STH Stereotactic Ablative Body Radiotherapy (SABR) Referral Form

This referral form is currently under development. DO NOT USE for live referrals yet.

The SABR MDT is held every Friday at 8.30am via MS Teams. For discussion in the same week, referrals need to be received by Wednesday at 12 noon. Incomplete referrals will be returned to the referrer.

– Referrer Information

Referring Clinician (please state full title) (Required)

Referring Clinician Email Address (nhs.net emails only) (Required)

Referring Hospital Trust (Required)

Email Address for MDT Outcome (only provide a single, valid nhs.net email address) (Required)

+ Patient Details

Patient Name (Required)

Patient Date of Birth (Required)

Patient Age

Patient STH Hospital Number (if known) or NHS Number (Required)

Is the patient aware of the referral and can be contacted directly if suitable for SABR? (Required)

+ Clinical Information

Primary Diagnosis and Site of Disease (please include TNM) (Required) (maximum 500 characters)

WHO Performance Status (Required)

If WHO Performance Status >2, please provide additional details to confirm suitability (maximum 500 characters)

Brief History (details of findings) (Required) (maximum 1000 characters)

Has the patient been discussed/considered for surgery? (Required)

Was this found via Lung Screening Programme (LHC)? (Required)

Comorbidities (Required) (maximum 500 characters)

Life expectancy >6 months? (Required)

Is the patient able to lie flat for up to 30 minutes? (Required)

Herder Score (%)

Biopsy feasible? (Required)

If biopsy is not feasible, why not? (maximum 500 characters)

Pathological Diagnosis if biopsy successful (maximum 500 characters)

Lung Function Tests: FEV1, FVC, TLCO (+/- CPEX) (Required) (maximum 500 characters)

Date of Local Site MDT

Outcome of Local Site MDT (Required) (maximum 500 characters)

+ Imaging

Please provide the relevant imaging dates. PET should be within 8 weeks of referral.

PET Date (within 8 weeks of referral) (Required)

CT Date (Required)

+ Other

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