Patient referrals

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A guide for physicians

• Any child (age <17 years) you suspect has a malignancy

• The diagnosis and treatment of childhood cancer can be extremely complex.  New information is continually available as efforts are made to improve the prognosis of a child with a malignancy.
• Accurate and timely diagnosis is important and is helped by a team of professionals that are experienced in the specialized laboratory, radiological, and surgical evaluation needed for diagnosis.
• The Division of Oncology, Hematology and BMT is a member of the Children's Oncology Group (COG), a cooperative group of prominent children's hospitals that are leaders in the diagnosis and treatment of childhood cancer.  This means that the oncologists in the division are in constant communication with centers all over the world and are able to decide on the best possible treatment for any childhood malignancy.

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• As soon as you suspect that your patient has a malignancy, you should call the oncologist on call to discuss the case with her or him.  He or she can be contacted 24 hours/day, seven days/week at: 604-875-2161.  Just ask the operator to page the oncologist on call.
• New patients are assigned to the oncologist who is taking calls for the week.
• It is important to refer your patient to Children’s before a biopsy or surgical intervention is initiated.  The issue is not one of technical competence, but rather optimal processing of tissue for diagnosis.  Many tests are performed on tissue that help make an accurate diagnosis.
• In many cases of childhood cancer, accuracy in diagnosis helps us to determine a treatment protocol.  The more specific a diagnosis, the more refined the treatment can be.  In many instances this may be a difference between a few months of potentially toxic treatment versus little or no treatment.
• It is also important not to initiate any treatment that may interfere with a potential treatment protocol.  For example, many protocols use steroids.  Giving a steroid before diagnosis has been established can not only interfere with the accuracy of the diagnosis, but influence the treatment protocol.
• When you call the oncologist on call, please have the following information ready:
• Name, age, suspected diagnosis/reason for referral, any laboratory or radiology test results, and any special family considerations
• information you have given the family and child
• The oncologist will discuss the urgency of the situation with you and decide on the mode of transportation.

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• While it is important to get your patient to Children’s as soon as possible, there are situations that are more urgent than others:
• For example, a child with suspected leukemia with a high white blood cell count, fever, and lethargy, should be transported on an urgent basis.  These medical transports are coordinated through the Intensive Care Unit physicians at Children’s.
• In contrast, a child with suspected leukemia who presents with adenopathy, hepatosplenomegaly, mild changes on the peripheral blood smear, and few peripheral blast cells, may be less urgent and would not require medical transport, but could be sent by another route.
• Some children may be seen in our Oncology Clinic at diagnosis, while others may need to come through the Emergency Department for admission to the inpatient unit. This may be discussed when you contact the oncologist on call.

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• When you refer a child to the Division of Oncology, Hematology, & BMT the pertinent information is given to members of the oncology team.
• If the child is to be admitted right away, the Emergency Department and the inpatient oncology ward, 3B, are notified.
• If the child will be seen in the Oncology Clinic, the staff is notified and an appointment is made.
• When the child and family arrive at Children’s, the oncologist on call is notified.  Although the child may initially be seen by one of our Clinical Assistants or Fellows, he or she will always be seen by an oncologist.
• The diagnostic workup will commence immediately.  Information and test results will be discussed with the parents and age-appropriate information will be conveyed to the child.
• Every new patient and family is seen by one of our social workers to assist them in dealing with the shock and the emotional and psychosocial aspects of coping with their new situation, as well as practical resources available.
• Nurses who are specially trained in pediatric oncology help guide the child and family through this stressful time.
• Other professionals who are part of the team include a psychologist, physiotherapist, occupational therapist, child life specialist, chaplain, dietitians, schoolteachers, volunteers, and a parent advocate.
• Parents are considered an integral part of the team and are included in all aspects of their child's diagnosis, treatment and care.
• The physician in the patient’s home community is an important member of the team.  Whenever possible, the child should be able to stay in his or her home community, in familiar surroundings with family and friends to provide support.  So anything we can do to facilitate this is a priority.

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• While the initial diagnosis of your patient's cancer is made at Children’s and treatment is started here, we are committed to the “Closer to Home” initiatives set by the government.
• Some of the treatment and monitoring can often be done in the child's home community.  This depends on the level of care you and your community hospital are able to provide.  We will be discussing this further with you as we prepare to send your patient back into your care.
• We will be giving you updates on your patient's diagnosis as well as clear instructions for you about treatment and monitoring. You will be given information about what to look for, when to call us and who to call, as well as when the child needs to come back to Children’s.
• In return, we will need regular updates from you.