SUSPECTED SOFT TISSUE SARCOMA REFERRAL FORM (SOUTHMEAD)

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 difficulties)?      
	Does the patient have the capacity to consent?
Yes    No   	
 Decision to Refer Date:
     	Translator Required: Yes    No   
Language:      	Mobility:
     	

REFERRAL GUIDANCE

•	Soft-tissue sarcomas are managed by the Bristol Sarcoma Service (www.nbt.nhs.uk/sarcoma) 
For patients who meet the agreed 2WW criteria; please complete this pro forma and refer to the Suspected Soft Tissue Sarcoma service via e-Referral
Email: cancerservices@nhs.net
Telephone: 0117 4140532 / 0117 4140509
•	Bone sarcomas should be referred directly to the Oxford Bone Sarcoma Service http://www.ouh.nhs.uk/oxfordsarcomaservice/
•	Suspected paediatric (age < 16) soft-tissue and bone sarcomas should be referred directly the Paediatric Oncology Service at Bristol Royal Hospital for Children using the Childhood Cancer referral form, and should be scanned within 48 hours.
Please refer to the NICE Guidance for suspected cancer referrals: http://www.nice.org.uk/guidance/NG12/chapter/1-Recommendations-organised-by-site-of-cancer#sarcomas
In general:
1.	Arrange an urgent direct access ultrasound scan locally (to be performed within 2 weeks) to assess for possible soft tissue sarcoma in adults with an unexplained lump that is increasing in size

2.	Arrange a suspected cancer pathway referral using this form for adults who have ultrasound scan findings that are suggestive of soft tissue sarcoma, or if ultrasound findings are uncertain and clinical concern persists

3.	In cases where suspicion is low (e.g. probable stable lipoma or cyst), refer for a routine ultrasound locally, with referral using this form only if the scan does not confirm benign disease
Features which may suggest a sarcoma: mass greater than 5cm, enlarging, deep to fascia
Benign lumps measuring less than 10cm in diameter, such as an ultrasound confirmed lipoma, can usually be safely observed. If the patient prefers to have an excision, then an application for NHS funding will be required before routine referral to plastic surgery.
     	

THE REFERRAL

1.	Site of abnormality:      

2.	Trust and Date Ultrasound was performed:      

Please can relevant radiology reports be included with the referral if not available on BNSSG ICE

3.	Reason for referral:      

Please include a medications list, medical history, and comorbidities from your practice system and consider a referral letter for complex cases

Medication 

Problems 

Allergies 

Alcohol Consumption 

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

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%	

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

For hospital to complete

UBRN:

Received date:

Triaged to 2WW clinic appointment: