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Spotting blood cancers early – a five point plan

Dr Karthik Ramasamy is a consultant haematologist who set up a rapid access haematology diagnostic service at GenesisCare. Here he gives practical advice to GPs who have a pivotal role in identifying blood cancer early.

Dr Karthik Ramasamy, consultant haematologist, GenesisCare
Dr Karthik Ramasamy, consultant haematologist, GenesisCare

One in every five diagnosed cancers is a blood cancer.1 It is not a preventable cancer, the only common risk factor is increasing age, and so the incidence is increasing too.

However, despite its prevalence there is no screening programme and symptoms are frustratingly vague. Not surprising then that 28% of blood cancers are diagnosed in emergency care, and an estimated 30% of patients have visited their GP three times or more before a referral.2

In 2019, blood cancer charity Bloodwise published a report highlighting an urgent need for better and earlier diagnosis, proposing rapid access clinics and more education for GPs to spot blood cancer.1

These five steps will help GPs meet this challenge.

1. Be alert to non-specific symptoms

Symptoms can be subjective or mistaken by patients for less serious conditions such as flu or being ‘run down’. Anecdotally, we know that on presenting in primary care, these symptoms can often be put down to other factors, lifestyle in the case of extreme fatigue; general wear and tear in the case of persistent back pain, and infection for an underarm or neck lump. But these are all red flags. NICE guidelines for haematological cancers advise investigating any of these symptoms:3

Leukaemia

  • Pallor
  • Persistent fatigue
  • Unexplained fever
  • Unexplained persistent or recurrent infection
  • Generalised lymphadenopathy
  • Unexplained bruising
  • Unexplained bleeding
  • Unexplained petechiae
  • Hepatosplenomegaly

Myeloma

  • Persistent bone pain, including back (particularly if over 60)
  • Unexplained fracture

Non-Hodgkin’s lymphoma

  • Unexplained lymph node enlargement
  • Splenomegaly
  • Fever
  • Night sweats
  • Shortness of breath
  • Pruritus
  • Weight loss

Hodgkin’s lymphoma

  • Unexplained lymph node enlargement
  • Fever
  • Night sweats
  • Shortness of breath
  • Pruritus
  • Weight loss

2. Red flags

As haematologists, we don’t underestimate the challenge that GPs face in separating these potential blood cancer cases from routine health problems. So, in practice it may be helpful to look for:

  • Leukaemia – extreme fatigue, bruising and bleeding, recurrent infection
  • Lymphoma – weight loss, a persistent lump, night sweats
  • Myeloma – bone/back pain, fatigue, recurrent infection

3. Diagnostic tests

An urgent full blood count should be taken if any one of these symptoms is persistent. In the case of leukaemia, a swift and accurate diagnosis can often be made with a blood test, but this doesn’t rule out other blood cancers.

Additional blood tests for calcium and kidney function, urgent protein electrophoresis and Bence-Jones urine test or serum free light chains will be needed to rule out myeloma.

There is no single blood test for lymphomas, which should be referred to a cancer pathway for biopsy.

4. Urgency is key

Urgency is the prevailing theme when it comes to diagnosing blood cancers, often requiring action within 48 hours. However, too often by the time they reach this stage, the cancer has already progressed beyond early stage.

Bloodwise research shows that more than 80% of people with myeloma and diffuse large B-cell lymphoma will survive for more than five years if diagnosed at the earliest stage, compared with just 26% and 40% if diagnosed at advanced stage respectively.2

Patients often delay coming forward to report symptoms and as discussed above red flags may be missed in primary care. Further delays can also occur in secondary care if patients are referred to the wrong specialty.4

A valid reason for this is lack of GP access to rapid diagnostics clinics – something that Bloodwise has challenged service providers to offer. These aim to speed and support timely referral decisions as well as reducing secondary care delay intervals resulting from incorrect pathway referrals.

5. Use rapid access services

Given the urgency of a blood cancer diagnosis, my final challenge is, ‘why wait another two weeks? The cancer pathways are primarily designed around solid tumours, but blood cancers often have a different level of urgency.

That’s why at GenesisCare we’ve designed a rapid access service as a touchpoint where GPs can get direct advice from a consultant haematologist and – based on their guidance - fast referral to same day diagnostics. It’s a real commitment to early diagnosis.

We see many cases where the prompt action of a GP has proved life-changing for a patient. Diagnosing earlier means that survival and quality of life outcomes for all patients can be improved.

GenesisCare

GenesisCare operates specialist outpatient oncology centres providing world-class multi-disciplinary care. Our Rapid Access Haematology GP service includes:

  • Pre-referral discussion with a haematologist – free service to GPs
  • Appointments available within 48 hours (of referral)
  • Same day clinic, imaging and blood tests (72 hours from telehealth consultation)
  • Results – same day (imaging) 48 hours (pathology)
  • Locations: Oxford, Milton Keynes, Windsor

Patients with private medical insurance will need a GP referral or pre-authorisation. Self-pay patients do not need a GP referral.

This article was funded by GenesisCare for GP Connect

References

  1. Blood Cancer UK. Facts and information about blood cancer [Internet]. 2021 [cited 12 May 2021]. Available from: https://bloodcancer.org.uk/news/blood-cancer-facts/
  2. Bloodwise. The Current State of Blood Cancer Diagnosis in England. 2019 p. 5-24. Available from: https://media.bloodcancer.org.uk/documents/bloodwise-delayed-diagnosis-report_RIQgdp7.pdf
  3. NICE. Suspected cancer recognition and referral: site or type of cancer [Internet]. NICE. 2015 [cited 12 May 2021]. Available from: https://pathways.nice.org.uk/pathways/suspected-cancer-recognition-and-referral/suspected-cancer-recognition-and-referral-site-or-type-of-cancer#content=view-node%3Anodes-haematological-cancers
  4. Hansen R, Vedsted P, Sokolowski I, Søndergaard J, Olesen F. Time intervals from first symptom to treatment of cancer: a cohort study of 2,212 newly diagnosed cancer patients. BMC Health Services Research 2011; 11(1).

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