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Haematological Malignancies in General Practice

Haematological Malignancies in General Practice. Judith Hanslip Consultant Haematologist Lister Hospital, Stevenage. Jon Lambert Consultant Haematologist UCLH & Mt Vernon Cancer Centre. Epidemiology Lymphoma Myeloma Referral of patients with suspected haematological malignancies.

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Haematological Malignancies in General Practice

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  1. Haematological Malignanciesin General Practice Judith Hanslip Consultant Haematologist Lister Hospital, Stevenage Jon Lambert Consultant Haematologist UCLH & Mt Vernon Cancer Centre

  2. Epidemiology • Lymphoma • Myeloma • Referral of patients with suspected haematological malignancies

  3. Epidemiology

  4. UK Cancer Registrations 2007 HMRN data http://www.hmrn.org/Statistics/Incidence.aspx

  5. Subtypes of haematological malignancies Annual crude rates per 100,000 (2004–2009). Myeloid Lymphoid Smith et al, BJC (2011) 105, 1684–1692

  6. Incidence increases with age

  7. Lymphoma

  8. Lymphoma • Different lymphomas – why the subtype matters • When to suspect lymphoma – are any tests useful? • Referral to hospital, when and how quickly?

  9. Many different subtypes of lymphoma… HMRN data 2012

  10. mostly curable mostly incurable …with very different clinical behaviour Aggressive Indolent Diffuse large B-cell Follicular Hodgkin Mantle cell T-cell Burkitt

  11. Survival in non-Hodgkin lymphoma depends on subtype HMRN 2004-2009

  12. But also on extent of spread Hodgkin lymphoma SEER data, NCI, 2008

  13. An isolated node, or the tip of the iceberg? Patient presenting with inguinal lymphadenopathy…

  14. Lymphoma – when to suspect • Can affect any organ, and symptoms vary accordingly • Typically present with an enlarging cervical, axillary or inguinal lump • B symptoms are rare and indicate high disease burden • Main question should be: is there an obvious reactive cause for LN?

  15. Lymphoma – are any tests helpful? • In most cases of lymphoma, the FBC, biochem and LDH are normal • Only whole-body imaging +/- biopsy are likely to be diagnostic (FNA is no use) • The best guide is from the history and examination

  16. Referral to hospital – when and how quickly? • Rapidly enlarging nodes with systemic or neurological symptoms need urgent referral - discuss same day • Otherwise follow 2-week wait procedure

  17. Myeloma

  18. Myeloma – epidemiology • Annual UK Incidence: 40 per x 106 (2500 new cases per year) • Median age at diagnosis 60-65 yrs • Higher incidence in Afro-Caribbean people

  19. Myeloma – epidemiology • 2% under 40 yrs • 35% under 65 yrs • 37% older than 75 yrs

  20. Myeloma – improvements in outcome over 30 years Kumar S K et al. Blood 2008;111:2516-2520

  21. Myeloma – survival varies with age at diagnosis Brenner et al, Haematologica, Feb 2009

  22. 82% 51% 81% 78% 79% n = 11,000 L Ellis-Brookes et al, Brit J Cancer, Sept 2012 Myeloma – route to secondary care… …and its effect on outcome 1-year overall survival

  23. Backache particularly if persistent, unexplained or associated with loss of height and osteoporosis (esp in males and pre-menopausal females) Bone marrow suppressionesp normochromic or macrocytic anaemia, but also neutropenia or thrombocytopenia Renal impairment When to suspect myeloma? • Recurrent infectiondue to ↓immunoglobulins or neutropenia • Hypercalcaemia • Persistent ↑ESR(or plasma viscosity) esp if no obvious infective or autoimmune cause • Spinal cord/nerve root compression

  24. ESR or plasma viscosity FBC U & E, Calcium Protein electrophoresis Immunoglobulin profile Urine for BJP X-rays of painful sites + Skeletal Survey, BM, BJP quantitation Investigations in Suspected Myeloma

  25. Monoclonal protein (M-protein or paraprotein) • Monoclonal immunglobulin secreted by abnormal plasma cell clone – detectable in serum and/or urine • Can either whole (heavy and light chain) Ig or just free Ig light chain

  26. Myeloma = M-protein + one of… Bone marrow plasma cells >10% Lytic lesions on skeletal survey Anaemia Hypercalcaemia or impaired renal function MGUS = M-protein < 3g/L and none of the above M-protein doesn’t necessarily indicate myeloma

  27. Kyle et al, NEJM, March 2006 MGUS Uncommon below age of 50 Prevalence increases with advancing age: Cumulative risk of progression c.1% per year

  28. Guidelines for referring patients with suspected haematological malignancies

  29. 2003

  30. 2010 Patient Experience Survey • 51% of myeloma patients had visited their GP at least 3 times before referralhighest probability of delay out of 24 cancers captured in survey • The overall probability of people with suspected cancer visiting their GPs > 3 times was increased in: • Younger pats • Women • Ethnic minorites

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