When to suspect cancer

Intro

[00:00:00] Munir Adam: Hello, it's Munir Adam here, and welcome to the first mini episode of Primary Care UK season two. Today we're going to be talking about the very important topic of cancer. In fact, in this mini episode, we'll be focusing on when to suspect cancer in primary care. And this is for all the frontline professionals.

What with every two minutes, somebody being diagnosed with cancer in the UK, according to Cancer Research UK, and 45% of those according to a study, were diagnosed at an advanced stage, and we know what that means. And the sobering truth is that one in two of us are going to be diagnosed with some form of cancer during our lifetime.

The one thing that everybody agrees on is that early diagnosis will lead to better survival. So this is something that all of us need to know or at least be aware of. And it may be that there's certain aspects of what we cover today that you already know, but a reminder is beneficial for us, wouldn't you agree?

So it's definitely useful for all of us to know when to suspect cancer, but the reality is that having a set of guidelines that will always allow us to pick up cancer early simply isn't possible. And that's because there are lots of cancers, lots of different presentations, and the symptoms and signs can very much overlap with lots of other conditions.

But it's an important task nonetheless, and to help us with this impossible task, we'll be hearing from Dr. Helen Stedeford who is cancer lead in Newham and far more involved with cancer than many of us are. So let's learn together.

You are a first contact physiotherapist and your next patient is a 68 year old gentleman who comes in, takes a seat, and he's a few minutes late. Sorry I'm late, he says, I seem to have to go to the toilet to open my bowel so much more lately. I dunno what's going on. Anyway, and he starts pulling his trousers up so that you can examine his knee for the arthritis that he's come for. And of course you deal with the arthritis. But what else do you do? 

Okay. How about this one? You're a physician associate and a 49 year old comes along for their usual diabetic review. You sound a bit croaky, you say to them, well, yeah, it's cold out there. With the weather that we're having, it's not a surprise. Well, I have to say, I would've expected it to have gone back to normal by now, and it's been about six weeks. And so you complete their diabetes review, but do you do anything? 

What about if you're a nursing associate and a young lady comes along for her new patient health check and while you're checking her blood pressure, you notice that she's got a funny mole on her arm?

And let's just have one more example. So you are a clinical pharmacist and you're doing a medication review and the patient remarks, I hope this medication's not gonna cause me to lose weight because I'm having trouble already as it is no matter what I eat. I just can't seem to keep my weight up. And of course, you complete the medication review in the usual way.

The unexplained diarrhea for two months, the unexplained croaky voice for several weeks, the funny mole and of course unexplained weight loss. These are all symptoms that hopefully would make you think, could this be cancer? They haven't necessarily come to see you for that problem, and it might not be your area of expertise, but if you can just get them to book an appointment to get it looked at, probably with a GP or somebody else who deals with this sort of thing, And if it is cancer, then you may just have saved a life.

So as professionals, most of us, yeah, we would be concerned if there's somebody with unexplained weight loss or other unexplained symptoms. I think the underlying word here is unexplained. Obviously if something's been um, investigated already, then that's fine, but things like unexplained change in bowel habit, voice change, especially if these symptoms last more than three weeks ,because a lot of symptoms do get better within three weeks don't they? 

They might come along with some sort of lump, maybe a lymph node that's enlarged or some sort of abdominal mass, or it may be something more non-specific like pain, fatigue, night sweats, fever. Again, these symptoms lasting for more than a few weeks. 

And something that I'm sure would definitely get us worried is when somebody complains of blood. Blood of some wherever should at least make us think, could this be cancer? And then get the patient checked by the most appropriate person. And if we're not sure about whether we should be worried about a symptom or not, then we can always re resort to the nice guidance, the two week cancer referral forms we have in our practices as well. Or just get a second opinion. 

And our speaker who I'll now hand over to is going to tell us a bit more about these not so straightforward symptoms as well, as well as telling us about the common cancers because hey, in primary care, common things are common. So it's worth knowing as much as we can about the common cancers, which he will also talk about.

So it's over to Helen.

Overview

[00:04:45] Helen: Hello, I'm Dr. Helen Stedeford. I'm a GP and clinical lead for cancer in Newham in East London, and today I'm talking about when to suspect cancer in primary care. . So the first thing I wanna say is, that it's not that easy. Yes, there are the common tumors with the sort of classic red flag presentations, and we can and should work at being better at diagnosing those picking them up as early as we can.

But there will always be cancers that present as emergencies. I'm thinking particularly of a lot of the pediatric cancers. And particularly in my practice, we had a very young man who was admitted with massive haemoptysis, needed emergency surgery, and it turned out to be a primary lung cancer, which you just would never have put money on when you first came across his presentation.

 And then you've got the very rare presentation. So cancer is one of those, conditions has a long tailed distribution, and by this I mean that they're at the common cancers. So the big four are breast, bowel, prostate, and lung. And each clinician will diagnose those multiple times over their career. But then you have a long tail of less common and then some downright very rare cancers that a large practice may see only once or a few times in several decades.

