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GPs TALK CANCER

Breast Cancer

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Published on: 12th September 2023

Breast Cancer

In this episode, our GP hosts cover breast cancer and share their clinical experiences to support better, faster, and more confident cancer diagnosis in primary care.

Hosts Dr Rebecca Leon and Dr Sarah Taylor are both practicing GPs and GP Leads for GatewayC. Dr Ellen Macpherson, a junior doctor, also joins our hosts.

This week, we welcome our first guest to the podcast – Pete Wallroth, Founder and CEO of the charity Mummy’s Star.

This episode covers:

• Statistics
• Patient cases
• Cancer and pregnancy
• Symptoms
• Investigations
• Family history
• Recurrence
• Safety netting
• NICE Guidelines
• Referral

If you loved it, you know what to do – leave us a review, a rating (hopefully 5 stars) and share.

GPs Talk Cancer is the podcast series from GatewayC. GatewayC is the free early cancer diagnosis resource funded by the NHS and is part of The Christie NHS Foundation Trust.

DISCLAIMER: We know this podcast might be of interest to anybody, however it is aimed at primary care health professionals. All patient cases are based on real stories from our clinical practice as GPs. They are fully anonymised with no identifiable patient data.

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Dr Rebecca Leon

[00:00:00] It just seems crazy and actually we were told that it is safer to have chemotherapy than actually a glass of wine from the second trimester onwards. Which is an amazing thing to almost think about, but it is getting the head round and getting a proper MDT discussion.

Hi, this is GPS Talk Cancer, brought to you by GatewayC. I’m Dr Rebecca Leon, and joining me through this podcast is Dr Sarah Taylor. We are both practicing GPs and GP leads for GatewayC. We are both passionate about diagnosing cancer early, and in this podcast, we want to share our clinical experiences with you, so you can make better, faster, and more confident cancer diagnosis in primary care.

So, there’s some official stuff to make you aware of. We know this podcast might be of interest to anybody, but it is really aimed at primary care health professionals. And although all patient cases are based on real stories from our clinical practice as GPs, they are fully [00:01:00] anonymised with no identifiable patient data.

GatewayC is funded by the NHS and is part of The Christie NHS Foundation Trust.

So, the official stuff out the way, kettle’s on, it’s time to talk about today’s podcast and we’ll be talking about breast cancer. I’m here alongside Sarah and Ellen is working up north today. Ellen is a junior doctor who works with us at GatewayC. But we are joined by my friend and colleague, Pete Wallroth, from the charity, Mummy’s Star.

Pete, I think you do a better job of actually telling us why you’re here and a bit about yourself.

Pete Wallroth

Thank you. I will of course. So, I’m the founder and CEO of a charity called Mummy’s Star, that’s been going 10 years and we focus our support on families where they get a cancer diagnosis during pregnancy or any time up to 12 months postnatally. And we’ve been supporting families all [00:02:00] over the UK and Ireland in that time to be able to support, be able to raise awareness of what the impact is of cancer and pregnancy, and how it challenges families in what should otherwise be a really exciting and celebratory time.

Dr Rebecca Leon

Well, thank you and it’s lovely to have you here. So, Sarah, how are you today? And have you had a nice weekend?

Dr Sarah Taylor

Yes, very nice, thank you. Yeah, my husbands on call so we couldn’t do very much, but yeah, it was, yeah, we did bits and pieces, walked the dog went for a run, which I won’t mention to Pete because I know he’s injured, but, you know. It’s all good.

Yeah, and Pete, how are you since I last saw you, what have you been up to?

Pete Wallroth

We’re good, yeah. Just busy celebrating 10 years as a charity, which is a massive milestone. And it’s, yeah, it’s been full of reflections and celebrations and you know, obviously looking back on, you know, sad times as well, but it’s, you know, looking at the positive difference we’ve been able to make in conversations just like this.

