Haematological Cancers
Red Flags — the bloods to do and the emergencies to catch
| Red flag | Why it matters | Action |
|---|---|---|
| 🟣 Unexplained bruising/petechiae, pallor, fatigue, recurrent infection, hepatosplenomegaly | Leukaemia / marrow failure. | Very urgent FBC (within 48h) + blood film — NICE NG12; children with petechiae or hepatosplenomegaly → immediate specialist assessment |
| 🟣 Persistent painless lymphadenopathy + B-symptoms ± hepatosplenomegaly/itch | Lymphoma. | FBC/film/LDH/ESR; urgent suspected-cancer referral/imaging — NICE NG12 |
| 🟣 60+ with persistent bone pain / fracture / recurrent infection / CRAB | Myeloma. | FBC, calcium, ESR/PV + serum protein electrophoresis + serum free light chains together; suspected cancer pathway referral if they suggest myeloma — NICE NG12 (2025) |
| 🔴 Neutropenic sepsis — unwell/febrile + immunocompromised/on chemo | Life-threatening; rapid deterioration. | Refer immediately (hotline/999); empirical IV antibiotics immediately in hospital (CG151); don't wait for the count |
| 🔴 Spinal cord compression / symptomatic hypercalcaemia / hyperviscosity | Myeloma/lymphoma complications — emergencies. | Emergency admission/assessment |
| Markedly abnormal FBC / pancytopenia / blasts on film | Acute leukaemia / marrow disease. | Urgent same-day haematology discussion/referral |
💉 The power of the FBC
Frame the blood test as the sensible, decisive step.
"A simple blood test tells us a huge amount here — it checks your blood cells and can pick up problems early. I'd like to do it urgently, within a day or two."⚖️ Thorough, not frightening
Pitch the urgency proportionately.
"Most of the time these tests are reassuring. But the combination of things you've described means the careful thing is to check quickly rather than wait."👫 Listening to the family
Validate the wife's concern.
"Your wife's noticed you're pale and have lost weight — that's important, and it's part of why I want to look into this properly."🤝 Holding uncertainty
Be honest while supportive.
"I can't tell you the cause until the tests are back, but I'd rather check thoroughly than miss something. We'll go through the results together quickly."🧓 "Not wanting to make a fuss"
Many older men minimise symptoms and present only when a partner insists. Raymond's hope for a tonic is partly a hope that nothing is wrong, and partly a wish not to be a burden. If you take the constellation seriously without making him feel foolish for coming, he is more likely to turn up for the blood test and to come back if things change.
"You've done exactly the right thing by coming in — and your wife was right to push you. Let's get this checked properly."Watch for the patient who agrees in the room and then doesn't attend for bloods — book the test before he leaves and agree how you will contact him with the result.
😨 The word "cancer"
Some patients ask outright; others are frightened of the word being said. A patient who doesn't understand why they are being fast-tracked may not prioritise the test or the appointment. Honesty, pitched gently and without false precision, is both kinder and safer.
"One of the things I need to rule out is a problem in the bone marrow, and that can include a type of blood cancer. Most people I test don't have one — but I'd never want to miss it."Ask how much he wants to know. Offer to include his wife in the conversation. Give written information about the fast-track pathway.
🧾 Practicalities that get in the way
A very urgent blood test is only useful if it happens. Transport, caring responsibilities, work shifts and fear can all delay it. Older couples may depend on each other for driving and caring, so the "well" partner's health matters too.
"Can you get to the surgery for a blood test today or first thing tomorrow? Is there anything that would stop you?"Use same-day phlebotomy where possible; a home visit for bloods if he is housebound; make sure the practice has an up-to-date phone number.
🔁 The patient who has "been before"
Haematological cancers — myeloma above all — often come after several consultations for apparently separate problems. If Raymond's record shows a chest infection last month and back pain before that, those are part of the pattern, not just past history. Reviewing the record is part of the history.
"I can see you were in a few weeks ago with a chest infection. I'd like to put all of this together rather than look at each thing on its own."Re-attendance for a vague complaint is a recognised prompt to step back and consider the whole picture, and to do a full blood count.
