Cancer Referral form - Breast

BREAST Suspected Cancer Referral
(2 Week Wait Referral)
To support NICE guidance 2005
Please FAX within 24 hours to the Cancer Referrals Office on:
01708 435074 or 01708 435367
Section 1 PATIENT INFORMATION (Please complete in BLOCK CAPITALS)
SURNAME
Date of Referral / /
Date of Birth / /
FIRST NAME
Miss Mrs Ms Mr Other: _________ M [ ] F [ ] Home Tel.
NHS number
UBRN - -
Address
Mobile/Daytime Tel.
Post Code
Language
Section 2 PRACTICE INFORMATION (Please use practice stamp if available)
Transport Y N Interpreter Y N
Referring GP Locum Y N
Practice Address
Telephone
Fax
Post Code
Section 3 CLINICAL INFORMATION (please TICK all applicable entries)
Please enclose print outs of CURRENT medications and PAST MEDICAL HISTORY
Solid lump
Nodularity
Inverted nipple
Skin infiltration or peau d’orange
SIGNS AND SYMPTOMS
Any age
[ ] with discrete, hard lump with fixation, + / - skin tethering
[ ] unilateral eczematous skin or nipple change that does not
respond to topical treatment
[ ] nipple distortion of recent onset
[ ] spontaneous unilateral bloody nipple discharge
[ ] skin distortion/ tethering/ discolouration/ nodule/ ulceration
Female aged > 30 years
[ ] with a discrete lump persisting after period / post menopause
[ ] with fixed, hard or enlarging lump
Male aged > 50 years
[ ] with a unilateral, firm subareolar mass + / - nipple distortion
or associated skin changes
Duration of Signs
and Symptoms and
further information
PLEASE REFER PATIENTS WHOSE ONLY SYMPTOM IS BREAST PAIN VIA THE ‘OTHER SYMPTOMS’ PROFORMA
Medical History, Known Allergies and Medication
Family History
Discussed urgent suspected cancer referral with patient Y
Comments/other reasons for suspecting cancer
N
Hospital use only: (Tick where appropriate)
Date Appointment Booked: / / Date of Referral receipt: / /
Target Dates 2ww / / Database: Patient confirmed:
62/7 / /
A separate letter need accompany only if you consider it necessary.
Approved by the North East London Cancer Network April 2006_REVISED April 2009_AM

LOCAL CONTACT DETAILS
Cancer Waiting Times Co-ordinator Tel. 01708 435169 Queen’s Hospital
CRITERIA 1 FOR URGENT SUSPECTED CANCER REFERRAL
Please FAX the referral form within 24 hours
Refer a patient who presents with symptoms suggestive of breast cancer to a team specialising in the
management of breast cancer.
In general:
Convey optimism about the effectiveness of breast cancer treatments and survival of breast
cancer patients
Discuss the information and support needs of your patient and respond sensitively
Encourage all patients, including women over 50 years old, to be breast aware²
Always take the patient’s history into account. For example, it may be appropriate, in discussion with
a specialist, to agree referral within a few days in a patient who reports a lump or other symptom that
has been present for several months.
Urgently refer patients with:
• of any age with a discrete, hard lump with fixation, with or without skin tethering
• of any age, with previous breast cancer, who present with a further lump or suspicious symptoms
• female, aged 30 years and older with a discrete lump that persists after their next period, or presents after
menopause
• with unilateral eczematous skin or nipple change that does not respond to topical treatment
• with nipple distortion of recent onset
• with spontaneous unilateral bloody nipple discharge
• male, aged 50 years and older with a unilateral, firm subareolar mass with or without
nipple distortion or associated skin changes.
Please do not use this proforma for non-urgent referrals, but
refer the patient by means of the ‘OTHER SYMPTOMS’ proforma
Incidence
Breast cancer is the most common cancer for women with more than 40,000 new cases in the UK in
2000. There are around 250 cases diagnosed in men each year. The strongest risk factor for breast
cancer is age: the older the woman the higher the risk. The full lifetime risk of developing breast cancer
is 1 in 9, see below for age specific risk information.
Age Risk Age Risk
25 1 in 15,000 60 1 in 23
30 1 in 1900 70 1 in 15
40 1 in 200 80 1 in 11
50 1 in 50 85 + 1 in 10
Source: Cancer Research UK
Most breast cancers detected by screening are stage I tumours with 5 year survival rates over 90% 2.

