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13.11.27 2 week rule referral guidelines

Bones
  • Palpable lump that is either: 
    • Greater than 5cm in diameter 
    • Deep to fascia, fixed or immobile
    • Increasing in size 
    • Painful 
    • A recurrence after previous excision 
  • Xray suspicious of cancer

Neuro
  • Progressive development of:
    • Limb weakness
    • Visual impairment
    • Ataxia
    • Dysphasia
  • Focal seizures with:
    • Post-ictal deficit
    • Progressive neurological signs
  • Progressive recent headache with:
    • Vomiting
    • Papilloedema
  • History of specific malignancies within 10 years:
    • Melanoma
    • Breast
    • Renal
    • Lung
  • New onset of:
    • Non-migraine headache
    • Epilepsy

Breast
  • Any age with a discrete, hard lump with fixation with or without skin tethering 
  • Discrete lump – Patient > 30 year persisting after next period or after menopause 
  • Breast skin distortion / ulceration / nodule 
  • New nipple retraction / distortion / eczema 
  • Spontaneous unilateral & / or Bloodstained nipple discharge 
  • Asymmetrical nodularity persisting after period in Patient > 30 years old 
  • Axillary lymphadenopathy 
  • Suspicion of recurrent breast cancer

Colorectal
  • Rectal bleeding with change of bowel habit of 6 weeks duration (age 40 and over) 
  • Rectal bleeding without change in bowel habit with no obvious cause 6 weeks duration (age 60 and over) 
  • Change of bowel habit persisting for 6 weeks or more without bleeding (age 60 years and over) 
  • Right Lower Abdominal mass consistent with involvement of large bowel (any age) 
  • Palpable rectal (not pelvic) mass (any age) 
  • Males of any age with Hb less than 110
  • Non menstruating female with Hb less than 100

Gynae
  • Suspicion of cervical cancer 
  • Suspicion of Vulval cancer 
  • Postmenopausal bleeding in women with a uterus 
  • Suspicious bleeding on HRT 
  • Suspicious mass on pelvic ultrasound (multilocular or solid mass with or without ascites) 
  • IMB in women age after 45 

Haematology
  • Persistent unexplained splenomagaly
  • Immediate referral:
    • Blood count/film reported as acute leukaemia 
    • Spinal cord compression or renal failure suspected cause myeloma 

Head and neck
  • Unexplained lump in the neck, of recent onset
  • Previously undiagnosed lump that has changed over a period of 3 to 6 weeks 
  • Unexplained persistent swelling in the parotid or submandibular gland 
  • Unexplained persistent sore or painful throat 
  • Unilateral unexplained pain in the neck and neck area for more than 4 weeks, associated with otalgia but a normal otoscopy 
  • Unexplained ulceration of the oral mucosa or mass persisting for more than 3 weeks 
  • Uexplained red and white patches (including suspected lichen planus) of the oral mucosa that are painful or swollen or bleeding

Lung
  • Smokers or ex-smokers >40 years with persistent haemoptysis 
  • Chest X-ray suggestive of lung cancer 
  • Normal chest X-ray where there is a high suspicion of lung cancer

Neuroblastoma
  • Child with:
    • Proptosis 
    • Unexplained back pain 
    • Leg weakness 
    • Unexplained urinary retention 
  • Wilm’s tumour (all ages) 
    • Abdominal mass with persistent/progressive abdominal distention (immediate referral)
    • Haematuria 
    • Suspicious symptoms unable to undertake abdominal examination

Skin
  • Pigmented skin lesion scoring 7 or more:
    • Change in size (2)
    • Irregular shape (2)
    • Irregular colour (2)
    • Largest diameter 7mm or more (1)
    • Inflammation (1)
    • Oozing (1)
    • Change in sensation (1)
  • Lesion suspected to be melanoma
  • Non-healing keratinizing or crusted tumours larger than 1cm with significant induration on palpation
  • Immunosuppressed patients with new or growing cutaneous lesions 
  • Histological diagnosis of squamous cell carcinoma

