Diagnostics: Challenges of a myeloma diagnosis in primary care

Dr Karthik Ramasamy, Consultant Haematologist at GenesisCare has been integral in the set up of the Rapid Access Haematology service across a number of GenesisCare centres in the UK. Here he explains the importance of an early diagnosis and gives practical advice to GPs who play a pivotal role in identifying blood cancers early.

Challenges of a myeloma diagnosis in primary care

This story is based on real life events, but the patient’s name has been changed.

When 64-year-old Bob developed gradual onset left leg pain and general fatigue he took over-the-counter painkillers and was later prescribed stronger analgesia by his GP when the pain remained persistent 4 weeks later. This helped to reduce pain, but it continued unabated on walking. With the pain still present, he underwent a leg x-ray which was unremarkable, and as such was given a follow up appointment with orthopaedics for 2 months’ time. Shortly after, whilst getting ready for work one morning, Bob collapsed in the shower with leg pains and was rushed to hospital where on assessment he was found to have paraparesis and a fracture of lumbar vertebra with spinal cord compression, for which he required spinal surgery. What had caused this? A post-surgery diagnosis confirmed myeloma. The apparent mystery was solved yet all the signs that are red flags for myeloma had been overlooked in the preceding months. 

Blood cancer symptoms can be frustratingly vague and Bob’s experience is not unusual. In fact, 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.¹ These sobering facts were highlighted in 2019 by blood cancer charity, Bloodwise, when they published a report calling for better and earlier diagnosis.¹

Urgency is the prevailing theme when it comes to diagnosing blood cancers, often requiring action within 48 hours. However, too often by the time patients reach this stage, the cancer has already progressed beyond the early stage. Bob’s case is a classic example of how continued delays, starting with the patient’s own hesitancy, so easily extend days into months. It’s common for patients to dismiss fatigue as being ‘run down’, or persistent back pain as ‘general wear and tear’. And when they do visit their GP, red flags can easily be missed.² Further delays can also occur in secondary care if patients are referred to the wrong speciality, as in Bob’s case with a referral to orthopaedics.  Anecdotally, we know that on presenting in primary care, 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 can all be indications of an underlying haematological condition.  

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.¹ As haematologists, too many of the patients we see in secondary care face the devastating consequences of months of delays before reaching a diagnosis, incurring spinal injuries like our patient here, as well as the additional mental anguish of knowing that their own delayed action in reporting symptoms may have contributed to the outcome.

We don’t underestimate the challenge that GPs face in separating these potential blood cancer cases from routine health problems but we can summarise the detail of NICE guidelines³ into some simple red flags to be aware of:

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

Also, be aware that these diseases aren’t rare, in fact, one in every five diagnosed cancers is a blood cancer.⁴ So if you do have concerns about a patient, you should take immediate action as follows:

  • 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. These can all be requested by the GP
  • There is no single blood test for lymphomas, which should be referred to a cancer pathway for biopsy

The Bloodwise report also challenged the lack of rapid diagnostic clinics available to GPs. These are invaluable to support timely referral decisions as well as reducing secondary care delay intervals resulting from incorrect pathway referrals. Here at GenesisCare, we’ve responded with a dedicated Rapid Access Haematology Service as a touchpoint where GPs can get direct advice from a consultant haematologist (at no cost) and – based on their guidance – a fast referral to same day diagnostics. We see no benefit in a 2-week wait when an undiagnosed blood cancer is already urgent.

The patient, in this case, Bob, has been left with a degree of leg weakness that could have been avoided. In general, we need to get better at ruling out haematological cancers and diagnosing earlier so that survival and quality of life outcomes for all patients can be improved. 

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

  • Pre-referral discussion with a haematologist – a free service for 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

Get pre-referral advice from a haematologist or refer a patient here

 

Sources:

  1. The Current State of Blood Cancer Diagnosis in England [Internet]. Bloodwise; 2019 p. 5-24. 
  2. 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).
  3. National Institute for Health and Care Excellence. Suspected cancer recognition and referral: site or type of cancer [Internet]. NICE. 2015 [cited 12 May 2021]. 
  4. Blood Cancer UK. Facts and information about blood cancer [Internet]. Blood Cancer UK. 2021 [cited 12 May 2021]. 

 

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