Dr Rebecca Leon

Fantastic. We’ll be talking about breast cancer today, and I’m going to be throwing some stats at you coming straight from CRUK [00:03:00] one in seven UK females will be diagnosed with breast cancer in their lifetime. But the good news is that 75% of women will survive breast cancer for 10 years or more following a diagnosis.

Right, back to the cases. And actually I’m going to start with Pete to talk about a case that’s very close to home.

Pete Wallroth

Sure. Yeah. So my, I guess, introduction to cancer and pregnancy as a, as a topic came from a personal experience 11 years ago. My late wife Mair was, 19 weeks pregnant with our second child, and she started to develop a dull ache in her left breast at about 19 weeks. We proceeded to have a sonography appointment about a week later, had a scan, found out that we were going to have a little boy, and then in the midwifery appointment that followed that it was just mentioned, in passing that this, this ache had, you know, had surfaced over the last week or so.

It wasn’t particularly worrying her. She [00:04:00] wasn’t, you know, staying awake at night with concern or anxiety. But nonetheless, the midwife that we, we disclosed this to, said, you know, yes it probably won’t be anything serious, but, we’ll, nonetheless, we’ll make the referral, we’ll put a referral through to the breast clinic, and that was it.

We carried on with, you know, for the next couple of weeks that appointment came and went. And sadly with it came a diagnosis that she had a six centimetre tumour in her left breast. And as a family with a relatively limited experience of cancer that’s, it’s quite an eye-opening and scary traumatic time.

But when it’s framed with, you know, a continuation of a, you know, growing pregnancy and all the excitement is, then it’s just that it’s that perfect storm that you know, that nobody would really, you know, sort of be able to imagine, you know, never mind be able to work out how to actually step through it.

And, from that point, we, you know, we had a, a really good team, very reassured, very quickly, MDT convened, we were involved in our MDT as a family. We actually sat there, you know, with all these different oncology and obstetric and midwifery, you know, professionals talking and making a [00:05:00] plan for us as a family.

We proceeded with chemotherapy, had four rounds of chemotherapy while Mair was pregnant, and then we had our baby by induction. He was born safe and well. And then she proceeded with treatment, you know, postnatally, the impact as a family trying to raise a, a little baby when somebody is so fatigued and, you know, and all the onset of chemotherapy side effects, especially when you’ve got that, that post labour, you know, physical and, and, you know, and psychological tiredness as well is a real challenge, you know, for any family.

And it was from that, that it I guess it spurned the idea of why wasn’t there a tailored support out there for families in our situation? Or what if more to the point, what if families weren’t as fortunate as us? What if they didn’t have the, the nature of support networks, friends, family close by that would’ve softened the blow.

And you could have planned, you know, around your, the rigors of treatment and then subsequent surgeries. And from that, I guess that seed was kind of planted. But, you know, ultimately it didn’t really turn, turn into Mummy’s Star until about nine months later. What sadly [00:06:00] happened for us, despite the initial cancer, you know, responding really well to treatment, the cancer had actually very silently spread with no, you know, outward signs to the meningeal lining of her brain.

And about eight weeks after Merlin’s birth, she presented with quite severe dehydration. She started to lose her balance, was losing her sight in one of her eyes, hospital admission. And then a subsequent lumbar puncture revealed that the nature of the spread and how rapid it was. And she sadly then died at 10 weeks postnatally as a result of that cancer.

Dr Rebecca Leon

And you mentioned that it was the midwife who actually was instrumental in picking up the lump in the first place. This was something, so you actually never visited a GP. It was a different line of diagnosing and, and subsequently, everything that went with that.

Pete Wallroth

Yeah. For, for us, when that symptom arose, you know, for her and she started, you know, to feel it [00:07:00] and, you know, mention it to me the next, the next juncture in our health journey, if you like, was that we just happened to have this appointment coming up anyway. So it seemed like the natural course of action. So well, why make another appointment when we’ve got that one next week? And it was just mentioned very casually. We didn’t go into that appointment fraught with, you know, concern or worry. It was just, you know what, we’re going to see the midwife, let’s mention it to them.