- Reassuring as "ageing"/offering a tonic; missing the constellation
- Not doing a (very) urgent FBC / not knowing the NG12 thresholds
- Missing neutropenic sepsis or other emergencies
- Not screening B-symptoms/bone pain/lymphadenopathy
Same day / 999
Immediate- Neutropenic sepsisUnwell/febrile + immunocompromised → admit + IV antibiotics
- Cord compression / hypercalcaemia / hyperviscosityEmergency assessment
- Markedly abnormal FBC / blastsSame-day haematology
48h / suspected cancer pathway referral
NG12- ?LeukaemiaVery urgent FBC (48h) + film (Raymond)
- ?LymphomaFBC/film/LDH/ESR; suspected cancer pathway referral/imaging
- ?MyelomaFBC, calcium, ESR/PV + electrophoresis + FLC together
+ safety-net
Lower probability- Single/transient featureFBC; re-check; safety-net
- Reactive lymphadenopathyReview at 6 weeks; refer if persistent
- Benign cause confirmedTreat & reassure
- Routine (non-urgent) bloods for a red-flag constellation
- Missing an emergency (neutropenic sepsis)
- Not examining nodes/spleen/liver
- Missing signs of sepsis/complications
- Not requesting a blood film / not reading the FBC properly
- Forgetting the myeloma screen when indicated
🚩 Recognise the pattern, do the FBC, refer urgently
Raymond's formulation is a constellation of marrow failure (anaemia, thrombocytopenic bruising, recurrent infection) with weight loss, night sweats, splenomegaly and lymphadenopathy — a strong suspicion of haematological malignancy (likely leukaemia). The plan: a very urgent FBC and blood film (NG12), same-day haematology discussion/referral if the count is grossly abnormal, the myeloma/lymphoma screens as indicated, an explicit neutropenic-sepsis safety-net, and honest, supportive communication.
- Settling on a benign label despite the constellation/abnormal FBC
- Not naming the need for urgent specialist input
- Not escalating a grossly abnormal FBC same-day
- Routine referral for a red-flag presentation
Validate — name the expectation and the hope behind it
Raymond's request is reasonable on its surface: he feels run down, he is 67, and a tonic or iron sounds harmless. Underneath it is a hope that nothing is seriously wrong, and a reluctance to be a nuisance. If you name both before disagreeing, he won't feel dismissed, and his wife will see that her worry has been heard too.
"I can hear you'd like something to perk you up, and I understand why — six weeks of feeling like this is miserable. And I can see your wife has been worried. Can I explain what I think we should do first?"Explain — why a tonic or iron would be the wrong first step
No tonic treats this picture. Iron without a blood count could hide a clue and delay the answer, and it would do nothing for low platelets or infections. Tiredness, bruising and small spots on the skin, two chest infections, weight loss, sweats and an enlarged spleen, all together, need a full blood count and a blood film within 48 hours (NICE NG12). Explain what the test looks for in plain language, and say that the likely next steps will depend on the result.
"Each of these on its own is common. But together — the tiredness, the bruises, the infections, the weight loss and what I can feel in your tummy — they make me want to check your blood cells properly, and quickly. If I gave you iron now, it might even muddy the picture."Negotiate — a concrete, time-bound plan
Offer something concrete today: the blood test booked before he leaves (today if the practice can, otherwise first thing tomorrow), a named person who will act on the result, a phone call the same day it's back, and a clear rule for what to do if he becomes feverish or unwell in the meantime. Ask what would make it hard for him to do this, and remove the obstacle.
"Here's what I'd like: a blood test today, which I'll look at myself as soon as it's back. I'll ring you either way. If it shows something that needs a specialist, I'll arrange that the same day. And if you get a temperature or feel suddenly worse before then, don't wait for me — go to A&E. Does that sound manageable?"Delays in haematological cancer often come from process failures rather than missed symptoms: a result filed as "abnormal — see GP routinely", a patient who isn't contacted, or a referral letter that isn't sent. A named clinician and a tracking log close those gaps.
Mark the request "very urgent — ?leukaemia" with the clinical details so the lab reviews the film. Record the expected result date. Use a practice log or task for suspected-cancer tests and referrals, and check it daily. Confirm the patient's phone number and agree how you'll contact him. If the lab phones an out-of-hours result, it needs to go to someone who can act on it.
