Lower GI referral form - Barts Health NHS Trust

LOWER GI Suspected Cancer Referral
(2 Week Wait Referral)
Please FAX within 24 hours to Cancer Pathways department on: 020 7363 8818
Section 1 PATIENT INFORMATION (Please complete in BLOCK CAPITALS)
SURNAME
Date of Referral / /
Date of Birth / /
FIRST NAME
NHS number
UBRN - -
Miss Mrs Ms Mr Other:_________ M [ ] F [ ] Home Tel.
Address
Mobile/Daytime Tel.
Post Code
Language
Ethnicity
Section 2 PRACTICE INFORMATION (Please use practice stamp if available)
Transport Y N Interpreter Y N
Referring GP Locum Y N
Practice Address
Post Code
Telephone
Section 3 CLINICAL INFORMATION (please TICK all applicable entries)
Please enclose print outs of CURRENT medications and PAST MEDICAL HISTORY
All ages
[ ] Definite, palpable, right sided, abdominal
mass
[ ] Definite, palpable, rectal (not pelvic) mass
[ ] Unexplained iron deficiency anaemia
AND:
[ ] Male with a Hb of < 11g/dl
[ ] Non menstruating female with a Hb
of < 10g/dl
Medical History, Known Allergies
DIABETIC: YES/NO
To support NICE guidance 2005
Fax
Over 40 years
[ ] Rectal bleeding WITH a change of bowel habit towards
looser stools &/or increased frequency 6 wks
Over 60 years
[ ] Rectal bleeding persisting 6wks WITHOUT a change in bowel
habit or anal symptoms (e.g. soreness, discomfort, itching, prolapse, pain)
[ ] Change in bowel habit to looser stools &/or more frequent stools
persisting 6 wks WITHOUT rectal bleeding
All Medication
WARFARIN: YES/NO
CLOPIDROGREL: YES/NO
Mandatory Investigations
[ ] PR examination
[ ] Abdo examination
Findings:
Family History incl. relative and age at diagnosis
Discussed urgent suspected cancer referral with patient: Y N
[ ] FBC: Hb:____ MCV ___ Date: __ /__/__
Fitness Rating (ECOG) Please circle approp. no.:
0 Fully active 3 Able to carry out limited self-care,
1 Unable to do strenuous activities mainly confined to bed or chair
2 Able to walk and self-care 4 Completely confined to bed or chair
Your patient may go straight to a diagnostic test, for example, Colonoscopy, Flexi sigmoidoscopy, CT abdo pelvis.
In your opinion would this patient be suitable to go straight to a diagnostic test? Yes / No
Have you told the patient they may go straight to a diagnostic test? Yes / No
Comments/other reasons for urgent referral:
Hospital use only: (Tick where appropriate)
Date Appointment Booked: / / Date of Referral receipt: / /
Target Dates 2ww / / Database: Patient confirmed:
62/7 / /
A separate letter only need accompany if you feel it necessary
To be Approved by the North East London Cancer Network April 2006

LOCAL CONTACT DETAILS
If you wish to discuss any clinical issues concerning this referral please contact:
Mr Roger Le Fur Consultant Colorectal Surgeon 020 7363 8037
Anne Smart Lower GI Nurse Specialist 020 7363 4000 Bleep 287
If you wish to discuss any other aspect of this referral, please contact the Cancer
Pathways Office on 020 7363 8817 / 9275 / 3399
CRITERIA FOR URGENT SUSPECTED CANCER REFERRAL 1
Please FAX the referral form within 24 hours
Refer a patient who presents with symptoms suggestive of colorectal or anal cancer to
a team specialising in the management of lower gastrointestinal cancer, depending on
local arrangements.
Investigations
Always carry out a digital rectal examination in patients with unexplained
symptoms related to the lower gastrointestinal tract.
Where symptoms are equivocal a full blood count may help in identifying the
possibility of colorectal cancer by demonstrating iron deficiency anaemia, which
should then determine if a referral should be made and its urgency.
When referring, a full blood count will assist specialist assessment in the
outpatient clinic.
When referring, no examinations or investigations other than abdominal and
rectal examination and FBC are recommended as this may delay referral

Risk factors
Offer patients with ulcerative colitis or a history of ulcerative colitis a follow-up plan
agreed with a specialist in an effort to detect colorectal cancer in this high-risk group.
Low Risk Criteria
Patients of all ages with the following symptoms and no abdominal or rectal mass
are at very low risk of colorectal cancer and should therefore not be referred under
the two-week system:
• Rectal bleeding WITH anal symptoms, e.g. soreness, discomfort, itching,
lumps, prolapse and pain
• Rectal bleeding with an obvious external cause for bleeding on simple
examination of the perineum, e.g. anal fissure, thrombosed or prolapsed pile
and rectal prolapse
• Transient changes in bowel habit, particularly to harder stools and/or
decreased frequency of defecation
• Abdominal pain as a single symptom WITHOUT other higher risk
age/symptom/sign profiles, an abdominal mass, an iron deficiency anaemia or
intestinal obstruction
If your patient fits these “low risk” criteria, please do not use this form
Refer the patient by means of a routine referral letter
Fitness rating or ECOG
The ECOG (Eastern Cooperative Oncology Group) performance score:
0 = fully active, the same as before suspicion of cancer
1 = unable to do strenuous activities but still able to do tasks such as light
housework or office work
2 = able to walk and carry out self-care (e.g. eating, dressing), but not able to work
3 = only able to carry out limited self-care, mainly confined to bed or chair
4 = completely confined to bed or chair and not able to carry out self-care
1 Based on Referral Guidelines for Suspected Cancer (NICE, 2005) Notes in grey refer to the evidence
grading used in the NICE guidelines, for more information see www.nice.org.uk/cg027NICEguideline)
2 In this guideline, unexplained is defined as ‘a symptom(s) and/or sign(s) that has not led to a diagnosis
being made by the primary care professional after initial assessment of the history, examination and
primary care investigations (if any)’. In the context of this recommendation, unexplained means a
patient whose anaemia is considered on the basis of a history and examination in primary care not to
be related to other sources of blood loss (for example, ingestion of NSAIDs) or blood dyscrasia.