Soft tissue sarcoma
  • Unexplained mass with following features:
    • Deep to fascia 
    • Non-tender 
    • Progressively enlarging 
    • Enlarging regional lymph node 
    • Mass greater than 2 cm

Thyroid
  • Thyroid swelling plus:
    • Solitary nodule, typically hard, increasing in size 
    • Unexplained hoarsness/voice change 
    • Enlarged cervical nodes 
    • Family history of endocrine tumour 
    • History of neck radiation 
    • Aged 65+ 
    • Prepubertal patients 

Upper GI
  • Dysphagia 
  • Over 45 with:
    • Unintentional weight loss with dyspepsia P
    • Persistent vomiting/anorexia/ early satiety 
    • Iron deficiency anaemia and dyspeptic symptoms 
    • Painless obstructive jaundice 
    • Persistent new-onset dyspepsia (despite 1/12 therapy) 

Urology
  • Prostate 
    • Hard, irregular prostate
    • Rising/raised age-specific PSA with normal prostate 
    • Symptomatic with high PSA
  • Bladder and renal 
    • Painless macroscopic haematuria without UTI 
    • Over 40 with persistent/recurrent urinary tract infection associated with macroscopic haematuria 
    • Clinical/imaged urinary tract mass 
    • Over 50 with unexplained microscopic haematuria on urine microscopy without infection 
  • Testicular 
    • Swelling/mass in body of testis 
  • Penile 
    • Symptoms/signs of penile cancer 

Urgent OGD
  • Chronic gastrointestinal bleeding
  • Progressive unintentional weight loss
  • Dysphagia
  • Persistent vomiting
  • Iron deficiency anaemia
  • Epigastric mass
  • Suspicious barium meal
  • Recent/Unexplained/Persistent symptoms in a patient over 55

Children under 16
  • Leukaemia 
    • Unexplained petechiae 
    • Hepatosplenomegaly
  • Lymphomas 
    • Hepatosplenomegaly 
    • Mediastinal or hilar mass on chest X-ray
    • Unexplained shortness of breath and unexplained petechiae or hepatosplenomegaly 
    • Non-tender, firm or hard lymph nodes 
    • Lymph nodes greater than 2cm in size 
    • Lymph nodes progressively enlarging 
    • Other features of general ill-health, fever or weight loss 
    • Axillary node involvement (in the absence of local infection or dermatitis) 
    • Supraclavicular node involvement 
  • Brain and CNS
    • Reduced level of consciousness 
    • Headache and vomiting that cause early morning waking or occur on waking 
    • Children younger than 2 years with:
      • New-onset seizures 
      • Bulging fontanelle 
      • Extensor attacks 
      • Persistent vomiting 
    • Abnormal increase in head size 
    • Arrest or regression of motor development 
    • Altered behaviour 
    • Abnormal eye movements 
    • Lack of visual following 
    • Poor feeding/failure to thrive 
    • Squint, urgency dependent on other factors  
  • Neuroblastoma
    • Children younger than 6 months with: 
      • Lump in the abdomen 
      • Small lumps on the skin 
    • Proptosis 
    • Unexplained back pain 
    • Leg weakness 
    • Unexplained urinary retention
  • Wilm’s tumour 
    • Lump
    • Haematuria 
  • Soft Tissue Sarcoma
    • Unexplained mass at almost any site that has one or more of the following features: 
      • Deep to the fascia 
      • Non-tender 
      • Progressively enlarging 
      • Associated with a regional lymph node that is enlarging 
      • Greater than 2cm in diameter 
  • Bone Sarcoma (osteosarcoma and Ewing’s sarcoma) 
    • Persistent localised bone pain/swelling with X-ray showing signs of cancer 
    • Rest pain, back pain and unexplained limp 
  • Retinoblastoma 
    • White papillary reflex (leukocoria) 
    • Suspicious new squint or change in visual acuity if cancer is suspected 
    • Family history of retinoblastoma and visual problems 
  • General 
    • Presents several times with the same problem, but with no clear diagnosis 
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