Haematological cancers - recognition and referral
Exam Tips
- In adults with suspected leukaemia features (fatigue, fever, bruising/bleeding, recurrent infection, generalized lymphadenopathy, hepatosplenomegaly), request a very urgent FBC within 48 hours.
- In children/young people with unexplained petechiae or hepatosplenomegaly, arrange immediate specialist assessment rather than routine testing pathways.
- For suspected myeloma in age >= 60 years with persistent bone/back pain or unexplained fracture, start with FBC, calcium, and ESR/plasma viscosity; if suggestive or if hypercalcaemia/leukopenia present, arrange very urgent electrophoresis and Bence-Jones testing (within 48 hours).
- Unexplained lymphadenopathy in adults usually triggers a 2-week suspected cancer pathway; in children/young people, unexplained lymphadenopathy/splenomegaly is typically very urgent (within 48 hours).
- Remember lymphoma-associated symptom clusters: fever, night sweats, weight loss, pruritus, shortness of breath, and possible alcohol-induced node pain (Hodgkin clue).
Definition
Haematological cancers are malignant disorders of bone marrow, lymphoid tissue, or plasma cells, classically including leukaemia, lymphoma (Hodgkin and non-Hodgkin), and myeloma. In UK primary care, the key clinical task is early recognition of red-flag symptom clusters and arranging the correct urgency of investigation/referral (immediate, within 48 hours, or suspected cancer pathway within 2 weeks) to reduce diagnostic delay.
Pathophysiology
These cancers arise from clonal genetic abnormalities in haematopoietic cells that disrupt normal proliferation, differentiation, and apoptosis. Leukaemias infiltrate marrow and suppress normal haematopoiesis, causing anaemia, neutropenia, and thrombocytopenia (fatigue, infection, bleeding/bruising). Lymphomas are malignancies of lymphocytes within nodal/extranodal lymphoid tissue, producing persistent lymphadenopathy, B symptoms, and possible splenic enlargement; Hodgkin lymphoma classically involves Reed-Sternberg cell biology (see Figure from page 742 in a standard pathology text such as Robbins). Myeloma is a plasma-cell neoplasm producing monoclonal immunoglobulin/light chains, with osteolytic bone disease, renal injury, hypercalcaemia, and marrow failure (CRAB-type pattern).
Risk Factors
- Increasing age (especially for myeloma and many non-Hodgkin lymphomas)
- Previous chemotherapy or radiotherapy exposure
- Ionizing radiation or benzene exposure
- Immunosuppression (e. g, post-transplant, HIV)
- Certain viral associations (e. g, EBV in some lymphomas)
- Family history/genetic susceptibility for some haematological malignancies
Clinical Features
Symptoms
- Persistent fatigue or pallor symptoms
- Unexplained fever
- Night sweats and unintentional weight loss
- Persistent or unexplained bone pain (especially back pain in age >= 60 years)
- Easy bruising, bleeding, or petechial symptoms
- Recurrent or persistent infections
- Pruritus or alcohol-induced lymph node pain (suggestive feature for Hodgkin lymphoma)
- Shortness of breath with lymphadenopathy/B symptoms
Signs
- Generalized or unexplained lymphadenopathy
- Splenomegaly or hepatosplenomegaly
- Pallor
- Petechiae/ecchymoses
- Signs of pathological fracture or bone tenderness
- Features of marrow failure (anaemia, infection tendency, bleeding tendency)
- Possible signs of myeloma complications (dehydration/renal impairment, hypercalcaemia features)
Investigations
Management
Lifestyle Modifications
- Give clear safety-net advice: seek same-day emergency care for bleeding, sepsis features, rapidly progressive breathlessness, or severe pain
- Avoid delaying referral for repeated routine reviews when red-flag criteria are met
- Discuss urgency and expected timeline (immediate, 48 hours, or 2-week cancer pathway) to support adherence
- Assess hydration and avoid nephrotoxic over-the-counter drugs in suspected myeloma/renal risk
Pharmacological Treatment
Symptom control while awaiting urgent assessment
- Paracetamol 1 g orally every 4-6 hours when required (max 4 g/day in adults)
Use for pain/fever if clinically stable; do not mask clinical deterioration. In frail adults, low body weight, or liver disease, use lower maximum daily dose per BNF.
Escalated analgesia for severe bone pain (usually after specialist input or in acute setting)
- Morphine sulfate immediate-release 2.5-5 mg orally every 4 hours as needed, then titrate carefully
Avoid undertreating severe pain, but monitor sedation/respiratory effects and constipation; use caution in renal impairment (common in myeloma).
Critical safety warnings and contraindications in suspected haematological malignancy
- Avoid routine NSAIDs (e. g, ibuprofen) in suspected myeloma with renal risk or thrombocytopenia
- Avoid empiric oral iron unless iron deficiency is confirmed
- Avoid starting systemic corticosteroids before diagnostic biopsy in suspected lymphoma unless specialist-directed
NSAIDs can worsen renal function and bleeding risk; premature steroids can reduce biopsy diagnostic yield; any febrile unwell patient with possible neutropenia requires emergency same-day hospital assessment.
Surgical / Interventional
- No primary-care surgical treatment; urgent specialist procedures include excisional lymph node biopsy and bone marrow biopsy for diagnosis
Complications
- Bone marrow failure causing severe anaemia, neutropenic infection, and bleeding
- Sepsis, including neutropenic sepsis
- Renal failure in myeloma
- Hypercalcaemia
- Venous thromboembolism (notably in myeloma)
- Pathological fractures and possible spinal cord compression
- Disease progression with systemic B symptoms and organ infiltration
Prognosis
Prognosis varies by subtype and stage. UK summary figures: many leukaemia subtypes have relatively high 5-year survival (with variation between subtypes), myeloma has about 50% 5-year survival, non-Hodgkin lymphoma is just under 70%, and Hodgkin lymphoma is around 85%. Earlier recognition and referral improve the chance of timely treatment and better outcomes.
Sources & References
✅NICE Guidelines(1)
📖Textbook References(4)
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 115)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1013)[context]
- Guyton and Hall Textbook of Medical Physiology (John E. Hall, Michael E. Hall) (Z-Library).pdf(pp. 718)[context]
- [Oxford Medical Handbooks] Ian Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona Ha - Oxford Handbook of Clinical Medicine (2017, Oxford University Press) - libgen.li.pdf(pp. 276)[context]