Chemotherapy, the disease itself (particularly acute leukaemia, which causes neutropenia, and CLL and myeloma, which impair antibody production) and steroids all reduce the ability to fight infection. Most serious infections come from the patient's own gut and skin flora, so hygiene and early recognition matter more than isolation.
Hand hygiene; good mouth care; food safety (the haematology team will advise on any specific food restrictions); avoiding people with obvious infections; household members vaccinated (flu, COVID-19). A working thermometer at home and the chemotherapy alert card with the 24-hour hotline number kept on them.
Exercise before and during cancer treatment helps preserve muscle mass and fitness, reduces cancer-related fatigue and improves mood and sleep. Fitter patients tolerate intensive treatment better and recover more quickly.
Walking and gentle resistance work, adjusted to the counts. Avoid contact sports and heavy lifting when platelets are low. In myeloma, avoid high-impact or heavy spinal loading because of lytic lesions, and ask the team about safe exercise. Signpost to Macmillan's physical activity resources and local cancer rehabilitation services.
Weight loss is common at diagnosis (a B-symptom) and during treatment, from mucositis, nausea, taste change and low appetite. Malnutrition worsens fatigue, infection risk and treatment tolerance.
Weigh at each contact. Small frequent meals and nutritional supplements if needed; dietitian referral if weight is falling. Treat mouth problems early. Steroid-containing regimens can raise blood glucose — check it if the patient develops thirst or polyuria.
Diagnosis, intensive treatment, "watch and wait" for indolent disease, relapse, and the end of treatment are each points of high distress. Anxiety and depression are common and under-recognised, and they affect adherence, sleep and pain.
Ask directly about mood. Use NHS Talking Therapies (many services have long-term-condition pathways) or hospital psycho-oncology. Signpost to condition-specific charities: Blood Cancer UK, Leukaemia Care, Lymphoma Action, Myeloma UK, Macmillan. For "watch and wait", explain that monitoring is an active and evidence-based strategy, not neglect.
Haematological cancers can deteriorate suddenly (infection, bleeding, relapse), and people with blood cancers are less often referred to palliative care and more likely to die in hospital than people with solid tumours. Early conversations about what matters to the patient allow care to match their wishes.
Introduce the idea gently once the diagnosis and prognosis are known. Record preferences using ReSPECT or the local equivalent, share them with out-of-hours services, and add the patient to the practice palliative care register when appropriate. Plan jointly with the haematology team, as transfusion and antibiotic decisions often continue until late.
"Take it in the morning with food. It can make you feel wired, hungry or unable to sleep, and it can raise your blood sugar. It also hides a temperature, so if you feel unwell on it, don't be reassured by a normal thermometer reading — ring the hotline."
SCA: knowing not to "try steroids" for unexplained nodes or fever before a diagnosis, and knowing the NG234 dexamethasone step for suspected cord compression, both show safe prescribing judgement.
"This helps protect your bones from the myeloma. Keep up regular dental check-ups and tell your dentist you're on it before any extraction. If you get pain, swelling or an exposed area in your jaw, or a new ache in your thigh or groin, tell us."
SCA: linking jaw pain in a myeloma patient to bisphosphonate osteonecrosis, and advising dental review, is a practical, safe-prescribing point that examiners value.
"This medicine must never be taken in pregnancy, and the hospital will go through the contraception rules with you. Don't share it or give leftover capsules to anyone. A painful, swollen leg or sudden breathlessness needs urgent attention, and so does a temperature."
SCA: recording hospital-only drugs on the GP record — so that interactions are caught and the out-of-hours clinician knows — is a simple patient-safety habit worth stating.
"Before you take any new medicine — including antibiotics, herbal remedies or St John's wort — check with us or the pharmacist, because some of them interfere with this drug. Tell us about palpitations, a racing heart or unusual bleeding."
SCA: a GP who pauses before prescribing clarithromycin for a chest infection in a patient on ibrutinib, and checks the interaction, is showing exactly the prescribing safety the examiners look for.
"These are to prevent infections while your immune system is low. They're just as important as the main treatment. Keep taking them until the hospital tells you to stop, even after the chemotherapy finishes."
