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