Bay of Plenty

Find the referral acceptance, access criteria and clinical pathway information for Haematology in the Bay of Plenty.

Referral acceptance

Referral acceptance

Haematology referrals are prioritised by senior medical officers based on the information contained within. Additional information should be attached where available. The prioritisation tool used to grade referrals can be found under the access criteria listed below.

All accepted referrals will be seen as indicated by the clinical priority, with a maximum waiting time of 4 months.

Referral acceptance is as follows:

First specialist assessments

Waiting priority 1

Accepted

Waiting priority 2

Accepted

Waiting priority 3

Accepted

Waiting priority 4

Declined

Access criteria

Access criteria

Category

Criteria

Examples (not an exhaustive list)

1. Immediate
  • Major risk of or from infection
  • Neutropenic sepsis
  • Newly diagnosed acute leukaemia or lymphoma
 
  • Major risk of or from bleeding
  • Haemophilia.
  • ITP with Platelets <20+ bleeding
 
  • Severe symptomatic anaemia
  • Autoimmune haemolytic anaemia
  • Aplastic anaemia
 
  • Hyperviscosity
  • Walderstrom’s macroglobulinaemia
  • CML with very high WBC count
  • Polycythaemia with cerebrovascular symptoms
 
  • Cord compression
  • Acute renal failure
  • Hypercalcaemia
  • Tumour lysis syndrome
  • Multiple Myeloma
  • High-grade non-hodgkins lymphoma.
  • Burkitts lymphoma

2. Urgent
  • Bone pain
  • Risk of bone fracture
  • Renal impairment
  • Multiple Myeloma
 
  • Moderate risk of infection
  • Neutropenia <1 x 109/L
 
  • Moderate risk of bleeding
  • Moderate to severe Thrombocytopenia < 50 x 109/L.
  • New Haemophilia
 
  • Progressive symptomatic anaemia
  • Some Myelodysplasia
  • Some Autoimmune Haemolytic Anaemia
 
  • Severe symptomatic leucocytosis
  • Chronic Myeloid Leukaemia
 
  • Headaches or hyperviscosity
  • Some Polycythaemia Rubra Vera (PRV)
  • Some Walderstrom’s macroglobulinaemia
 
  • Lymphadenopathy/Lymphocytosis.
  • Stage C Chronic Lymphocytic Leukaemia.

3. Semi-urgent
  • Moderate anaemia
  • Thrombotic risk
  • Mild risk of spontaneous bleeding
  • Autoimmune Haemolytic anaemia
  • Anaemia refractory to iron/B12/folate
  • Myeloproliferative conditions
  • PRV/Myelofibrosis/Essential
  • Thrombocythaemia
  • Thrombotic disorders for investigation
  • Walderstrom’s macroglobulinaemia
  • Stage B Chronic Lymphocytic Leukaemia
  • Bleeding Diathesis for investigation

4. Routine
(Not accepted)
  • Mild bleeding risk
  • No pain or no impairment of function
  • Mild infection risk
  • Mild anaemia

 
  • Stable to mild Thrombolytopenia patients in the category may not need to be seen but specialist input may be given through management guidelines.
  • Possible platelet function defect.
  • Monoclonal Gammopathy of uncertain significance.
  • Stage A Chronic Lymphocytic Leukaemia.
  • Some Immunodeficiency.
  • Macrocytosis for investigation.
  • Erythrocytosis (not PRV).
  • Early myelodysplasia.
  • Haemoglobinopathy for investigation or review.
  • Chronic haemolytic anaemia (hereditary spherocytosis enzymopathies).


Additional information:

  • Categorisation must take account of the patient’s social situation, the severity of the haematological abnormalities and other co-morbid conditions.
  • Acute referrals may be admitted directly to the inpatient unit having been assessed in the emergency department or telephone conversation with the specialist.

Managament of CLL - clinical pathway guidance

Managament of CLL - clinical pathway guidance

Management of CLL

Background

Symptoms

  • In the early stages, the condition is asymptomatic, the only feature being a peripheral lymphocytosis.
  • CLL usually progresses slowly with increasing lymphocytosis, lymphadenopathy, splenomegaly, hepatomegaly and bone marrow involvement with cytopenias. Systemic symptoms (fever, weight loss and night sweats) are rare.
  • Other complications of CLL include:
    • autoimmune haemolytic anaemia
    • immune thrombocytopenia
    • hypogammaglobulinaemia with recurrent infections and herpes zoster. CLL can also transform to high-grade lymphoma (Richter’s transformation).
    • Due to the increased risk of infections prompt antibiotic therapy should be offered.

Signs

The following are considered as one area of organ enlargement each:

  • neck
  • axillae
  • groin
  • spleen
  • liver e.g. bilateral cervical nodes = one site

Lymphadenopathy in CLL is usually bilateral, soft, mobile and painless. Unilateral lymphadenopathy is unusual in CLL and may require further investigation.

Staging

Stage Definition Prognosis (median survival – years)

A

0-2 areas of organ enlargement

>12+ years

B

3-5 areas of organ enlargement

7 years

C

Hb <100 g/L or platelets <100x109/L

(unless due to immune mechanisms)

2 years

Assessment of Peripheral Lymphocytosis

  1. <7 x 10^9 /L with no lymphadenopathy or other concerning features:

    • No further investigation.
    • No follow-up needed.

  2. <7 x 10^9 /L with lymphadenopathy:

    • Request flow cytometry.

  3. >7 x 10^9 /L:

    • Request flow cytometry.

  4. Any lymphocyte count with haematologist recommendation for further investigation:

    • Request flow cytometry.

Management post-flow cytometry

  1. If no monoclonal population, no follow-up is needed.

  2. If other monoclonal B-cell lymphoproliferative disorders (e.g. hairy cells, mantle cells), discuss with a haematologist.

  3. If raised monoclonal B-cells and < 0.5 x 10^9 /L monoclonal B-cells:

    • Diagnosis = low count B-cell lymphocytosis.
    • No follow up.

  4. If raised monoclonal B-cells and 0.5 - 4.9 x 10^9 /L monoclonal B-cells:

    • Diagnosis = high count B-cell lymphocytosis.
    • 1-2% progression per year to CLL.
    • Annual lymph node examination and FBC.
    • No need for referral.

  5. If raised monoclonal B-cells >5 x 10^9 /L monoclonal B-cells:

    • CLL diagnosis.

  6. If CLL diagnosis, see signs, symptoms and staging in above background information.

  7. If CLL diagnosis, laboratory Investigations and age appropriate screening for breast, prostate and colon cancer:

    • Perform direct Coombs test (DCT) and immunoglobulins.
    • Discuss with haematologist if DCT positive.

  8. If CLL diagnosis and asymptomatic stage A, no need for referral:

    • Discuss diagnosis and prognosis with patient.
    • Ask about symptoms of fever, persistent night sweats, weight loss, history of recurrent infections.
    • Ask about any signs to suggest skin malignancy.
    • Examine for lymphadenopathy and hepatosplenomegaly.
    • 6-monthly follow up for 1st year (then yearly if stable or slow, asymptomatic progression).
    • Check FBC.
    • Annual flu vaccination recommended.
    • Pneumococcal vaccination recommended .

Patient resources

Leukaemia and Blood Cancer NZ (LBC) charity produce patient information booklets on chronic lymphocytic leukaemia and factsheets on active monitoring. These can be downloaded from the website www.leukaemia.org.nz (external link)

They also run local patient support groups and may be able to offer one-one support as appropriate.

Contact details

Leukaemia and Blood Cancer NZ

Bay of Plenty Cancer Society

Located at:

111 Cameron Road
Tauranga
3110