Shaping better health
REMEDY : BNSSG referral pathways & Joint Formulary

Haematology - 2WW

Checked: 06-01-2022 by vicky.ryan Next Review: 05-01-2023

Service Overview

This service is provided by UHBW at Bristol Haematology and Oncology Centre and at Weston General Hospital and by NBT at Southmead Hospital.

At time of referral please issue the relevant BNSSG 2WW Patient Information Leaflet - COVID-19 edition, which is available in English and 14 additional languages.  There is also an Easy Read version of the leaflet.

Referral

Patients should be referred to this service only if they meet the Haematological Cancer 2WW wait criteria as per the NICE CKS Guidance (1)

Patients should be referred using the Haematological Cancer 2WW proforma (word doc).

There are also Local Haematology Guidelines written by UHBW consultants  available in the Haematology section of Remedy and the Haematology Advice and Guidance service run by UHBW and NBT which is available via e-referral.

For Children with suspected Haematological Cancers please refer to the Child and Young People section.

MDT

If advised to refer into an MDT, then please submit a 2WW referral to the relevant secondary care team who will ensure that all the required information is available to enable an effective MDT discussion. 

(1)NICE CKS guidelines: Haematological cancers - recognition and referral

Clinical Guidance

Please also see the following guidelines:

 

Acute Leukaemia

 Acute leukaemia may present with the following:

  • breathlessness 
  • unexpected bruising/petechiae/bleeding
  • recurrent infections 
  • pain in joints or extremities – may be the only presenting symptom in children 
  • fatigue
  • headaches 
  • visual disturbances
  • persistent bone pain
  • bone fractures 

 Initial investigations:

  • full blood count (FBC):
    • in acute leukaemia this will typically show a raised white cell count with low haemoglobin and platelets
  • blood film:
    • usually shows the presence of excess blasts
    • however, in some cases clearly identifiable blasts may not be present, or the white blood cell (WBC) count may even be lower than normal – the only abnormal sign in these cases may be a few atypical cells in the blood film or the presence of leukoerythroblastic features 

If a blood film suggests an acute leukaemia please arrange an immediate admission with a haematologist.

Please note that Chronic Lymphocytic Leukaeamia (CLL) is not an indication for a 2 week wait referral. See the Lymphocytosis section of the Haematology guidelines in primary care for further information.

Lymphoma

Investigation of patients with unexplained lymphadenopathy should include:

  • FBC
  • U+Es
  • LFTs
  • LDH (Lactate Dehydrogenase)

Hodgkin's & Non-Hodgkin's lymphoma - 2WW referrals. Refer if:

  • Unexplained lymphadenopathy - is defined as >1cm and persisting for six weeks (Please note that patients with isolated neck lumps should be referrred to the head and neck service)
  • Unexplained palpable splenomegaly
  • Unexplained radiological splenomegaly plus symptoms or signs

When considering referral, take into account any associated symptoms, particularly unexplained high fever, drenching night sweats (with or without weight loss), shortness of breath, pruritus or alcohol-induced lymph node pain.

Please also see the Lymphadenopathy section of the Haematology guidelines in primary care page for further information.

Myeloma

Symptoms which should trigger consideration of myeloma include:

  • bone disease (common):
    • bone pain especially non-lumbar back pain (e.g. thoracic)
    • pathological fracture or low impact fracture
    • spinal cord compression
  • recurrent or persistent bacterial infection (common)

A myeloma screen includes:

  • Full blood count
  • renal function
  • calcium
  • serum protein electrophoresis & urinary BJP (these must be requested together for screening)

Myeloma is unlikely with a IgG <15g/l or IgA<10g/l in the absence of other symptoms (e.g. renal failure, hypercalcaemia, back pain, bone marrow failure), in which case consider a routine referral

Spinal cord compression or acute kidney injury suspected of being caused by myeloma should be discussed more urgently with on call haematologist

A polyclonal (diffuse) increase in gammaglobulin is not associated with haematological malignancy.

Refer via 2WW if: 

  • results of serum protein electrophoresis AND urinary BJP suggest myeloma
  • radiology reported as suggestive of myeloma and myeloma screen confirms myeloma

When considering referral, take into account other features including: Hypercalcaemia, abnormal full blood count, acute kidney injury.

Please also see the Paraproteins section of the Haematology guidelines in primary care page for further information.