South east london cancer network head & Neck Urgent Suspected Cancer Referral

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Head & Neck Urgent Suspected Cancer Referral

Please tick the box of the hospital clinic you are referring to and fax this form to the relevant Urgent Referral Team within 24 hours. Guidelines are on the reverse side.

Princess Royal

Fax: 01689 863187

Tel: 01689 865676

Guy’s & St Thomas’

Fax: 020 7188 0923

Tel: 020 7188 0902

Queen Mary’s

Fax: 020 8308 9264

Tel: 020 8308 3230

King’s College

Fax: 020 3299 1515

Tel: 020 3299 1516


Fax: 020 8333 3451

Tel: 020 8333 3450

Section 1 – PATIENT INFORMATION. Please complete in BLOCK CAPITALS.


Patient visited this hospital before?

Y / N







M / F


Patient aware the referral is urgent?

Y / N


Post Code

First language

Interpreter required?

Y / N

Transport required?

Y / N

Daytime Telephone

Home Telephone (if different)

/ Mobile No.

Section 2 – PRACTICE INFORMATION. Use practice stamp if available.

Referring GP / GDP

Date of referral

Practice Address

Post Code



Section 3 – CLINICAL INFORMATION. Please tick the relevant boxes.

Cancer Area Suspected

Signs and Symptoms

Risk Factors





 Salivary glands


 Other (please specify)


 Floor of mouth





NB: do not use this proforma for Thyroid referrals

 Neck lump of recent onset or change

 Swelling in parotid or submandibular gland

 Persistent sore or painful throat

 Hoarseness >2 weeks, negative X-ray

 Dysphagia / pain on swallowing

 Unilateral pain, associated with otalgia

 Ulceration of oral mucosa, or mass persisting for more than 3 weeks

 Red and white patches (speckled / non speckled) of the oral mucosa that are painful, swollen or bleeding

 Heavy smoker / tobacco use

 Heavy alcohol consumption

 Family history of H&N cancer


Additional information - Attach patient computer record summary if available. Continue on separate sheet if required.


Information to support Head & Neck referrals

Refer urgently patients with:

  • An unexplained lump in the neck, of recent onset, or a previously undiagnosed lump that has changed over a period of 3 to 6 weeks.

  • An unexplained persistent swelling in the parotid or submandibular gland.

  • An unexplained persistent sore or painful throat.

  • Hoarseness persisting for more than 2 weeks, with a negative chest X-ray.

  • Dysphagia (localised to neck) or pain on swallowing.

  • Unilateral unexplained pain in the head and neck area for more than 4 weeks, associated with otalgia (ear ache) but a normal otoscopy.

  • Unexplained ulceration of the oral mucosa or mass persisting for more than 3 weeks.

  • Unexplained unilateral red and white patches (including suspected lichen planus) of the oral mucosa that are painful, swollen or bleeding.

  • For patients with persistent symptoms or signs related to the oral cavity in whom a definitive diagnosis of a benign lesion cannot be made, refer or follow up until the symptoms and signs disappear. If the symptoms and signs have not disappeared after 6 weeks, make an urgent referral.

Use this proforma to refer urgently (2 Week Wait)

Other referrals:

All urgent referrals for suspected thyroid cancer should now be made using the new thyroid referral proforma.

Refer urgently to a dentist patients with unexplained tooth mobility persisting for more than 3 weeks.

  • Monitor for oral cancer patients with confirmed oral lichen planus, as part of routine dental examination

  • Advise all patients, including those with dentures, to have regular dental checkups.

Refer urgently for chest X-ray patients with hoarseness persisting for more than 2 weeks, particularly smokers aged older than 50 years and heavy drinkers. If there is a positive finding, refer urgently using the Lung Urgent Suspected Cancer Referral proforma. If there is a negative finding, refer urgently using this proforma.

Refer non-urgently a patient with unexplained red and white patches of the oral mucosa that are not painful, swollen or bleeding (including suspected lichen planus). Use Choose & Book or a letter to refer non-urgently.

Investigations in Primary Care:

With the exception of persistent hoarseness, investigations for suspected head and neck symptoms (like ultrasonography or isotope scanning) are not recommended as they can delay referral.

Patient information and support:

Consider the information and support needs of patients and the people who care for them while they are waiting for the referral appointment. Resources for GPs / GDPs to use are available from the Cancer Network on 020 7188 7090, or visit our website

Approved by the South East London Cancer Network in May 2010

For comments or additional copies contact the Network on Tel 020 7188 7090 / Fax 020 7188 7120 or visit our website:

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