SCA: stating that prophylaxis should continue per the haematology plan, and that you would check before stopping it, shows awareness of shared care.
"This should ease the bone pain. Take the laxative every day, not just when you're constipated. You may feel drowsy at first — don't drive until you know how it affects you. If the pain in your back suddenly changes, or your legs feel weak or numb, ring straight away — that's an emergency."
SCA: pairing opioid prescribing with a laxative, a renal check and a cord-compression safety-net is the complete answer.
Work and income
Treatment can mean months off work, and infection risk may rule out some jobs for a time (healthcare, childcare, teaching). Under the Equality Act 2010, cancer counts as a disability from the point of diagnosis, so employers must consider reasonable adjustments. Many patients don't know this.
Fit notes can suggest phased returns or altered duties. Financial strain is common: signpost to Macmillan's benefits advice and grants, and remember that people with cancer in England can apply for a medical exemption certificate for prescription charges.
"Is money or work a worry at the moment? There's practical help available — including free prescriptions and benefits advice — and your employer has a legal duty to make adjustments."Driving and the DVLA
Most people with a haematological cancer do not need to tell the DVLA. For a car licence, they must notify it if the illness or treatment affects the brain or nervous system, if their doctor has concerns about fitness to drive, or if medication side effects make driving unsafe. Bus and lorry (Group 2) licence holders must tell the DVLA about leukaemia or lymphoma (gov.uk condition pages). Central nervous system lymphoma carries specific restrictions.
Practical issues matter more often: severe anaemia, sedating opioids, peripheral neuropathy from treatment, and leg weakness from cord compression (which means no driving).
"At the moment you're fine to drive as long as you feel well and alert. If the treatment makes you drowsy, or your hands or feet go numb, let's talk about it — and if you ever drive a bus or lorry, tell me, because the rules are different."Partner and family
Raymond's wife is frightened and has been carrying the worry alone. Partners of people having intensive treatment become carers overnight: driving to appointments, watching for fever, managing medicines. Their own health often slips. Under the Care Act 2014, carers are entitled to an assessment of their needs by the local authority.
"How are you doing with all this? You've been the one who noticed. Can I make sure you're on our records as Raymond's carer, so we can support you too?""Watch and wait" and living with uncertainty
For CLL, some low-grade lymphomas and smouldering myeloma, the right treatment is often monitoring without treatment. Patients can find this harder than chemotherapy: "I've got cancer and they're doing nothing." Explaining that treating early doesn't improve outcomes for these conditions, and that monitoring is active care, reduces anxiety.
"Watching and waiting isn't doing nothing. For this type, starting treatment before it's needed doesn't help you live longer — it just brings the side effects sooner. The team are keeping a close eye, and so am I."Identity, body and intimacy
Hair loss, weight change, steroid-related mood swings, fatigue and loss of physical strength change how people see themselves. Fertility can be affected by treatment in younger patients: fertility preservation should be discussed before treatment starts, which the specialist team arranges. Sexual health and intimacy are rarely raised unless the clinician asks.
"Sometimes treatment changes how people feel about themselves, their body or their relationship. That's common, and it's fine to talk about it here."Relapse, the end of treatment, and end of life
The end of treatment can be unexpectedly hard: hospital contact stops and fear of relapse starts. Myeloma and some leukaemias relapse, and each relapse brings a harder conversation. When the illness is incurable, early palliative input improves symptom control and planning; the practice palliative care register, ReSPECT or an equivalent plan, and anticipatory medicines keep the patient's wishes central.
"Whatever happens with the treatment, I'll still be your GP. If things change, we'll plan together what matters most to you."Today — Test, safety-net, ownership
FBC and blood film (very urgent, marked "?leukaemia"), with U&E, calcium, LFTs, LDH, ESR or plasma viscosity, coagulation and haematinics. Add myeloma tests if the picture fits. Neutropenic-sepsis and bleeding safety-net, verbally and in writing. Phone number confirmed. Named clinician responsible for the result, and a task set to chase it.
