Suspected Lower GI Cancer Referral Form

Patient Details Surname: «Pat.Surname» Date of Birth: «Pat.DOB{dateFormat:=%zda/%zmo/%zce %zye}» Forename(s): «Pat.Forenames» Gender: «Pat.Sex» Address (inc postcode): NHS Number: «Pat.NHSNumNew» «Pat.CurrAdd.Full» Hospital Number: Telephone Numbers Tel No (Home): Tel No (work): Tel No (Mobile): Please check tel no's with patient «Pat.HomeTel.Tel» «Pat.WorkTel.Tel» «Pat.MobileTel.Tel» GP Details Referring GP: «Pat.RefDocFullName» GP Tel No: «Prac.Tel» Practice Name: «Prac.Name» Practice Email Address: «Prac.Email» Practice Address: Date of decision to refer: «CurrDate.short» «Prac.AddFull»

Patient Information Does your patient have a learning disability? Yes No Is your patient able to give informed consent? Yes No Is your patient fit for day case investigation? Yes No If a translator is required, please specify language:

IMPORTANT INFORMATION FOR CONSULTANT TO ENABLE TRIAGE STRAIGHT TO TEST: It is very helpful to have Hb, HbA1c, U&E’s and a stool sample for MCS checked within last 6 weeks. If the patient has iron- deficiency anaemia a ferritin level would also be useful. If the patient has diarrhoea testing should ideally include B12, folate, TFTs, TTG, LFTs, calcium and plasma viscosity Is patient on any of the following medications? Aspirin Yes No Indication for therapy: Clopidogrel /Prasugrel etc . Yes No Indication for therapy: Warfarin Yes No Indication for therapy: NOAC (Rivaroxaban etc.) Yes No Indication for therapy: Insulin Yes No Type 1 Type 2

It would be helpful if you could provide performance status information (please tick as appropriate) Fully active Able to carry out light work Up & about 50% of waking time Limited to self-care, confined to bed/chair 50% No self-care, confined to bed/chair 100%

Please confirm that the patient is aware that this is a suspected cancer referral: Yes No 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.

Level of Cancer Concern (completion optional) All patients should meet NICE guidelines for suspected cancer 2015 “I’m very concerned that my patient has cancer” “I’m unsure, it might well be cancer but there are other equally plausible explanations.” “I don’t think it likely that my patient has cancer but they meet the guidelines.”

Reasons for referring Please detail patient and relevant family history, examination ideally including pr, and investigation findings, your conclusions and what needs excluding or attach referral letter.

«Pat.NHSNumNew» Suspected Lower GI Cancer Referral Form

Referral Criteria Colorectal cancer Aged under 50 with rectal bleeding and any of the following unexplained symptoms or findings (consider): abdominal pain;

change in bowel habit;

weight loss;

iron-deficiency anaemia (Hb and ferritin within the past four weeks would be extremely helpful)

Aged 40 and over with unexplained weight loss and abdominal pain

Aged 50 and over with unexplained rectal bleeding

Aged 60 and over with either of: iron-deficiency anaemia or

changes in bowel habit

Consider referring any adult with a rectal or abdominal (but not pelvic) mass that you suspect could be cancer (No age range in NICE guidance)

The NICE guidance suggests faecal occult blood testing for some patients. This test is not yet available. Please use your own clinical judgement regarding the best course of action as you are presently.

For Plymouth Hospitals Trust: Please note the IDA form is no longer in use. Anal cancer unexplained anal mass or unexplained anal ulceration (consider) Additional Information The Lower GI Cancer Team would like to stress that you have referred this patient on the 2ww pathway for cancer exclusion, therefore  We would kindly ask that the referral form is fully completed. Incomplete forms may result in it not being possible to triage your patient and this may lead to a delay in their treatment.  If cancer is not detected and no further action is required, the patient will be discharged back to your care with advice if needed.  Any urgent findings will be acted upon by the consultant team.

Clinical Summary

Clinical History (significant past and current medical history): «Pat.Readcodes{problems;}» «Pat.Readcodes{current:=50y;type:=Non-Pat»

Current Medication: «Pat.CurrRepeats{current:=12m;fulldose:=Y» «Pat.CurrAcutes{current:=3m;fulldose:=Yes»

Blood Tests (if available – last 3 months) It is very helpful to have Hb, HbA1c, U&E’s, and a stool sample for MCS checked within last 6 weeks. If the patient has iron-deficiency anaemia a ferritin level would also be useful. If the patient has diarrhoea testing should ideally include B12, folate, TFTs, TTG, LFTs, calcium and plasma viscosity. In addition to these suggested blood tests, we would appreciate any other blood test results within the past three months as they may help diagnosis and treatment

Allergies: «Pat.Allergies{current:=12m;}»

Smoking: «Pat.EncValue{field:=SMOKING» «Pat.NHSNumNew» New Devon CCG 2ww Lower GI Cancer Referral Form V1 Nov 2016 Suspected Lower GI Cancer Referral Form

BMI (if available): «Pat.EncValue{field:=BMI;latest:=yes;}»

Alcohol (if available) Pat.EncValue{field:=ALCOHOL CODE;current:=12m;latest:=yes;}

Please send this Suspected Lower GI Cancer referral to the appropriate Provider for your area using their preferred method

2ww Provider Please Use Select Service/email address Plymouth Hospitals NHS Trust NHS e-Referral DRSS-Western-2WW Lower GI -NEW Devon CCG-99P Torbay & South Devon NHSFT NHS e-Referral 2WW Colorectal Clinical Assessment-TSDFT-RA9 Royal Devon & Exeter NHSFT NHS email [email protected] Northern Devon Healthcare NHS Trust NHS e-Referral 2WW Colorectal Surgery/Lower GI - NDHCT - NDDH - RBZ

For hospital to complete UBRN: Received Date:

«Pat.NHSNumNew» New Devon CCG 2ww Lower GI Cancer Referral Form V1 Nov 2016