SUSPECTED UPPER GASTROINTESTINAL TRACT CANCER REFERRAL FORM

Use ICE Straight to Test Endoscopy/Urgent Direct Access Diagnostics where appropriate
Do not delay referral while waiting for blood test results
Please ensure all fields are completed, this will help ensure the patient is seen in the most appropriate clinic and in a timely way.  Requesting additional information can delay appointments.

REFERRER DETAILS	PATIENT DETAILS 	
Name:	Free Text Prompt 
	     	Forename:
Given Name 	Surname:
Surname 	DOB: Date of Birth 	
Address:
Organisation Full Address (stacked) 
	Address:
Home Full Address (stacked) 	Gender: Gender(full) 
	
		Hospital No.: Hospital Number 
	
		NHS No.: NHS Number 	
Tel No:
Organisation Telephone Number 	Tel No. (1): Patient Home Telephone 	Please check telephone numbers	
	Tel No. (2): Patient Mobile Telephone 		
Email:
Organisation E-mail Address 	Carer requirements (has dementia or learning disabilities)?      
	Does the patient have the capacity to consent? 
Yes          No 	
Decision to Refer Date:
     	Translator Required: Yes    No 
Language:      	Mobility:
     	

 High Level of Concern

Within the limits of this test, if it is negative for cancer the patient will be taken off the cancer pathway, but if there are specific concerns, the endoscopist can refer the patient to clinic. For this to happen effectively and so the correct clinic can be requested, please explain your specific clinical concerns/questions below:  
     
	
Please confirm that the patient has been made aware that this is a suspected cancer referral: Yes No

Please confirm that the patient has received the urgent fast track referral leaflet: Yes No

Please provide an explanation if the above information has not been given:

     

If your patient is found to have cancer, do you have any information which might be useful for secondary care regarding their likely reaction to the diagnosis (e.g. a history of depression or anxiety, or a recent bereavement from cancer might be relevant) or their physical, psychological or emotional readiness for further investigation and treatment?
     
	
Date(s) that patient is unable to attend within the next two weeks:      

For patients to be managed in a timely way for any eventual treatment, we aim to see them within 10 days of receiving this referral.  Please ensure that the patient understands this expectation and the clinical importance of making themselves available for urgent assessment.	
Oesophago-gastric Disease	
Oesophageal and Stomach Cancer
 Gastrointestinal endoscopy suggestive of oesophageal or stomach cancer    Please include report
If meets below criteria and medically fit for OGD please refer for an USC Upper GI endoscopy on ICE, only refer via ERS if not fit for straight to test OGD
Consider whether also meets criteria for urgent direct access CT Abdomen/Pancreas
 Dysphagia
 Upper abdominal mass consistent with stomach cancer
 Age ≥55 with weight loss AND any one of the following (please record which):
 Reflux             Upper abdominal pain          Dyspepsia 	
Hepatobiliary Disease	
Pancreatic cancer
For patients with suspected pancreatic cancer, please perform a liver function test in parallel with the referral. Please do not delay referral waiting for the blood results or scans if not already performed
Further information on the pancreatic pathway can be found on the SWCN website here
JAUNDICED PATIENT
 Jaundiced patient with suspected pancreatic cancer symptoms
 CT indicates pancreatic cancer                Please attach report
 Ultrasound indicates pancreatic cancer    Please attach report

NON JAUNDICED PATIENT
 Patient has symptoms that suggest new pancreatic cancer 
 CT indicates pancreatic cancer                Please attach report
 Ultrasound indicates pancreatic cancer    Please attach report
	
Liver cancer
 Ultrasound result indicates liver cancer Please attach report
 CT result indicates liver cancer Please attach report
 MRI result indicates liver cancer Please attach report
	
Gall bladder cancer 
 Ultrasound result indicates gall bladder cancer Please attach report
 CT result indicates gall bladder cancer Please attach report
	
Gall bladder polyps 
 Ultrasound result indicates gall bladder polyp Please attach report
 CT result indicates gall bladder polyp Please attach report
These patient may be directed to a non-2ww pathway if the findings are not considered concerning and interval follow-up imaging is planned	
Pancreatic cysts
 Ultrasound result indicates pancreatic cyst  Please attach report
 CT result indicates pancreaticcyst Please attach report
These patient may be directed to a non-2ww pathway if the findings are not considered concerning and interval follow-up imaging is planned	
	
Patient Information
If the patient has a mobile phone, please provide the number and advise the patient to bring their phone when they attend the hospital. 
Mobile phone number:     
The first appointment may be a test (USS, CT or MRCP).  If this inappropriate please state the reasons:
     

	
	
Suggested Blood Tests and Clinical Details 
Please ensure that the following recent blood results are made in parallel with the referral (less than 8 weeks old):

FBC, MCV, LFT, U&E, EGFR, Iron studies

For suspected pancreatic cancer, include CA 19-9, Clotting
For suspected liver cancer, include Ca19-9, alpha feto protein and CEA

 Patient on anticoagulants (please specify which)      
	
Smoking status
Smoking 

	WHO Performance Status: 
 0  Fully active
 1  Able to carry out light work
 2  Up and about greater than 50% of waking time
 3  Confined to bed/chair greater than 50%
 4  Confined to bed/chair 100%	
BMI if available
BMI 

Please attach the additional clinical issues list from your practice system
Details to include:

Current medication, significant issues, allergies, relevant family history, alcohol status and morbidities	
Trust Specific Details

Medication 

Problems 

Allergies 

Alcohol Consumption 	

Family History – please add any relevant information from the patient’s record
     

For hospital to complete	UBRN:
				Received date:	

Refer to:
UHB		
NBT		
Weston