Skip to main content
  1. Right Decisions
  2. Back
  3. Scottish referral guidelines for suspected cancer
  4. Haematological cancers

Emergency (same day) referral

Refer a person with any of the following as an emergency (same day):

  • Blood count/film reported as suggestive of Acute Leukaemia or Chronic Myeloid Leukaemia (CML).
  • Blood tests or imaging suggestive of myeloma with symptoms/signs of Malignant Spinal Cord Compression or acute kidney injury

 

Urgent suspicion of cancer (USC) referral

Refer a person with any of the following to the Haematology Service as a USC:

  • Lymphocyte count >5 x 109/l and any of the following features:
    • weight loss, fever, or drenching night sweats
    • lymphadenopathy and/or splenomegaly
    • cytopenia (haemoglobin less than 100g/l, neutrophils less than 1.0 x 109/l, platelets less than 100 x 109/l)
  • Test results reported as suggestive of a diagnosis of myeloma (raised paraprotein concentrations, paraprotein bands, or abnormal sFLC or urinary Bence Jones proteins) with one or more CRAB criteria (Raised Calcium, Renal impairment, Anaemia, or Bone pain)
  • Generalised lymphadenopathy particularly with systemic upset (g. drenching night sweats or unintentional weight loss) and/or hepatomegaly and/or splenomegaly

Refer the following for consideration of assessment and / or biopsy via local pathways as a USC:

  • Unexplained isolated lymphadenopathy (2cm or more in size, persisting for six weeks or more, or increasing in size)

 

Assessment of suspected haematological cancers

 

Leukaemia (acute and chronic):

Acute leukaemia often presents rapidly with clinical features of bone marrow failure such as fatigue, pallor, bruising, bleeding and infections which can be particularly severe. Due to extramedullary leukaemic infiltration there can be lymphadenopathy and/or hepatosplenomegaly.

Chronic myeloid leukaemia (CML) usually develops gradually and in the early chronic phase people are often asymptomatic. CML can progress to a more accelerated phase with symptoms arising from the accumulation of abnormal cells in the bone marrow and blood. Clinical features include, anaemia, low platelets, repeated infections, splenomegaly, drenching sweats and weight loss.

Chronic lymphocytic leukaemia (CLL) is an indolent haematological cancer that can be an incidental finding on a blood test or present with lymphadenopathy, splenomegaly, symptoms of associated cytopenia (breathlessness, fatigue, petechiae, infections) or B symptoms (weight loss, fever, or drenching night sweats).

Consider urgent clinical assessment, including full blood count (FBC), of an adult patient with any of the following unexplained features:

  • Pallor
  • Bleeding, bruising or petechial haemorrhage
  • Fatigue
  • Breathlessness
  • Recurrent infections
  • Fever
  • Drenching night sweats
  • Lymphadenopathy (lymph node 2cm or more in size, persisting for six weeks or more, or increasing in size, or generalised lymphadenopathy)
  • Hepatomegaly and/or splenomegaly

 

Lymphoma:

Common presenting features include fatigue, weight loss, night sweats, lymphadenopathy and hepatomegaly and/or splenomegaly. 95% of people with Hodgkin’s Lymphoma present with lymph node involvement.

Consider full blood count, renal function, liver function, calcium, lactate dehydrogenase (LDH), serum protein electrophoresis and HIV serology, for an adult patient with any of the following unexplained features: 

  • Lymphadenopathy (lymph node 2cm or more in size, persisting for six weeks or more, or increasing in size, or generalised lymphadenopathy)
  • Fatigue
  • Drenching night sweats
  • Fever
  • Splenomegaly and/or hepatomegaly
  • Breathlessness
  • Pruritus
  • Weight Loss

 

Myeloma:

Clinical features at presentation include bone pain, symptoms of anaemia, renal impairment (e.g. fatigue, pruritis without rash), and symptoms of hypercalcaemia (e.g. constipation, confusion, polyuria, or polydipsia).

