2.3 Initial referral
If the diagnosis of MM is confirmed or the results are inconsistent or indeterminate, the general practitioner must refer the patient to an appropriate specialist (haematologist) or a health service with a multiple myeloma-specific multidisciplinary team to make the diagnosis.
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 for suspected or diagnosed MM should include the following essential information to accurately triage and categorise the level of clinical urgency:
- important psychosocial history and relevant medical history
- family history, current symptoms, medications and allergies
- results of current clinical investigations (imaging and pathology reports)
- results of all prior relevant investigations
- 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.
The timing of specialist referral is guided by clinical severity and the presence of end-organ damage.
Indicators of end-organ damage in patients with MM include (Quach & Prince 2019; Rajkumar et al. 2014):
- hypercalcaemia: corrected serum calcium 0.25 mmol/L above the upper limit of normal or higher than 2.75 mmol/L
- renal impairment: creatinine clearance 177 μmol/L (> 2 mg/dL)
- anaemia: haemoglobin below 100 g/L or 20 g/L below the lower limit of normal
- bone lesions: one or more osteolytic lesions on skeletal radiography, CT or positron emission tomography (PET) CT.
Patients with evidence of end-organ damage should be seen by a haematologist as soon as possible, ideally not longer than one week.
Patients without overt end-organ damage should ideally be seen by a haematologist within four weeks.
Patients with severe hypercalcaemia, renal failure, symptoms of hyperviscosity, severe new-onset back pain or acute neurological symptoms should be immediately referred to a haematologist or emergency department.