Within 48 hours — Act on the result
Blasts, pancytopenia, a very high or very low white count, or severe thrombocytopenia → phone on-call haematology the same day; if the patient is unwell or bleeding, admit. Abnormal but not acute → suspected-cancer pathway referral with the results attached, and tell the patient why. Normal count but persistent symptoms and signs (nodes, spleen, sweats) → it does not end there: refer on the clinical picture — suspected cancer pathway referral for unexplained lymphadenopathy or splenomegaly (NG12); do not delay because the FBC is normal.
After the specialist
Check the referral was received and the appointment happened. Once a diagnosis is known: offer an appointment for the patient and partner; answer questions; check mood, sleep and support; add to the practice cancer register; make sure the alert card and the 24-hour hotline number are in hand; record hospital-only drugs on the GP system. Vaccination review before treatment where there is time.
During treatment — The in-between weeks
Every contact: is this infection, and could it be neutropenic sepsis? Interactions for every new prescription. Symptom control (pain, nausea, constipation, mood). Carer support. Fit notes. Flu, COVID-19, pneumococcal and Shingrix vaccines as the specialist advises; no live vaccines. Offer a cancer care review, covering physical, emotional, practical and financial needs.
After treatment — Survivorship and late effects
A treatment summary from the hospital should state the late-effects risks and what to monitor. Common tasks: cardiovascular risk management after anthracyclines or chest radiotherapy; annual thyroid function after neck radiotherapy; early breast screening for women who had radiotherapy to the chest at a young age (the NHS very-high-risk breast screening programme); lifelong irradiated blood products after Hodgkin lymphoma, purine analogues (for example fludarabine), bendamustine or alemtuzumab (BSH 2020); bone health after long steroid courses; fertility, mood and fatigue. Low-risk MGUS may be monitored in primary care per the haematology plan.
Memory rule — "FIBS" at every contact with a patient under haematology
Fever or feeling unwell (suspected neutropenic sepsis until proven otherwise — hotline/999) · Interactions (every new prescription against hospital-only drugs) · Bleeding, bruising, bone pain and back pain (thrombocytopenia; myeloma progression; cord compression) · Support and symptoms (mood, carer, money, pain, bowels).
| What | How | Timing | Action threshold |
|---|---|---|---|
| Very urgent FBC and film (Raymond) | FBC, film comment, practice tracking log | Result within 48 hours; reviewed the day it's reported | Film or count reported as suggesting acute leukaemia → immediate referral (Macmillan rapid referral guide) — phone haematology the same day. Pancytopenia, very high or very low WCC, severe thrombocytopenia → same-day discussion. Other abnormalities fitting leukaemia/lymphoma → suspected-cancer pathway |
| Myeloma tests | FBC, calcium, ESR or PV + serum protein electrophoresis + serum free light chains (urine Bence-Jones if unavailable), sent together | At presentation where NG12 criteria are met (60+, persistent bone pain or unexplained fracture) | Paraprotein or abnormal light chains suggesting myeloma → suspected-cancer pathway (NG12). Paraprotein with hypercalcaemia, AKI, anaemia or bone pain → same-day haematology discussion |
| Calcium (known myeloma or lymphoma) | Albumin-corrected calcium, U&E | When drowsy, confused, thirsty, constipated or deteriorating | Symptomatic hypercalcaemia → urgent hospital assessment and management; severity depends on the calcium level, rate of rise, symptoms, renal function and hydration — not a single threshold; reduced consciousness or AKI → emergency (see malignant hypercalcaemia protocol) |
| Back pain in myeloma / lymphoma | History, neurological examination | Every contact with back pain | Pain suggesting spinal metastases (no neurology) → discuss with the MSCC coordinator/acute oncology; MRI within 1 week; neurological symptoms or signs → immediate contact, MRI within 24 hours, dexamethasone 16 mg (NICE NG234) |
| MGUS (under monitoring) | FBC, creatinine, calcium, paraprotein ± serum free light chains | Per the haematology plan (interval set by risk group — BSH 2023) | Rising paraprotein, new anaemia, falling eGFR, hypercalcaemia, bone pain or recurrent infection → re-refer promptly; don't wait for the next scheduled check |
