STEP 2: Presentation, initial investigations and referral
This step outlines the process for the general practitioner to initiate the right investigations and refer to the appropriate specialist in a timely manner. The types of investigations the general practitioner undertakes will depend on many factors, including access to diagnostic tests, the availability of medical specialists and patient preferences.
Low-grade lymphomas frequently present with symptoms of gradual onset occurring over many weeks or several months. People can often be asymptomatic at diagnosis, with low-grade lymphomas discovered incidentally after imaging or laboratory tests reveal an abnormality.
The following signs and symptoms should be investigated:
- a lump or mass in any organ
- lymphadenopathy, particularly lymphadenopathy persistent beyond two weeks
- splenomegaly with or without systemic symptoms in the absence of, or after resolution of, any infection
- one or more of these systemic symptoms even in the absence of lymphadenopathy: fever, drenching night sweats, unexplained weight loss, frequent infections
- unexplained cytopenias
- persistent
The presence of multiple signs and symptoms, particularly in combination with other underlying risk factors, suggesting lymphoma should be considered more prominently in the differential diagnosis.
Presenting symptoms should be promptly and clinically triaged with a general practitioner.
Patients suspected to have lymphoma, based on the clinical assessment during the initial general practitioner visit, should be immediately referred to a specialist for diagnosis.
For patients where there is a lower index of suspicion, further examinations/investigations by the general practitioner should include (but are not limited to):
- a thorough history and physical examination of the skin, all lymph node groups, oral examination for enlarged Waldeyer’s ring, abdominal examination and cardiorespiratory examination
- blood tests to assess organ dysfunction including: full blood count, urea, electrolytes, creatinine, liver function tests, lactate dehydrogenase (LDH); other tests may include beta-2 microglobulin (no laboratory test can exclude these lymphomas)
- imaging of the affected area including ultrasound, chest radiography and computed tomography (CT) scan as appropriate
- biopsy as appropriate, depending on local access (referral to a specialist prior to biopsy may be appropriate where there is a high clinical suspicion for lymphoma)
- fine-needle aspiration (FNA) is generally considered inadequate for diagnosing low-grade lymphomas but in some instances may be an appropriate initial investigation (e.g. in evaluating an enlarged lymph node when a non-haemopoietic neoplasm is strongly suspected (such as head and neck cancer).
Indicators of concern that should lead to prompt referral to a specialist include:
- symptoms or results indicating organ dysfunction and low blood counts
- symptoms that suggest neurological involvement
- markedly elevated LDH
- marked B symptoms (weight loss > 10 per cent, persistent fevers > 38°C, or persistent drenching night sweats).
For patients who do not need a prompt referral to a specialist, all investigations should be completed, and a path of action decided, within four weeks of first presentation.
If a low-grade lymphoma diagnosis is confirmed by biopsy, the general practitioner must refer the patient to a haematologist or medical oncologist with professional expertise in lymphoma management. If the general practitioner considers the likelihood of lymphoma as high based on
the initial consultation, referral for urgent tissue diagnosis and ongoing management at a specialist centre with access to lymphoma multidisciplinary team support should occur.
Patients should be enabled to make informed decisions about their choice of specialist and health service. General practitioners should make referrals in consultation with the patient after considering the clinical care needed, cost implications (see referral choices and informed financial consent on page 9), waiting periods, location and facilities, including discussing the patient’s preference for health care through the public or the private system.
Referral documentation for a suspected low-grade lymphoma should incorporate appropriate documentation to allow accurate triage regarding the level of clinical urgency. Where there is clinical urgency as indicated by the features described (see 2.1.1 Timeframe for general practitioner consultation), contact the relevant specialist for advice and to ensure prompt consultation.
Documentation includes:
- important psychosocial history and relevant past history, family history, current medications and allergies
- results of current clinical investigations (imaging and pathology reports)
- results of all prior relevant investigations including imaging
- notification if an interpreter service is
Many services will reject incomplete referrals, so it is important that referrals comply with all relevant health service criteria.
If access is via online referral, a lack of a hard copy should not delay referral.
The specialist should provide timely communication to the general practitioner about the consultation and should notify the general practitioner if the patient does not attend appointments.
Aboriginal and Torres Strait Islander patients will need a culturally appropriate referral. To view the optimal care pathway for Aboriginal and Torres Strait Islander people and the corresponding quick reference guide, visit the Cancer Australia website. Download the consumer resources – Checking for cancer and Cancer from the Cancer Australia website.
For patients with indicators of concern such as organ dysfunction or neurological involvement, urgent referral to a specialist centre is needed. Specialist healthcare providers should provide clear routes of rapid access to specialist evaluation to ensure patients with indicators of concern (outlined above) are contacted and reviewed urgently.
Where lymphoma is identified by biopsy or strongly suspected, referral to specialist should occur within 72 hours.
Where there are no indicators of concern, the initial investigations outline above should take place and referral to a specialist should occur within four weeks.
The patient’s general practitioner should consider an individualised supportive care assessment where appropriate to identify the needs of an individual, their carer and family. Refer to appropriate support services as required, keeping in mind the long duration with which patients live with low- grade lymphomas. See validated screening tools mentioned in Principle 4 ‘Supportive care’.
A number of specific needs may arise for patients at this time:
- assistance for dealing with the emotional distress and/or anger of dealing with a potential cancer diagnosis, anxiety/depression, interpersonal problems and adjustment difficulties (this should include assessment of existing coping strategies and abilities to identify the needs for the patient, their carer and family)
- management of physical symptoms including pain, nausea and fatigue
- encouragement and support to increase levels of exercise (Cormie et 2018; Hayes et al. 2019)
- assessment of health literacy for self-care early in the diagnosis
- identifying impairments and providing targeted interventions to improve the patient’s function level (Silver & Baima 2013)
- an integrated and structured approach to self-care enquiry – identifying Social Health, Exercise, Education, Diet and Sleep Hygiene (SEEDS) is one such practical tool (Arden 2015)
- psycho-oncology support to improve their knowledge and motivation towards healthy self-care care behaviours and to emotionally regulate throughout the course of the disease and treatments (this is particularly the case in patients on a ‘watch and wait’ approach, which can be associated with significant stress and anxiety)
- reviewing the patient’s medication to ensure optimisation and to improve adherence to medicine used for comorbid conditions
- nutritional assessment and
See validated screening tools mentioned in Principle 4 ‘Supportive care’.
For more information refer to the National Institute for Health and Care Excellence 2015 guidelines, Suspected cancer: recognition and referral .
For additional information on supportive care and needs that may arise for different population groups, see Appendices A, B and C.
The general practitioner is responsible for:
- providing patients with information that clearly describes to whom they are being referred, the reason for referral and the expected timeframes for appointments
- requesting that patients notify them if the specialist has not been in contact within the expected timeframe
- considering referral options for patients living rurally or remotely
- supporting the patient while waiting for the specialist appointment (Cancer Council 13 11 20, Leukaemia Foundation 1800 620 420 and Lymphoma Australia 1800 953 081 are available to act as a point of information and reassurance during the anxious period of awaiting further diagnostic information).
More information
Refer to Principle 6 ‘Communication’ for communication skills training programs and resources.
