Combinations of the following symptoms and signs warrant full examination, further investigation (including a blood count and film) and possible referral:

• fatigue
• drenching night sweats
• fever
• weight loss
• generalised itching
• breathlessness
• bruising
• bleeding
• recurrent infections
• bone pain
• alcohol-induced pain
• abdominal pain
• lymphadenopathy
• splenomegaly.

The urgency of referral depends on the symptom severity and findings of investigations.

Refer immediately patients:

• with a blood count/film reported as acute leukaemia
• with spinal cord compression or renal failure suspected of being caused by myeloma

Refer urgently patients with persistent unexplained splenomegaly.

Investigations:

In patients with:

• persistent unexplained fatigue carry out a full blood count, blood film and erythrocyte sedimentation rate, plasma viscosity or C-reactive protein (according to local policy). Repeat at least once if the patient’s condition remains unexplained and does not improve
• unexplained lymphadenopathy carry out a full blood count, blood film and erythrocyte sedimentation rate, plasma viscosity or C-reactive protein (according to local policy)
• any of the following additional features of lymphadenopathy then investigate further and/or refer :
  • persistence for 6 weeks or more
  • lymph nodes increasing in size
  • lymph nodes greater than 2 cm in size
  • widespread nature
  • associated splenomegaly, night sweats or weight loss
• unexplained bruising, bleeding and purpura or symptoms suggesting anaemia, carry out a full blood count, blood film, clotting screen and erythrocyte sedimentation rate, plasma viscosity or C-reactive protein (according to local policy)
• persistent and unexplained bone pain, carry out a full blood count and X-ray, urea and electrolytes, liver and bone profile, PSA test (in males) and erythrocyte sedimentation rate, plasma viscosity or C-reactive protein (according to local policy)

Reference:

1. NICE (June 2005). Referral Guidelines for Suspected Cancer