| CLL on "watch and wait" | FBC, symptoms, node and spleen examination | Per specialist plan (some stable patients are monitored in primary care) | B-symptoms, rapidly enlarging nodes or spleen, new anaemia or thrombocytopenia, autoimmune haemolysis, or recurrent infections → contact haematology |
| Hospital-only drugs | Recorded on GP system; interaction check | Every new prescription | CYP3A4 interaction, anticoagulant with a BTK inhibitor, or new AF → discuss with haematology before prescribing |
| Late effects after treatment | BP, lipids, HbA1c; TFTs after neck radiotherapy; breast screening after chest radiotherapy; bone health | Annually, or per treatment summary | Abnormal TFTs → treat; cardiovascular risk → manage actively (anthracycline/chest radiotherapy history); breast symptoms after chest radiotherapy → urgent assessment regardless of age |
⚠ Three scenario-specific phrases — use these verbatim
Why safety-netting matters beyond clinical care
- No urgency / no result follow-up
- No neutropenic-sepsis safety-net
- Insensitive news-breaking; no support for patient/family
Who you are
Raymond Clarke, 67, here with your wife. Six weeks of feeling "washed out" — fatigue, breathless on stairs. You've got several bruises you can't explain, and you've had two chest infections in two months. Your wife says you look pale and have lost weight, and you've had some drenching night sweats. You've put it down to getting older and you're hoping for a tonic or iron tablets so you can get on. You don't feel feverish right now.
Hidden concerns (reveal if explored)
Wants a quick fix: you'd rather not make a fuss; a tonic would do.
Your wife's worry: she's quietly frightened and pushed you to come — she'll say so if asked.
Fear (if doctor seems concerned): you become worried it's serious; you respond to calm, honest explanation.
Clinical details if asked
- 6 weeks progressive fatigue, breathlessness, pallor; unexplained bruising and a few petechiae
- Two chest infections in two months; weight loss; drenching night sweats
- No fever today; no severe back pain/leg weakness; no confusion/extreme thirst
- On examination: pale, scattered bruising/petechiae, a firm spleen tip, small cervical lymph nodes
- No regular medications; previously fairly well
Reactions at key moments
- If offered a tonic/iron and sent away: you're satisfied — so a strong candidate must NOT do this and should investigate urgently.
- On "I'd like an urgent blood test": a bit surprised, reassured by calm explanation.
- On the neutropenic-sepsis advice: you take it seriously.
- On possible serious news: anxious; respond well to honesty and support, especially with your wife there.
- Challenge line: "It's just my age though, isn't it? Can't you just give me something to perk me up?"
Resolution: Raymond is well served if the GP: (1) recognises the constellation (fatigue/pallor/breathlessness = anaemia; bruising/petechiae = low platelets; recurrent infection; weight loss/night sweats; splenomegaly and lymphadenopathy) as suspected haematological malignancy rather than ageing; (2) arranges a VERY URGENT full blood count and blood film (NICE NG12), plus LDH/calcium and a myeloma screen as indicated, and chases the results; (3) refers same-day to haematology if the count is grossly abnormal, or on the suspected cancer pathway, and recognises any emergency (notably neutropenic sepsis) with an explicit safety-net; (4) communicates the need for urgent investigation honestly and supportively, involving his wife. He is poorly served if given a "tonic"/iron and reassured it's just age.
Leukaemia: unexplained bruising/petechiae, pallor, fatigue, recurrent infection, hepatosplenomegaly → very urgent FBC (48h) + film (children: petechiae/hepatosplenomegaly → immediate specialist assessment; other features → very urgent FBC). Lymphoma: persistent painless lymphadenopathy + B-symptoms ± splenomegaly/itch → FBC/film/LDH/ESR + suspected cancer pathway referral. Myeloma (60+): bone/back pain, fracture, recurrent infection, CRAB → FBC, calcium, ESR/PV + serum protein electrophoresis + serum FLC together (NG12, 2025); suspected cancer pathway referral if they suggest myeloma.
Neutropenic sepsis (unwell/febrile + immunocompromised) → immediate admission + IV antibiotics; don't wait for the count. Also cord compression, hypercalcaemia, hyperviscosity, tumour lysis. Markedly abnormal FBC/blasts → same-day haematology. Otherwise Suspected cancer pathway referral (NG12). Safety-net explicitly; act on persistence not reassurance.