Oncology & 2WW · Full case
Haematological Cancers
Haematological Cancers (Leukaemia · Lymphoma · Myeloma) · Clinical Reasoning Framework v2
GP & SCA · NICE NG12 · the vague-symptom cancers · FBC & blood film · very urgent FBC for leukaemia · 2WW · myeloma (CRAB) · neutropenic sepsis
The vague-symptom cancersHaematological cancers present with non-specific symptoms — fatigue, weight loss, night sweats, recurrent infection, bruising/bleeding, bone pain, lumps — easily attributed to benign causes. A high index of suspicion and a simple FBC are the GP's most powerful tools
🟣 Very urgent FBC for leukaemiaNICE NG12: offer a VERY URGENT full blood count (within 48 hours) to assess for leukaemia in adults with unexplained: bruising/bleeding, petechiae, pallor, fatigue, recurrent/persistent infection, hepatosplenomegaly. In children/young people with these features → immediate specialist referral. Don't sit on suspicious bloods
Lymphoma = nodes + B-symptomsConsider Hodgkin/non-Hodgkin lymphoma with unexplained lymphadenopathy (persistent, >6 weeks, painless, >1–2cm), hepatosplenomegaly, or B-symptoms (fever, drenching night sweats, weight loss). Itch and alcohol-induced node pain are classic clues. FBC, film, LDH, ESR + urgent referral/imaging
Myeloma = CRAB + the testsSuspect myeloma in those 60+ with persistent bone pain (esp. back), pathological fracture, recurrent infection, or the CRAB features (hyperCalcaemia, Renal impairment, Anaemia, Bone lesions). NICE NG12: FBC, calcium, ESR/plasma viscosity, then very urgent protein electrophoresis & serum-free light chains / Bence Jones
Read the FBC properlyCytopenias (anaemia, low platelets, low/abnormal white cells), a raised or very low WCC, or blasts/abnormal cells on the film point to marrow disease. Pancytopenia, blasts, or a markedly abnormal count need urgent haematology — request a blood film and discuss with haematology
🔴 Neutropenic sepsis = emergencyA patient with (or being treated for) haematological cancer who is unwell/febrile may have neutropenic sepsis — a life-threatening emergency. Do not delay: immediate admission for IV antibiotics within the hour; don't wait for the neutrophil count. Also: tumour lysis, hyperviscosity, cord compression, hypercalcaemia
Persistent > transientMany features (lymphadenopathy after infection, mild fatigue) are benign and transient. It is PERSISTENCE, progression, the combination of features, and the abnormal blood count that should trigger referral — safety-net explicitly and re-check rather than falsely reassure
Children: act fastIn children/young people, unexplained petechiae, hepatosplenomegaly, persistent fatigue, bone pain, unexplained lymphadenopathy or recurrent infection warrant a very urgent FBC and immediate paediatric referral — leukaemia is the commonest childhood cancer (see Childhood Limp pathway)
📋 Clinical Stem — Haematological Cancers
A 67-year-old man with weeks of fatigue, easy bruising, recurrent chest infections and "feeling washed out", whose wife says he looks pale and has lost weight
Raymond Clarke, 67, attends feeling increasingly "washed out" over 6 weeks, with fatigue, breathlessness on the stairs, and several bruises he can't account for. He's had two chest infections in two months. His wife, with him, says he looks pale and has lost weight, and is worried. He's had some drenching night sweats. There's no obvious bleeding, no localising symptoms, and he assumed it was "just getting older". On examination he is pale, has scattered bruising and a few small petechiae, and you can feel a firm spleen tip and some small cervical lymph nodes. He hopes you'll "give him a tonic" and send him on his way.
This stem tests the ability to recognise the non-specific presentation of a haematological cancer — unexplained fatigue, pallor, easy bruising/petechiae, recurrent infection, weight loss, night sweats, hepatosplenomegaly and lymphadenopathy — as a constellation pointing to marrow disease (leukaemia) rather than "just ageing"; to act on the NICE NG12 guidance with a VERY URGENT full blood count (within 48 hours) and a blood film, plus the relevant screen (LDH/ESR, calcium, protein electrophoresis if myeloma suspected); to recognise and not miss neutropenic sepsis or other haematological emergencies; to make the appropriate urgent/2WW haematology referral on abnormal results or strong suspicion; and to communicate uncertainty and the need for urgent investigation to a patient who wants reassurance. The SCA challenge is converting a "give me a tonic" consultation into urgent, appropriate investigation, sensitively, without either falsely reassuring or causing undue alarm.