So a clinician may only see those once in a career if that. But they are out there. And that is why always having cancer in the back of your mind is really essential. 

So I'm gonna talk about the big form about the straightforward symptoms, less straightforward symptoms, and then my tips for what to do in practice.

 Throughout you're gonna hear this sound ! And that represents safety netting, because safety netting is such an important tool in our diagnostic toolbox. So much of what we see evolves over time and it's the same for symptoms that may be cancer. 

The big four cancers

[00:06:32] Helen: Okay, so the big four , these represent, yeah, usually at least half of cancer cases.

And certainly that was true in the audit in my practice of cancers diagnosed in 2022. Over 50% of them were breast, prostate, bowel, and lung. And I'm not gonna talk through symptoms suggestive of breast cancer. I think we are very lucky in this country to have one stop shops. Nowadays we are investigating all breast lumps. Certainly when I was at the beginning of my training, we were bringing lumps back to reassess after a period and you know that is appropriate a lot of the time. But you know, women do expect to be investigated generally.

And sometimes we have seen lumps that appeared only two or three days before the GP saw them, they were referred straight away and they did turn out to be cancer. So, yeah, I think make the best of your breast pathways where you. 

Okay. Symptoms of prostate cancer, this is clearly not as straightforward. Of course you've got your lower urinary tract symptoms, which are most probably due to benign prostatic hypertrophy rather than cancer. But, you know, cancer is there in the differential, and then you've got asymptomatic cancer cases. The one thing I want to say about prostate is that demographics are really important here:

 Black men have twice the average population risk of prostate cancer. And any man who has a brother or father with prostate cancer is particularly if at a young age is at increased risk. So, when you are thinking about investigating the prostate always bear that in the back of your mind, what is their sort of background population risk because that may Affect how you counsel someone about having a PSA test.

Of course, PSA tests, there's all the caveats about avoiding intercourse and vigorous exercise beforehand. You might got to make sure that you've excluded a UTI but having said that, always have a cancer in the back of your mind. One little bit of learning, which has been new for me, which is very niche, but it's worth sharing, is that transgender women, so people who are assigned male at birth, who have then transitioned to become female, do still have a prostate.

So if you are seeing a trans woman with symptoms that would make you worry about prostate if they were male. Do remember that they do still have a prostate, so, you may want to do a psa. 

Okay. Bowel cancer, again, don't want to rehash things that clinicians already know, but certainly when I was training there was a lot of emphasis on change in bowel habit and much less an abdominal pain, but abdominal pain but being found to be, be quite a key, kind of low risk, but not no risk symptoms. So, pay attention to it when you see somebody with abdominal pain that's persistent. 

And then lung cancer. Again, learning from my own experience, persistent chest pain is a red flag for lung cancer that is on the two week wait forms and certainly I remember seeing somebody, we were managing them for pain around their scapula, was felt to be musculoskeletal. And it was only the third time that I saw them I realized that they were an elderly smoker and we needed to do a chest x-ray. And unfortunately they did have a lung cancer. Please bear persistent chest pain in mind.

 One more thing I want to say about lung cancer is, non-smokers with lung cancer. If you considered them as a separate tumor group, that would be the 10th most common tumor in the uk. So please don't discount lung cancer just because somebody has never smoked that you could always have a lymphoma or something in the lung. But you can also have primary lung cancers in never smokers. So please bear that in mind. 

Common alerting symptoms

[00:09:55] Helen: Okay. Moving on to the more straightforward symptoms. And these are the classic bleeding mass persistent localized pain. Again, not gonna rehash a lot of two week sort of pathways. Please have a look at the forms to familiarize yourself with with the symptoms of concern.

. But one thing I want to say about hematuria is always consider that it could be an endometrial cancer in a woman, particularly postmenopausal woman, we have had three endometrial cancers diagnosed in the last year at the practice and two of them presented with hematuria. So obviously if it's only very small amount of blood, it won't necessarily look like PV bleed. It might just be obvious when they're passing urine in. So when you are sending people down a urology pathway, we're obviously excluding UTI. If they're a woman of a certain age, please always do an urgent pelvic ultrasound scan as well. Now, mass again. If it's a barn door lipoma, then imaging may not be necessary.

But if you're just not quite sure, then please do arrange imaging. We've had an awful lot of sarcomas. Diagnosed at our practice recently. It's very rare, a sort of random cluster. It's not gonna happen again for a number of years, i'm sure. But they do exist. So please bear in mind about sarcoma, safety netting. Somebody with enlarge lymph nodes. Make sure they know when to come back to be reviewed if the node hasn't. And if somebody needs a bit of help navigating the system, it's probably best for you to arrange that follow up yourself.

 One thing I wanna throw in is, changing skin lesions. It is worth making sure that you know what Seborrheic warts look like. I would always advise getting somebody in to look at the lesion in person, because when you can see it 3D is obviously often a lot easier to tell whether it's a melanoma or a seborrheic wart. . And then again, this is very rare, but in our practice we've had two cutaneous angio sarcomas in the last five years.