And then they said, right, do you know what? I’ll just make the referral that you’re here anyway. There’s, you know, there’s no point in delaying any further. And granted, that could have caused, you know, some you know, temporary anxiety in somebody to think, oh, well why are you referring me? What, you know, you must be worried about something.

But for us it was better that than to go away and think, should we have said something? Should we have not said something? And ultimately, it led to what was a very rapid diagnosis. And that’s what you’d hope, any other family would, you know, would be able to receive in that kind of situation?

Dr Sarah Taylor

Did Mair notice a lump herself?

Pete Wallroth

She, yeah, she first noticed it when she was sleeping and she just said, you know, just there’s a soreness. And I think because we’d breastfed our daughter for, you know, for well [00:08:00] over a year, the natural position for us as a couple was, it’ll be something to do with, with milk production. It’ll be a, possibly a blocked milk duct, a bit of, you know, massage or, you know, warm pads on the breast tissue might, you know, might help ease it out. We didn’t, you know, Google symptoms, we didn’t look it up because it just wasn’t a concern for her. And because we didn’t have a long wait to another medical appointment of any, of any discipline, it just felt easier to just say, well, we’ll just mention it there. But it wasn’t keeping her awake. It wasn’t a, it wasn’t a physical lump that she could feel, for example. It was just this dull ache is how she always described it.

Dr Rebecca Leon

I mean, Sarah, we, we talk about an ache, a pain, a discomfort, which we see a lot in general practice. What do you think about breast pain and, how is the best way to manage this? Particularly hearing about Pete’s story and, and things like that.

Dr Sarah Taylor

I think breast pain is very common, isn’t it? I think that’s the first thing, and I think that [00:09:00] there’s, you know, we’ve just done quite a lot of talking and research about it. I’ve just spoken to one of the consultants and we’ve been designing a local breast pain pathway. It, it is very common. There’s lots of causes for it. You know, a lot of women who have pain actually, it’s cyclical, which is related to hormones in their periods. I think a lot of people have pain that is actually chest wall pain rather than actual breast pain.

I think it’s really important to have a, like we always say, we say this every week, don’t we? It’s important to have a clear history, and it’s really, really important to examine a patient because obviously if somebody has a breast pain that’s related to a lump or any other changes in the breast, any physical changes in the breast, then that has to be taken really seriously.

The evidence is that breast pain alone is not an, a symptom of breast cancer, but in association with a lump, or with other breast changes, and it has to be taken seriously. And I think the key thing at the moment, well, not at the moment, there just generally, [00:10:00] is to make sure you assess the patient thoroughly.

And I think, you know, it’s part of what, we’ll, we’ll talk, we’ll come onto this again in a minute, I’m sure, but part of that assessment I think for breast cancer also, particularly in younger women, has to be a really clear family history. Because if you’ve got a positive family history and you’ve got symptoms, then you become, you become more concerned.

Dr Rebecca Leon

Yeah. And, and I think it’s examine, examine, examine and off air Pete, you, you said something that will, will definitely stick with Sarah and I about symptoms not being in isolation.

Pete Wallroth

Yeah, I think from, from the, I think what we’ve seen with, you know, with the charity over the last 10 years, we’ve supported nearly 1,600 people in that, in that time.

So we’ve seen how people have presented and how they’ve described their initial symptoms. And what the emerging theme has been is that when people are presenting that the symptom is seen in isolation of whatever stage of pregnancy they are, or even whatever stage they are postnatally because there’s so much body change, you know, postnatally as well. And that sometimes gets missed when people are, [00:11:00] are presenting with symptoms is that, you know, if we, if we did have, you know, two or three women sat in front of us and one of them was pregnant and then the other two weren’t, and they all presented with the same symptom, there is the possibility that the person who is pregnant may not necessarily have their symptoms elevated in terms of the concern.

And it’s, and the only way around that is to just almost put aside the, the fact that they’re pregnant or post and say, right. How do, how do we see that symptom in independence? How concerning is it? Does it match the red flags when we’re going through that safety netting process? And then step forward from there in terms of referral and the next stages.

