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SOUTH WEST LONDON CANCER NETWORK: Lung Cancer Referral Form Powered By Docstoc
					   SW LONDON CANCER NETWORK Suspected Skin Cancers Referral Form (Melanoma and Squamous Cell Carcinoma) (NICE 2006)

                                                                     Date of GP decision to refer:                                        No. of pages faxed:
         Urgent Referrals Criteria
           (Please tick category)
                                                                                                                                    GP DETAILS
SK 1      Any lesion suggestive of skin cancer                      GP name and initials:                                                GP Practice Code:
SK 2     Any lesion confirmed on biopsy to be
                                                                    Address:                                                             Post Code:

SK 3     Any lesion suspected to be a                     
         melanoma                                                    Telephone No:                                                        Fax. No:
SK 4     Non healing lesions larger than 1                
         cm, with induration and present for
         over 8 weeks
                                                                                                                                  PATIENT DETAILS

                                                                     Last Name:                                                           First Name:

                                                                     Address:                                                             Post Code:

                                                                     Daytime Tel or Mobile:
                                                                                                                                          Gender:            M       F   
                                                                     Date of Birth:
                                                                     Interpreter required?           Y/N
                                                                                                                                          Language:                  Ethnicity:
                                                                     Hospital No:
                                                                                                                                          NHS No:

                                                                           Patient Awareness Questions:                              COMMENTS/OTHER REASONS FOR URGENT REFERRAL

                                                 1. Has the patient been made aware of the nature of their referral? Yes  No 
Please note:-                                    2. Has the patient been supplied with supportive information
     PLC = Pigmented Lesion Clinic              about the Urgent Suspected Cancer referral process?                Yes  No 
     Non-cancerous, benign or                   3. Have you asked the patient if they will be available
cosmetic moles/ lesions will not be removed.     to attend an appointment within the next two weeks?               Yes  No 
     Patients may be asked to                   4. Has the patient indicated to you that they
fully undress for total skin examination.        would be available to attend an appointment within the            Yes  No 
For written/illustrated guidelines               next two weeks?
please contact your local dermatologist.       Please be advised that all applicable fields must be fully completed, and the form properly submitted, or it may be necessary to return this document for
                                               amendment prior to the referral being accepted or actioned. Patients with Basal Cell Carcinoma should not be referred using this form

                                                                                                                                                                                                   April 2006
                  How to make urgent referrals for suspected skin cancers
                        (melanoma and squamous cell carcinoma)

Please FAX this form to the Cancer Office at the relevant hospital, with or without an accompanying
letter. You should receive acknowledgement by fax that your referral has been received. Please
ensure that the referral reaches the hospital within 24 hours of the GP’s decision to refer.

Guidelines for urgent referral:
1. Melanoma
 Pigmented lesions on any part of the body which have one or more of the following features:
                Growing in size                              Changing shape
                Irregular outline                            Changing colour
                Mixed colour                                 Ulceration
Note: Melanomas are usually 5mm or greater at the time of diagnosis, but a small number of patients with
very early melanoma may have lesions of a smaller diameter.

2. Squamous Cell Carcinoma
   Slowly growing non-healing lesions with significant induration on palpation with documented expansion
    over a period of 1-2 months.
   Positive biopsy.
   Patients who are therapeutically immunosuppressed after organ transplant have a high incidence of skin
    cancers, especially squamous cell carcinomas which can be unusually aggressive and metastasize.
    Transplant patients who develop new or growing cutaneous lesions should be referred under the two week
Note: Cancers tend to be larger (>1cm) than actinic keratoses and have a palpable component deep to the
skin surface.

NB Patients with Basal Cell Carcinoma should not be referred using this form.

         Epsom and St Helier NHS Trust                         Epsom and St Helier NHS Trust

           Epsom General Hospital                                   St Helier Hospital
            Dorking Road, Epsom                                  Wrythe Lane, Carshalton
             Surrey KT18 7EG                                        Surrey SM5 1AA

FAX:                       020 8296 2741             FAX:                       020 8296 2741
TEL:                       020 8296 2742             TEL:                       020 8296 2742

          Mayday Healthcare NHS Trust                         St George’s Healthcare NHS Trust

         Mayday University Hospital                                St George’s Hospital
        London Road, Thornton Heath                              Blackshaw Road, Tooting
             Croydon CR7 7YE                                        London SW17 0QT

FAX:                  020 8401 3337                  FAX:                         020 8725 0778
TEL:                  020 8401 3986                  TEL:                         020 8725 1111

          Kingston Hospital NHS Trust                            Kingston Hospital NHS Trust

              Kingston Hospital                                    Queen Mary’s Hospital
               Galsworthy Road                                      Roehampton Lane
              Kingston KT2 7QB                                      London SW15 5PN

FAX:                          020 8934 3306          FAX:                           020 8934 3306
TEL:                          020 8934 3305          TEL:                           020 8934 3305

                                                                                                             April 2006

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