotics)
urinary tract infection associated with pyuria in patients aged over 50 years
Unexplained non visible haematuria greater than a trace in patients aged over 50 years
An abdominal mass identified clinically or radiologically that is thought to arise from the urinary tract
Swellings in the body of the testis
Symptoms or signs of penile cancer, including progressive ulceration or a mass in the glans or prepuce
or involving the skin of the penile shaft
Raised or rising age-specific PSA - in men with other co-morbidities or life expectancy <10 years,
consider discussion with patient/carers and/or a specialist before urgent referral
Clinically malignant prostate on DRE. Prostate- specific antigen (PSA) should be measured and the
result should accompany the referral
In male or female patients with symptoms suggestive of a urinary infection and macroscopic haematuria,
diagnose and treat the infection before considering referral. If infection is not confirmed, refer them urgently.
Investigations in primary care required for referral:


PSA –
o If initial PSA result is >20, then an immediate urgent referral should be made.
o Raised or rising age-specific PSA (in men with other co-morbidities or life expectancy <10 years),
consider discussion with patient/carers and/or a specialist before urgent referral
o Where possible and at the discretion of the referrer, two PSA tests should be obtained, 4 weeks
apart, unless the prostate feels malignant upon examination or the first PSA test is >20.
Creatinine –
o All Trusts operate a ‘one stop’ clinic for urgent referrals. Receipt of referrals with renal status
will ensure that patients can undergo contrast imaging at the time of initial appointment
o Referral can be submitted without the results of the creatinine test as long as the test has been
requested at the time of referral and is provided upon request from secondary care.