Dr Rebecca Leon

Because with Covid and with us now doing more remote consultation, particularly telephones, it, we can imagine getting a phone call from a pregnant woman saying that she’s got breast changes. And as Sarah and I talked about last week about we don’t want to overly reassure. In some ways patients almost just ring up and say, it’s nothing, doctor, is it?

So again, back to the point that we, that actually, I think with [00:12:00] any breast changes, we should be inviting the patient in for a face-to-face and a, and an examination, but keeping the pregnancy and the symptoms separate.

Pete Wallroth

Yeah, absolutely. And I think for that, for that patient, if that initial call is a, you know, a phone call assessment or even a video call, it’s about making sure that not, don’t be afraid to elevate your symptoms.

If it’s a concern to you, it will be a concern to the health professional that’s seeing you as opposed to playing down your symptoms or thinking that you’re, you’re taking somebody’s time up. We, you know, there’s this constant reiteration that the NHS is open and if you’re, you know, if it, if it doesn’t feel or function right, go and get it checked. Go and make an appointment. Don’t be afraid to make the phone call because it’s better for your own reassurance to have an intervention, either to diagnose that it isn’t something you’re worried about, and been able to go through the different stages of tests to be able to ascertain what is causing the problem.

Or in the worst case scenario, if it does turn out to be a cancerous, in, you know, instance, then at least earlier intervention that net of options and treatment options and [00:13:00] surgeries remain, you know, is, is much wider from the, from the starting point.

Dr Sarah Taylor

I always make a point of if I see somebody who comes in with a lump that for a variety of reasons I’m not concerned about, of saying, I’m really not concerned about this. But I absolutely think that you did the right thing in coming in to see me about it because it’s my job to know all of the things to be concerned or not concerned. And if you get something like this and you’re concerned in the future, so sometimes you do see people with lumps that are, or symptoms that I’m really not concerned about. And I, and just to, to add to them, because I don’t want them to think, oh, she wasn’t worried last time. When they’ve got something different the next time to think, oh, she wasn’t worried about that or she made me feel like I was wasting her time. I want them to know that actually, I’m perfectly happy to assess because that’s my job.

And if they’ve got another concern in the future, they should come back.

Pete Wallroth

Yeah, absolutely. And I think what also matters with that is, ensuring that the, the body vigilance messages that we’re sharing with people

Dr Sarah Taylor

Yeah.

Pete Wallroth

That they have to remain during pregnancy and postnatally. I think there is, there is this [00:14:00] I guess a, an approach that, you know, when the, when the, the body goes through so much change during pregnancy and what we’re advised is going to happen and what you expect yourself, either from previous pregnancies or from friends or families, you know, notions of what they have experienced themselves is, oh, you know, I’m going to have so much change, how would I tell the difference between a concerning symptom versus something that’s normal anyway? And it’s just reiterating that message that keep checking yourself, keep doing the, you know, whether it’s a monthly breast check, you’ve got a reminder on your phone or any other, you know, issues that come up in and around pregnancy.

It’s making sure that you’re just body vigilance remains high just as it would outside of pregnancy.

Dr Sarah Taylor

I think we were talking about the common cancers in pregnancy being just the common cancers in people of that age. Cause the other thing that’s springing to mind is the idea that women, a lot of women have rectal bleeding, don’t they? And it’s always.

Dr Rebecca Leon

Haemorrhoids.

Dr Sarah Taylor

You’ve got haemorrhoids. But actually again, that, I don’t know whether you see many women with haemorrhoids.

We do. We, it’s the, the common things that we hear are around breast [00:15:00] complaints, abdominal discomfort, gynaecological issues, whether it’s discharge, but where it’s, you know, whether it’s not clearly bleeding, but other types of discharge that could be early signs of other, you know, UTIs, infections, thrush, rectal bleeding, sign of haemorrhoids, early signs of, you know, different types of bowel cancer, breathlessness.

