fast-track referral form for women with breast cancer

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Transcript fast-track referral form for women with breast cancer

August 2014 CJ
FORM FOR REFERRING WOMEN WITH BREAST CANCER FOR GENETICS ASSESSMENT
Please indicate type of referral:
Routine referral
FAST TRACK referral*
*NB. FAST TRACK referrals should only be made when outcome will
impact on immediate treatment options and should be agreed with the
on call cancer genetics consultant BEFORE referral is sent.
Telephone: 020 7188 1364
Fax: 020 7188 1369 (for URGENT attn. on call cancer genetics consultant)
Guy’s Genetics Department referral criteria for women with breast cancer
Refer any woman with 1) Breast cancer before age 30, 2) Triple negative breast cancer before age 50, 3) Breast
cancer at any age and a family history of breast and/ or ovarian/ prostate cancer.
Genetic testing may be offered to a woman with breast cancer if she meets the following criteria:
•
Bilateral breast cancer (both cancers diagnosed <50 years)
•
Breast and ovarian cancer
•
Triple negative breast cancer diagnosed <50 years
•
Bilateral breast cancer and a close relative with breast cancer <60 years
•
Breast cancer <45 years and a relative with breast cancer <45 years
•
Breast cancer and three or more relatives with breast or ovarian cancer
•
Jewish or Polish ancestry and breast cancer <50 years
Referring clinician:
Sign:
Title:
Contact number:
Key worker:
Print name:
Hospital:
Email address:
Date:
(NB. Genetics clinician – for GSTT referrals include Key Worker & Breast Unit Manager in all correspondence.)
Patient details:
Full name:
Date of birth:
Address:
NHS number:
GP name, address and telephone no:
Telephone no:
Age at diagnosis:
Hospital number:
Date of diagnosis:
Family history:
Jewish ancestry/ ethnic origin:
*For FAST TRACK REFERRALS ONLY Please answer all questions and continue overleaf if necessary
1.What is the treatment plan (inc. timescales for chemo, planned date of surgery/radiotherapy etc.)?
1.Can surgery be delayed if necessary?
2.What is the histology and receptor status? (NB patient will not be accepted for fast track referral until
the hormone receptor status is known unless she is eligible based on family history alone.)
1.What impact will genetics assessment have on decision-making?
2.Have possible surgical/ treatment implications of assessment been discussed with patient?
(NB. Please refer as soon as possible after diagnosis in order for rapid testing to be considered)