SUSPECTED GYNAECOLOGICAL CANCER REFERRAL FORM

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:
     	

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.

I understand that based on the information given the referral may be triaged into a non 2ww appointment as clinically appropriate. Yes No

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

	
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.	

Ovarian cancer
 physical examination identifies ascites (without known cardiac/liver cause) and/or a pelvic or abdominal mass (which is not obviously uterine fibroids)
 ultrasound suggests ovarian cancer
Please perform CA125 test in parallel with referral (plus LDH, BHCG, AFP if the patient is under 40 years of age)	
Endometrial cancer

Please examine the patient before referral to assess for alternative causes eg cervical cancer
Patients with unscheduled bleeding on <6 months of continuous HRT with no risk factors for hyperplasia or those on cyclical HRT (including perimenopause) please see unscheduled bleeding on HRT pathway (LINK)
 
 Post-menopausal bleeding not on HRT (unexplained vaginal bleeding more than 12 months after menstruation has stopped because of the menopause).
 Persistent unscheduled bleeding on continuous or cyclical HRT >6 months since starting or >3 months since dose or preparation change

 Unscheduled bleeding on HRT <6 months with risk factors for hyperplasia (BMI>40, lynch syndrome, history of un-opposed oestrogen use) or heavy bleeding. 

 Imaging suggests endometrial cancer

Please provide information on the IUS at the point of referral as this may be offered at their OPA

For  heavy peri-menopausal bleeding over 45 / irregular bleeding / heavy menstrual bleeding despite medical treatment, consider an urgent referral to General Gynaecology as per NICE guidelines.
	
Cervical cancer
 appearance of their cervix on examination is consistent with cervical cancer 
For persistent unexplained post-coital bleeding please send swabs to exclude infection, request pelvic USS and consider a referral to Gynaecology/colposcopy
	
Vulval cancer
 unexplained vulval lump, ulceration, bleeding or concern about vulval intraepithelial neoplasia (VIN)	
Vaginal cancer
 unexplained palpable mass in or at the entrance to the vagina 	
Please ensure the following recent blood results are available FOR ALL REFERRALS (less than 8 weeks old)
FBC, Us and E’s	

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 

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 two week wait referral leaflet: Yes No

Please confirm that the patient is aware that their first appointment may be for an USS/CT/MRI or out-patient hysteroscopy: 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?
     

	

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

Medication 

Problems 

Allergies 

Alcohol Consumption 

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

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

	

For hospital to complete	UBRN:
				Received date:

Refer to:
UHB		
NBT		
Weston