FAMILY HISTORY INFORMATION 3
Please make symptomatic MEDIUM or HIGH risk family history referrals
via the ‘OTHER SYMPTOMS’ proforma
For advice, see ‘local contacts section’ or contact the Cancer Genetics clinic,
Chris Harocopos, CNS Cancer Genetics, on 020 7905 2138
Low risk women do not need to be seen
Breast awareness information should be offered to the patient 4
In patients aged > 50 yrs participation in the NHSBSP should be encouraged
Before a decision on referral is made, primary care professionals should note that a woman outside the 40–49 year age
group who is estimated to be at moderate risk (e.g., she has only one relative with breast cancer diagnosed at any age, or
she has two relatives diagnosed with breast cancer older than an average age of 50 years) will not generally be offered
additional mammography.
Women at moderate risk outside the 40–49 year age group may be referred for risk counselling and advice on risk
management or consideration for prevention trials. Advice should be sought from the designated contact in secondary care
about the appropriateness of referral.
Women who meet the following criteria should be offered referral to secondary care:
one 1 st degree female relative diagnosed with breast cancer < 40
one 1 st degree male relative diagnosed with breast cancer at any age
one 1 st degree relative with bilateral breast cancer where the 1st primary was diagnosed < 50
or
two 1 st degree relatives, or one 1 st degree AND one 2 nd degree relative, diagnosed with breast cancer at any age, or
one 1 st degree or 2 nd degree relative diagnosed with breast cancer at any age AND one 1 st degree or 2 nd degree
relative diagnosed with ovarian cancer at any age (one of these should be a 1 st degree relative)
or
three 1 st degree or 2 nd degree relatives diagnosed with breast cancer at any age
Advice should be sought from the designated secondary care contact if any of the following are present in the family history
in addition to breast cancers in relatives not fulfilling the above criteria:
• bilateral breast cancer
• male breast cancer
• ovarian cancer
• Jewish ancestry
• sarcoma in a relative younger than age 45 years
• glioma or childhood adrenal cortical carcinomas
• complicated patterns of multiple cancers at a young age
• paternal history of breast cancer (two or more relatives on the father’s side of the family)
Discussion with the designated secondary care contact should take place if the primary care health professional is uncertain
about the appropriateness of referral because the family history presented is unusual or difficult to make clear decisions
about, or where the woman is not sufficiently reassured by the standard information provided.
Direct referral to a specialist genetics service should take place where a high-risk predisposing gene mutation has been
identified (for example, BRCA1, BRCA2 or TP53).
1 Based on Referral Guidelines for Suspected Cancer (NICE, 2005)
Notes in grey refer to the evidence grading used in the NICE guidelines, for more information see
www.nice.org.uk/cg027NICEguideline
2 Breast Cancer Factsheet (Cancer Research UK, Feb 2004)
3 National Institute for Clinical Excellence (2004) Familial breast cancer: the classification and care of women at risk of
familial breast cancer in primary, secondary and tertiary care. NICE Clinical Guideline No. 14. London: National
Institute for Clinical Excellence. Available from: www.nice.org.uk/CG014
4 Breast awareness means the woman knows what her breasts look and feel like normally. Evidence suggests that there
is no need to follow a specific or detailed routine such as breast self examination, but women should be aware of any
changes in their breasts ~see website below for further information:
www.cancerscreening.nhs.uk/breastscreen/breastawareness