Scenario A — Suspected leukaemia (this stem) Fatigue, pallor, bruising/petechiae, recurrent infection, hepatosplenomegaly, weight loss/night sweats. VERY URGENT FBC (48h) + film; urgent haematology if abnormal/strong suspicion (NG12).
Scenario B — Lymphoma Persistent painless lymphadenopathy + B-symptoms (fever/night sweats/weight loss) ± itch/hepatosplenomegaly. FBC/film/LDH/ESR; urgent referral/imaging (NG12).
Scenario C — Myeloma 60+ with persistent bone/back pain, pathological fracture, recurrent infection, CRAB features. FBC, calcium, ESR/PV; very urgent protein electrophoresis + serum-free light chains/BJP (NG12).
Scenario D — Haematological emergency Neutropenic sepsis (unwell/febrile, immunocompromised) → immediate admission + IV antibiotics; also tumour lysis, hyperviscosity, cord compression, hypercalcaemia.
Scenario E — Child / incidental abnormal FBC Child with petechiae/hepatosplenomegaly/bone pain → very urgent FBC + immediate paediatrics. Incidental cytopenia/blasts on FBC → blood film + urgent haematology discussion.
Key variables to adapt for Leukaemia vs lymphoma vs myeloma; the NG12 thresholds & very-urgent FBC; reading the FBC/film; B-symptoms & lymphadenopathy; CRAB/myeloma screen; emergencies (neutropenic sepsis, hypercalcaemia, cord compression, hyperviscosity); children; persistence vs transient; the reassurance-seeking patient.
Steps:
1
Step 1
History — The Constellation · B-Symptoms · Bleeding/Infection · Bone Pain · ICE
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The history's job is to recognise a constellation: individually, fatigue, the odd bruise or a chest infection are benign — together, with pallor, weight loss, night sweats, recurrent infection and bleeding, they point to marrow disease. Pull each thread (B-symptoms, bleeding/bruising, recurrent infection, bone pain, lumps) and resist the pull toward "just ageing" or a "tonic". A simple FBC is the decisive next step.
🎓 SCA framing — don't reassure away a constellation
"I know you were hoping for a tonic, and I'd love it to be that simple — but a few things together, the tiredness, the bruising, the infections and losing weight, mean I don't want to just put it down to age. I'd like to do an urgent blood test to be sure we're not missing anything."
The skill is to take the cluster seriously, explain why an urgent blood test is needed, and neither dismiss nor catastrophise.
1A — The constellation, B-symptoms and emergencies
1B — Red flags
🚨
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 → immediate paediatrics |
| 🟣 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 → very urgent protein electrophoresis + serum-free light chains/BJP — NICE NG12 |
| 🔴 Neutropenic sepsis — unwell/febrile + immunocompromised/on chemo | Life-threatening; rapid deterioration. | Immediate admission; IV antibiotics within the hour; 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 |
1C — ICE
💭 Ideas
"What do you think has been going on — you mentioned wanting a tonic?"
Raymond attributes it to age. Surfacing this lets you respectfully explain why the combination of symptoms warrants an urgent blood test rather than a tonic — bringing him with you rather than overriding him.
😟 Concerns
"Has anything worried you or your wife about how you've been?"
His wife is worried (often the more accurate barometer). Naming the concern legitimises the urgent work-up and helps pitch it as careful and proportionate.
🎯 Expectations
"Let me explain what I'd like to do and why it needs to be quick."
He expects reassurance and a quick fix. Naming this lets you set out the urgent blood test, possible referral, and timeframe — honest, not alarmist — so he understands the plan.
1D — Psychosocial context
🩸 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."🎓 SCA Checkpoint — Step 1TasksRelating to OthersGlobal Skills
Key phrases that score
"The tiredness, bruising, infections and weight loss together make me want an urgent blood test." — assembles the constellation.
"Any drenching night sweats, lumps, or bone pain?" — screens lymphoma/myeloma.
"If you ever feel feverish and unwell, that's an emergency — go straight to hospital." — neutropenic-sepsis safety-net.