These are very rare. I couldn't even find any learning about it in a module that was on sarcoma, but they're basically weird looking vascular skin lesions. If you have something that looks a bit strange,[!!!] Arrange imaging, make sure that you follow-up what it looks like. If the imaging suggests it's a bit weird and needs repeating, please[!!!] make sure you safe net that, scan gets repeated. These are quite aggressive it is best to pick them up as early as possible. 

And then persistent localized pain that you. Just can't explain. And even if there is a working diagnosis, often a musculoskeletal, a diagnosis, just always be aware that it could be a presentation of cancer.

I would always advise bringing somebody in, in person to palpate their spine if they're presenting for the first time with neck or back pain. And they're presenting with it a number of times over a short period. . Unfortunately, we have had quite a few younger patients who presented with metastatic cancers of different primaries. And yeah, their presenting complaint was back pain and unfortunately they had spinal mets. 

So always do a very careful examination. Obviously there's other differentials, particularly in my area, TB abscess in the spine. But yeah, have a chat with your local non-specific pathway clinic or even radiology. If you've just got somebody with a, a persistent pain, you can't understand. 

Dealing with less-straightforward symptoms

[00:13:02] Helen: Right. So moving on to less straightforward symptoms and I'm thinking about abdominal pain and discomfort, fatigue, loss of weight and appetite. And the reason I'm saying these is less straightforward is cuz they map onto multiple tumor groups like upper and lower GI lung gynae, hematological malignancies.

They also map onto lots of non-cancer pathologies. And in fact, they also map onto well, mental health pathology; and also no pathology at all, just normal variation of life. And this is where [!!!]safety netting is so key. In this day and age when we are managing so many things remotely, it's really worth bringing these patients in for a face-to-face exam and document their weight so that you've got something to compare with when you review them again. 

I want to give a plug for the Gateway C Mind map. I don't know the exact address, but if you Google Gateway C Mind Map or Cancer Mind Map you will find it. What the website does is it condenses all the guidance from NG 12 on what symptoms need to equate investigations or referral. It's really handy. You put in the gender of the patient and their age at the top, and then you take all the symptoms or indeed, investigation findings that they have, like anem. And it will tell you what pathways they map onto. So for example, anemia is on the endometrial cancer pathway as well as upper and lower GI pathways.

So that is another thing that's really important to bear in mind, that cancers often surprise you, you may be pretty convinced it's one tumor site and it turns out to be a different tumor site. It's always worth keeping an open mind and not narrowing in, in too quickly on the tumor site particularly with these less straightforward symptoms.

So then investigation. It's always worth running quite a large panel of blood tests. I mean, not necessarily the tumor markers unless that's particularly indicated with ovarian symptoms. But for example, raised platelets, raised inflammatory markers that are persistent can be markers for lung or hematological malignancies.

And then the other thing to say about investigations,[!!!] make sure that you safety net because abnormal investigations, or even if they're just almost normal, it is worth following them up in the context of the patient's symptoms. 

One thing to say about FIT, certainly in the pandemic, the guidance to us about referring in to lower GI It was almost like a cutoff, positive and negative, but that is not the way to think about FIT. Even if a FIT is less than the threshold for referral locally please bear in mind that it still could be a colorectal cancer.

Please always safety net the symptoms with the patient. You can also repeat the FIT after about four to six weeks. Even if it remains negative, it's worth getting advice from your colorectal team. 

And then the thing with safety netting is[!!!}] that it can be really easy now, particularly with the text messaging services that a lot of us are using since the pandemic. You know, you can put in an automated message to go to the patient in a month's time saying if your symptoms have not resolved, please do see us.

So I would recommend doing that as much as you can, just so that you are being proactive as well as making sure the patient understands to come back. 

So then finally I guess the thing to bear in mind is anything that is not behaving as normal, it is always worth considering cancer in the differential. For example, we had a lady who has had a rash, sort of a non-specific rash for a couple of years, not responding to any topicals. And eventually it got diagnosed as cutaneous T-cell lymphoma, for which she's now having treatment. So just always bear in mind that if things are really just not quite doing what you think they should, it could be an unusual presentation of cancer, either an unusual cancer or an unusual presentation of quite a common cancer.

And don't forget the non site specific clinics that now exist. Locally to me, that's called the Multidisciplinary Rapid Access Diagnostic Center. They'll all have different names, but these clinics are set up to help us with those less straightforward symptoms. And they will always be contactable for advice as well as accepting referrals.

Great. Think that's all I want to say and hope that's been helpful.

Until next time

[00:18:24] Munir Adam: That's it for today. We hope you found this discussion useful and that it raises your awareness of cancer in your day-to-day work. We are considering covering specific cancers later in the series, and it'd be great to know what you think about that idea. Do leave us your feedback on Apple Podcasts or using the links in the show notes.

And join us on the 1st of May when we'll have our next episode speaking to Professor Roger Neighbour about enjoying our consultations. See you then.