DISEASE SITE PATIENT APPROPRIATE FOR REFERRAL REQUIRED FOR REFERRAL PROVIDE IF AVAILABLE BREAST Symptomatic of breast cancer and/or follow up on abnormal mammogram -> Referral to BAC Referral to Breast Assessment Center BAC Phone: 905-521-2100 Ext. 42497 BAC Fax : 905-381-70849o9084 All recent mammography and breast ultrasound reports and pathology on previous biopsies. Biopsy proven breast cancer JCC Referral form History and Physical Mammogram Operative note Pathology U/S CT Scan MRI Previous breast surgery notes and surgical pathology Bone Scan Discharge Summary ER/PR, HER 2Nu status CENTRAL NERVOUS SYSTEM Radiological suspicious mass/or biopsy proven lesion JCC Referral form History and Physical MRI CT brain Associated consult notes Discharge summary if applicable Labs Operative notes Pathology GASTROINTESTINAL (esophagus, stomach, colon/rectum, anus, pancreas, liver, biliary tract/gall bladder) Suspicious esophageal/gastric mass/no tissue -> Referral to EDAP EDAP referral Biopsy proven cancer or high grade dysplasia JCC Referral form History and Physical Labs (CEA, CBC, LFT) Imaging for appropriate anatomy (endoscopy, colonscopy, ERCP) Pathology Tumor markers: liver – AFP Pancreas-19-9 Neuroendocrine- Ki67% Operative Note Discharge summary CT Scan, upper GI series, barium enema, U/S, ERCP, liver scan, bone scan Any associated consult notes GENETICS (Cancer Risk Assessment Clinic) Referral Criteria: JCC Referral form Cancer family history details including age of diagnosis and primary site of cancer in relatives OR OBSP High Risk Screening Requisition referrals for personal and/or family history of breast and/or ovarian cancer ( Completed Family History Questionnaire (FHQ). () Name(s) of relatives that have been seen in our clinic Previous consult notes or laboratory reports of cancer genetic testing from patient and/or family members DISEASE SITE PATIENT APPROPRIATE FOR REFERRAL REQUIRED FOR REFERRAL PROVIDE IF AVAILABLE
KIDNEY Suspicious mass on imaging/or biopsy proven JCC Referral form History and Physical U/S Abd/Pelvic CT Labs: Bun, Cr Pathology Operative Notes LUNG Suspicious mass /no tissue -> Referral to LDAP LDAP referral Suspicious nodule(s) / lesion / mass and Biopsy proven cancer JCC Referral form History and Physical Chest Xray Chest CT Pathology Operative Note Associated consult notes LDAP reports Bronchoscopy Discharge Summary Labs CT, MRI,U/S, Bone Scan Medication List PFT Echo MELANOMA Biopsy proven lesion JCC Referral form History and physical Pathology (biopsy & excision) Operative notes for Wide Local Excision if done Associated consult notes CT U/S MRI Bone Scan MYCOSIS FUNGODIES Biopsy proven JCC Referral form History and Physical Pathology LABS: CBC,LYTES, LFT, BUN, CA, LD, TSH and CMPB if possible Previous treatments including any radiation records Associated consult notes CT Chest/Abd/Pelvis CXR PRIMARY UNKNOWN Metastatic diagnosis without focus of primary JCC Referral form History and Physical Labs Imaging Any pathology done during investigations Past hx of malignancies Operative notes Associated consult notes CT Mammogram U/S MRI Bone scan CXR Any workup done SARCOMA Suspicious mass or biopsy proven sarcoma Suspicious or aggressive bone lesion on imaging JCC Referral form History and Physical Biopsy pathology if available Imaging reports Send CD of U/S, MRI, Bone scan, CXR to be uploaded prior to apt Operative notes Associated consult notes Surgical pathology Discharge summary DISEASE SITE PATIENT APPROPRIATE FOR REFERRAL REQUIRED FOR REFERRAL PROVIDE IF AVAILABLE SKIN Biopsy proven JCC Referral form History and Physical OR notes Photos