Deductions
- 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
🔴 Red
"Just ageing"/tonic; no FBC; constellation & red flags missed; no safety-net
🟠 Amber
Recognises something's wrong; orders FBC but not urgently; partial red-flag screen; ICE partial
🟢 Green
Assembles constellation; very urgent FBC + film (NG12); screens lymphoma/myeloma/emergencies; safety-nets neutropenic sepsis; ICE all three
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Step 2
Triage — Emergency · Very Urgent FBC / 2WW · Investigate & Safety-Net
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Triage by acuity: haematological emergencies (neutropenic sepsis, cord compression, hypercalcaemia, hyperviscosity, markedly abnormal FBC) are same-day; the NG12 red-flag presentations get a very urgent FBC and 2WW referral; and lower-probability cases get investigation with explicit safety-netting. Raymond needs a very urgent FBC today and likely same-day haematology if the count is grossly abnormal.
🔴 Emergency
Same day / 999
Immediate- Neutropenic sepsisUnwell/febrile + immunocompromised → admit + IV antibiotics
- Cord compression / hypercalcaemia / hyperviscosityEmergency assessment
- Markedly abnormal FBC / blastsSame-day haematology
🟣 Very urgent
48h / 2WW
NG12- ?LeukaemiaVery urgent FBC (48h) + film (Raymond)
- ?LymphomaFBC/film/LDH/ESR; 2WW referral/imaging
- ?MyelomaFBC, calcium, ESR/PV → electrophoresis/FLC
🟢 Investigate
+ safety-net
Lower probability- Single/transient featureFBC; re-check; safety-net
- Reactive lymphadenopathyReview at 6 weeks; refer if persistent
- Benign cause confirmedTreat & reassure
🎓 SCA Checkpoint — Step 2Tasks
Triage rationale
"Given everything together, I'm arranging an urgent blood test within 48 hours, and I'll chase it personally. If it's significantly abnormal you'll be seen by the blood specialists very quickly — possibly the same day."
Deductions
- Routine (non-urgent) bloods for a red-flag constellation
- Missing an emergency (neutropenic sepsis)
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Step 3
Examination — Pallor/Bruising · Nodes & Spleen/Liver · Bone Tenderness · Systemic
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Examination looks for the signs of marrow failure and infiltration — pallor, bruising/petechiae, lymphadenopathy, hepatosplenomegaly, bone tenderness — and for signs of complications and infection.
🎓 SCA Checkpoint — Step 3TasksGlobal Skills
Narration that scores
"I'll check for pallor and bruising, feel for swollen glands in your neck, armpits and groin, check your tummy for an enlarged spleen or liver, and check your temperature — these help tell me what's going on in the blood and marrow."
Deductions
- Not examining nodes/spleen/liver
- Missing signs of sepsis/complications
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Step 4
Investigations — FBC & Film First · LDH/Calcium/ESR · Myeloma Screen
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The full blood count and blood film are the decisive first investigations; LDH/ESR support lymphoma, calcium and the protein screen support myeloma, and a markedly abnormal count goes straight to haematology. Read the FBC carefully — cytopenias, abnormal white cells or blasts are the clue.
🎓 SCA Checkpoint — Step 4Tasks
Key reasoning
"I'll request an urgent full blood count and a blood film, plus markers like LDH and calcium. If the count is very abnormal, I'll speak to haematology the same day; if it points to myeloma, I'll add the protein tests."
Deductions
- Not requesting a blood film / not reading the FBC properly
- Forgetting the myeloma screen when indicated
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Step 5
Diagnosis — Leukaemia · Lymphoma · Myeloma · Benign Mimics
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The GP recognises the pattern and acts; the definitive diagnosis (and type) is the specialist's. Hold the benign mimics, but let persistence and the FBC drive the decision.
🚩 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.
🎓 SCA Checkpoint — Step 5Tasks
Explaining it plainly
"The combination of things makes me concerned there may be a problem with how your blood and marrow are working. I don't want to guess — an urgent blood test will tell us a lot, and if needed I'll get the blood specialists involved quickly. I'll be honest with you as we get the results."
Deductions
- Settling on a benign label despite the constellation/abnormal FBC
- Not naming the need for urgent specialist input
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Step 6
Referral — Emergency Haematology · 2WW · Same-Day on Abnormal FBC
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Referral is driven by acuity and results: emergencies (neutropenic sepsis, cord compression) are admitted now; a grossly abnormal FBC/blasts gets same-day haematology; and the NG12 red-flag presentations get the 2WW suspected-cancer pathway.