Consider FBC, plasma viscosity or Erythrocyte Sedimentation Rate (ESR), renal function and calcium blood tests for a person, particularly if aged 60 years or over, with any of the following unexplained features:

  • Bone pain, particularly bony back pain
  • Fractures (pathological or fragility), or bone x-rays reported as being suggestive of myeloma
  • Fatigue
  • Polyuria, polydipsia
  • Peripheral neuropathy
  • Recurrent infection (e.g. blood stream infection, pneumonia)

CRAB features of myeloma:

  • Raised Calcium
  • Renal impairment
  • Anaemia
  • Bone pain

Further testing should be done if there are suspicious abnormalities in these initial blood tests or ongoing clinical concern of a myeloma diagnosis. This should include serum immunoglobulins, serum protein electrophoresis, serum Free Light Chains (sFLC) or urinary Bence Jones Proteins if sFLC testing is not available.

Good practice points

Lymphocytosis or raised paraproteins:

Blood test results showing lymphocytosis or raised paraprotein levels without the additional features outlined in the referral criteria above, should not be referred as USC. Local guidelines should be followed for non-USC referral or primary care management.

Myeloma is a difficult cancer to identify, especially in its early stages as it often presents with vague symptoms which could also have many other alternative causes. If blood tests are normal, myeloma is unlikely and other causes of the symptoms should be considered, investigated or referred via non-specific pathways as appropriate40.

Detailed clinical information submitted at the time of request for a blood test helps to improve advice and onward referral for patients.

 

Safety netting:

Baseline tests and investigations should be repeated if a person’s condition remains concerning and unexplained following investigation for other causes. This should be combined with safety netting advice for the patient. For people presenting with non-specific symptoms, the clinician should always consider checking HIV status along with other routine investigations.

 

Splenomegaly:

Splenomegaly can be identified on imaging (e.g. USS or Computed Tomography (CT) abdomen). When assessing splenomegaly, the spleen size calculator could be a useful resource. 

 

Rarer blood cancers:

Further information on blood cancers including rarer cancers such as myeloproliferative neoplasms and myelodysplastic syndromes can be found via Blood Cancer UK or Cancer Research UK resources.

 

Children and young people:

The SRG for haematological cancers in children and young people has different criteria than the adult guideline. Please check the relevant section when considering children and young people.

 

Background

This Guideline is for adult cancer referrals. Please see the Cancer in children and young people guideline for a person within that age range in whom there is concern about a possible haematological cancer.

Haematological cancer is an overarching term for three main groups of cancers: leukaemia, lymphoma and multiple myeloma. These are further divided into sub-types.

Route to diagnosis data for emergency presentations versus GP referrals for haematological cancers is not yet publicly available for Scotland. However, in England (2019 data) the highest proportion (40.0%) of haematological cancers are diagnosed following a GP referral, with emergency presentations accounting for 26.6% of all referrals19. Survival for those diagnosed with a haematological cancer via an emergency route is significantly worse compared to other routes37. There are differences in haematological cancer incidence based on ethnicity. For example, there is a higher incidence of myeloma in people of black ethnicity38.

 

Leukaemia (acute and chronic):

Approximately 670 people are diagnosed with leukaemia in Scotland each year1. Although all ages can be affected, around 70% of new cases occur in people aged 60 years or over1. The most common form of leukaemia in adults is Chronic Lymphocytic Leukaemia (CLL), which is often an indolent disease and an incidental finding.

 

Non-Hodgkin’s lymphoma:

Approximately 1,050 new cases of Non-Hodgkin’s lymphoma are diagnosed in Scotland each year1. Although all ages can be affected, around 75% of cases occur in people aged 60 or over1.

 

Hodgkin’s lymphoma:

Approximately 180 new cases of Hodgkin’s lymphoma are diagnosed in Scotland each year, with around 45% of new cases occurring in people under the age of 40 years1.

 

Myeloma:

Approximately 510 new cases of multiple myeloma and malignant cell neoplasms are diagnosed in Scotland each year, with around 85% occurring in people aged 60 years or over1.

The presence of an isolated paraprotein or Monoclonal Gammopathy of Unknown Significance (MGUS) is not a cancer and is a common incidental finding in the elderly (8.9% of people over 85 years of age)39. MGUS can progress to myeloma or related lymphoplasmacytic malignancies at a rate of 1% per year39. Monitoring of patients with MGUS should be considered after shared decision-making taking into account the risk, benefits, and limitations of further surveillance.