This referral can be used for both Reconstructive and Cosmetic Plastic Surgery Referrals
If the referral is for treatment outside the agreed criteria, please ensure that the Exceptional Factors questions are completed.
FAILURE TO COMPLETE THESE QUESTIONS WILL RESULT IN THE REFERRAL BEING RETURNED TO YOU.
The CCI Referral Guidelines can be found at Plastic Surgery Referral Pathways
Approximately 3,000 people are diagnosed with a primary oesophago-gastric, hepatobiliary or pancreatic cancer in Scotland every year.
Common symptoms of oesophago-gastric cancer include weight loss, dysphagia, heartburn or pain, vomiting and anaemia. Common symptoms of hepatobiliary or pancreatic cancer include jaundice, abdominal mass, epigastric pain and weight loss. The risk of developing an oesophago-gastric cancer is higher in patients of East Asian origin and a higher suspicion of risk should be used in these patients.
An abdominal examination and appropriate blood tests (for example, full blood count, ferritin, urea and electrolytes test [U&Es] and liver function tests [LFTs]) should be performed on all patients with symptoms suggestive of these cancers. These findings can facilitate triage in secondary care. Referral should not be influenced by Helicobacter pylori (H pylori) status. Proton pump inhibitors should be avoided if possible prior to investigation. H2 antagonists may be used for symptomatic relief.
All patients with high-risk features should be referred to a team specialising in the management of oesophago-gastric, hepatobiliary or pancreatic cancers, depending on local arrangements.
Dysphagia (interference of the swallowing mechanism that occurs within 5 seconds of the swallowing process) or odynophagia (pain on swallowing) at any age.
New onset upper gastrointestinal pain or discomfort in people over 55 years.
New or worsening upper gastrointestinal pain or discomfort combined with one or more of the following features:
Persistent vomiting more than 4 weeks.
Upper gastrointestinal pain or discomfort combined with at least one of the following risk factors:
Features of hepatobiliary or pancreatic cancer can be vague and non-specific, and may include:
Dyspepsia under 55 years without accompanying symptoms or risk factors should be managed according to local or national guidelines.
There should be a low threshold for considering investigation (perhaps with discussion about appropriate imaging with a radiologist) or routine referral for patients presenting with:
Reference:
Scottish Referral Guidelines for Suspected Cancer. Scottish Government, August 2014
SIGN Guideline 87 – Management of oesophageal and gastric cancer
Clinical Lead Mr Hakim BenYounes, Chief of Medical Services, NHS Lanarkshire
Review Date March 2017
Lower gastrointestinal symptoms are common presentations in primary care. Rectal bleeding for instance is estimated to affect 14,000 individuals per 100,000 population each year. There are large differences in the predictive value of rectal bleeding for cancer according to its association with other symptoms and signs and the age of the patient. For example, the positive predictive value of rectal bleeding alone is 2.4%, which rises to 8.5% in combination with an abnormal rectal examination.
Different management strategies should be adopted according to cancer risk so that those patients with transient lowrisk symptoms caused by benign disease avoid unnecessary investigation. The following guideline is recommended for managing patients with features associated with a possible diagnosis of colorectal cancer. Guidance for referral to regional genetics centres for those with a family history of colorectal cancer is available available at Scottish Government Health and Social Care website. In patients with ulcerative colitis, a plan for follow up should be agreed.
| High-risk features Urgent suspicion of cancer referral | |
|---|---|
| Bleeding | Repeated rectal bleeding without an obvious anal cause Any blood mixed with the stool |
| Bowel Habit | Persistent change in bowel habit especially to looser stools (more than 4 weeks) |
| Mass | Right-sided abdominal mass Palpable rectal mass |
| Iron deficiency anaemia In men of any age with unexplained iron deficiency anaemia and a haemoglobin of 11g/100ml or below. In non-menstruating women with unexplained iron deficiency anaemia and a haemoglobin of 10g/100ml or below. | Unexplained iron deficiency anaemia |
| Other | Past history of lower gastrointestinal cancer with any of the symptoms above |
Low-risk features
Watch and wait (4 weeks)
Refer if symptoms persist or recur
Reference:
Scottish Referral Guidelines for Suspected Cancer. Scottish Government, August 2014
SIGN Guideline 126 – Diagnosis and Management of Colorectal Cancer
Lead Clinician Mr A Brown, NHS Lanarkshire
Review Date March 2017
Breast symptoms are a relatively uncommon presentation in primary care. It is estimated that between 0.35% and 0.6% of all consultations in Scotland are for breast symptoms. Many of these consultations will be in young women, whereas the biggest risk factor, after gender, is increasing age. Incidence of breast cancer in women aged 30-35 is 33 per 100,000 population and approximately 81% of breast cancers occur in women over the age of 50.
Breast cancer accounts for 30% of cancers in women and around 4,400 people are diagnosed with breast cancer in Scotland each year; approximately 20 of these are men. The following recommendations seek to improve the referral and effective management of breast symptoms in women and men in primary care. Guidance for referral to regional genetics centres for those with a family history of breast cancer is available at Health Improvement Scotland website.
| Urgent suspicion of cancer referral | Routine Referral | Primary care management Issue relevant advice leaflet |
|
|---|---|---|---|
| Lump | Any new discrete lump (in patients over 35 years) New asymmetrical nodularity that persists at review after menstruation (in patients over 35 years) Unilateral isolated axillary lymph node in women Cyst persistently refilling or recurrent cyst | Any new discrete lump in patients under 35 years with no other suspicious features New asymmetrical nodularity that persists at review after menstruation (in patients under 35 years) | Women with longstanding tender lumpy breast and no focal lesion Tender developing breasts in adolescents |
| Nipple symptoms | Bloodstained discharge New nipple retraction Nipple eczema if unresponsive to topical steroids (such as 1% hydrocortisone) after a minimum of 2 weeks | Persistent discharge sufficient to stain outer clothes | Transient nipple discharge which is not bloodstained Check prolactin levels when discharge present Longstanding nipple retraction Nipple eczema if eczema present elsewhere |
| Skin Changes | Skin tethering Fixation Ulceration Peau d'orange | Obvious simple skin lesions such as sebaceous cysts | |
| Abscess/infection | Mastitis or breast inflammation which does not settle after one course of antibiotics | Abscess or breast inflammation even after settled in patients over 35 years | Abscess* or inflammation - try one course of antibiotics to cover staphylococcus and streptococcus (also consider possible anaerobic infection as per local guidelines) |
| Pain | Unilateral persistent pain in post menopausal women Intractable pain that interferes with the patient's lifestyle or sleep | Women with moderate degrees of breast pain and no discrete palpable lesion | |
| Gynaecomastia | Exceptional aesthetics referral to plastic surgery pathway if required Exclude or treat any endocrine cause prior to referral | Examine and exclude abnormalities such as lymphadenopathy or evidence of endocrine condition Review to exclude drug causes Measure hormones (oestrogen, testosterone, prolactin, human chorionic gonadotropin and alpha-fetoprotein) Reassure |
* Any acute abscess requires immediate discussion with secondary care.
Reference:
Scottish Referral Guidelines for Suspected Cancer. Scottish Government, August 2014
SIGN Guideline 134 – Treatment of Primary Breast Cancer
Clinical Lead Dr Juliette Mitchell, Consultant Surgeon, Wishaw General Hospital
Review Date March 2017