🎓 SCA Checkpoint — Step 6Tasks
Acting on results
"I'll chase your blood test results myself. If they're very abnormal, I'll phone haematology today and they'll see you urgently; otherwise I'll refer you on the two-week-wait pathway so you're seen quickly either way."
Deductions
- Not escalating a grossly abnormal FBC same-day
- Routine referral for a red-flag presentation
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Step 7
Management — Urgent Work-up & Referral · Safety-Net · Support · The GP's Ongoing Role
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The GP's management is to investigate urgently, refer appropriately, safety-net the emergencies (especially neutropenic sepsis), support the patient and family through a frightening diagnosis, and — once the patient is under specialist care — continue general care, recognise complications, and support treatment side effects.
🎓 SCA Checkpoint — Step 7TasksRelating to OthersGlobal Skills
A plan that scores
"Here's the plan: an urgent blood test within 48 hours which I'll chase, a fast referral to the blood specialists depending on the result, and a clear instruction — if you become feverish or unwell at any point, go straight to hospital, as that can be an emergency. I'll support you and your wife through whatever comes next."
Deductions
- No urgency / no result follow-up
- No neutropenic-sepsis safety-net
- Insensitive news-breaking; no support for patient/family
Haematological Cancers — SCA Consultation Scorecard
Recognise the constellation · very urgent FBC/film (NG12) · 2WW · myeloma screen · neutropenic-sepsis safety-net
0/ 33 pts
Global Skills
Structure, language, responsiveness
0/7
Tasks
Clinical reasoning, diagnosis, management
0/15
Relating to Others
Communication, rapport, shared decisions
0/11
RAG Self-Assessment
🔴 Red
"Just ageing"/tonic; no FBC; constellation/red flags missed; neutropenic sepsis not safety-netted; false reassurance
🟠 Amber
Recognises concern; FBC ordered but not urgent; partial screen; referral not clearly tiered; ICE partial
🟢 Green
Constellation recognised; very urgent FBC/film (NG12); lymphoma/myeloma screened; neutropenic-sepsis safety-net; tiered referral; ICE all three; support
Complete the checklist to see your score and feedback
"Doctor, I've just been feeling completely washed out for weeks — no energy, breathless on the stairs. The wife says I look pale and I've got these bruises from nowhere. I expect it's just my age — can you give me a tonic or some iron?"
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?"
"Come on doctor, it's just getting old, isn't it? Can't you give me a tonic or some iron tablets and save us all the fuss of tests?"
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 2WW 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.
Clinic Quick Reference
Haematological Cancers — Clinical Decision Framework
NG12 · constellation · FBC/film · 2WW
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🚦 1 — Recognise & investigate
Leukaemia: unexplained bruising/petechiae, pallor, fatigue, recurrent infection, hepatosplenomegaly → very urgent FBC (48h) + film (children → immediate paeds). Lymphoma: persistent painless lymphadenopathy + B-symptoms ± splenomegaly/itch → FBC/film/LDH/ESR + 2WW. Myeloma (60+): bone/back pain, fracture, recurrent infection, CRAB → FBC, calcium, ESR/PV → very urgent protein electrophoresis + FLC/BJP.
🔴 2 — Emergencies & referral
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 2WW (NG12). Safety-net explicitly; act on persistence not reassurance.
SCA Quick Reference
Haematological Cancers — Consultation Playbook
See the constellation · do the FBC · refer · safety-net sepsis
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🎯 The three pivots that pass this case
1 · See the constellation
Fatigue/pallor + bruising/petechiae + recurrent infection + weight loss/sweats + nodes/spleen = marrow disease, not ageing.
2 · Do the FBC, refer right
Very urgent FBC + film (NG12); same-day haematology if grossly abnormal; 2WW otherwise. Myeloma → calcium + electrophoresis.
3 · Safety-net sepsis
Neutropenic sepsis (fever/unwell, immunocompromised) = immediate admission + IV antibiotics — don't wait for the count.
⛔ Don't dismiss the constellation as "ageing" or offer a tonic · Don't sit on suspicious bloods — very urgent FBC/film, same-day haematology if grossly abnormal · Don't miss neutropenic sepsis (immediate IV antibiotics) or other emergencies · Don't forget the myeloma screen in the over-60s with bone pain/CRAB · Act on persistence, safety-net, support the family