SUSPECTED HAEMATOLOGICAL CANCER REFERRAL FORM
Referrer Details 	Patient Details 	
Name:	Free Text Prompt 
	     	Forename:
Given Name 	Surname:
Surname 	DOB: Date of Birth 	
Address:
Organisation Full Address (stacked) 
	Address:	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 difficulties)?      
	Does the patient have the capacity to consent?
Yes    No   	
Decision to Refer Date:
     	Translator Required: Yes    No  
Language:      	Mobility:      	

Level of Concern
 I think it is likely that this patient has cancer, and would like the patient to be investigated further even if the first test proves negative, including a Consultant to Consultant referral if deemed appropriate. All non-site specific symptoms (e.g. iron deficiency anaemia, unexplained weight loss) are listed in the clinical details section below.

Clinical details
Please detail your conclusions and what needs to be excluded, or attach referral letter.
     

Acute Leukaemia
If a blood film suggests an acute leukaemia please arrange an immediate admission with a haematologist.	
Myeloma
 results of serum protein electrophoresis AND urinary BJP suggest myeloma
 radiology reported as suggestive of myeloma and myeloma screen confirms myeloma

When considering referral, take into account other features including:
Hypercalcaemia, abnormal full blood count, acute kidney injury.

•	A myeloma screen includes: full blood count, renal function, calcium, serum protein electrophoresis AND urinary BJP 
•	Myeloma is unlikely with a IgG <15g/l or IgA<10g/l in the absence of other symptoms (e.g. renal failure, hypercalcaemia, back pain, bone marrow failure), in which case consider a routine referral 
•	Spinal cord compression or acute kidney injury suspected of being caused by myeloma should be discussed more urgently with on call haematologist 
•	A polyclonal (diffuse) increase in gammaglobulin is not associated with haematological malignancy.

Please refer to local guidelines here.	
Hodgkin's & Non-Hodgkin's lymphoma

 unexplained lymphadenopathy 
Unexplained lymphadenopathy is defined as >1cm and persisting for six weeks
Please note that patients with isolated neck lumps should be referred to the Head and Neck service 
 unexplained palpable splenomegaly 
 unexplained radiological splenomegaly plus symptoms or signs
When considering referral, take into account any associated symptoms, particularly unexplained high fever, drenching night sweats (with or without weight loss), shortness of breath, pruritus or alcohol-induced lymph node pain.	
Please ensure the following recent pathology results are available (less than 8 weeks old)

Myeloma
FBC, renal function, calcium, serum protein electrophoresis, urinary BJP
Lymphoma
FBC U+Es, LFTs, LDH	

CLL is not an indication for a 2 week wait referral

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 for greater than 50%
 4  Confined to bed/chair 100%	
BMI if available
BMI 		

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:      

If the patient is not available for the next 2 weeks, and is aware of the nature of the referral, consider seeing again to reassess symptoms and refer when able and willing to accept an appointment.	

Please attach additional clinical issues list from your practice system.

Details to include:

Medication 

Problems 

Allergies 

Family History 

Alcohol Consumption 

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

Trust Specific Details	

For hospital to complete	UBRN:
				Received date:	
Refer to:
UHB		
NBT		
Weston