We’ve seen lymphomas, lung cancers diagnosed, but, but the narrative that surrounds it is, this is to be expected in pregnancy and it’s just that consideration of yes, it probably will, it could happen and it is something to look out for, but if it’s concerning, you go and get it checked and don’t ignore symptoms.

And I think even with all the awareness we’ve had over the last 12 months, especially just because you’ve used the example around rectal bleeding, bowel cancer, check your poo, all of those symptoms, there’s still that element of taboo around it. And we’ve got to keep continuing those conversations. People say, get it checked.

Dr Rebecca Leon

Because Pete with women being older now, now that they’re conceiving older, women are having babies later. Do you think that’s going to also increase the chances of cancers being [00:16:00] seen in pregnancy and generally cancers?

Pete Wallroth

I think because we’ve got these birth trends and they’re not showing any change in, you know, in families leave it until later into the thirties, early forties, there’s going to be that overlap into higher risk categories around, around age. And it’s, it’s important to, to clarify that there’s not causation between breast cancer and pregnancy, but people are just going to overlap and they’re, you’re going to have these coincidental diagnosis. So, you know, when, when we talk about this subject, yes, we are probably only more likely to see cases over the next, you know, 10 to 15 years while those birth trends stay.

But that’s not to say that women who are feeling those symptoms at younger age groups in the twenties, thirties, you know, equally, you know, are going to, we’re going to see diagnosis as well, and, I think that’s where some of the issue lies is you don’t expect to be diagnosed with breast cancer at 22, 24, 27. And then all the other issues that come with it.

Dr Sarah Taylor

Yeah. And in terms of treatment, so I, I can imagine, you know, when, when I started as a GP, if you’d seen, diagnosed somebody and [00:17:00] with cancer in pregnancy, the treatments would’ve been very difficult for somebody to tolerate and not possible. And I think that would’ve made me think, oh gosh, what we know, what, what should I do now? Has that changed? And what’s the position in terms of treating?

Pete Wallroth

When, from, from all the, the senior oncologists that treat and have treated people and the, and the, the research that exists from the Institute of Cancer, Infertility and Pregnancy in Belgium, the research shows that there isn’t any adverse impact on the development of baby if chemotherapy is given in the second trimester onwards.

But it’s clear to state that in, in the first trimester, it’s far more complex and it’s not routinely given because of, you know, the period of, you know, fastest foetal growth. But I think the, the issue isn’t necessarily, whether you can or can’t, it’s how people psychologically get their head round the notion that you would have, you would combine chemotherapy, something that we know has side effects as well as you know, as well as ability to, to treat or cure with the growth of a baby and that special, precious time and people hold pregnancy so sacred that the idea of putting the two things together for [00:18:00] medical professionals as well as members of the public, it’s just, if they haven’t come across it, it’s actually quite a difficult thing for people to get their heads around that it’s possible.

And once you do look at the options, like our experience, we were instantly given reassurance because our team, purely by chance had actually treated two other women in, in previous years with, you know, chemotherapy and pregnancy. They knew the safe parameters you could do so, but the, you know, the, the unseen traumas that I think that hides is, you know, for women who were, you know, who were pregnant and being treated is there is that impact on breastfeeding and that is a fundamental, core part of pregnancy for so many people. And it’s, some people get bothered by the cancer diagnosis, but then you lose something like breastfeeding from maternity experience and it’s actually really devastating.

Dr Rebecca Leon

I mean, Sarah, for us, we’ve been in this cancer world for a while and I had the pleasure of speaking to Pete probably about 18 months ago, and we did a cancer conversation as part of GatewayC. And one of the things that I really learned about, was about that chemotherapy [00:19:00] can be given during pregnancy and you’ve put it eloquently that a baby’s growing and then you’re actually giving a toxic substance.

Pete Wallroth

Yeah

Dr Rebecca Leon

You said it better than me, but you know what I’m saying. And that I think to any GPs listening, it just seems crazy. And actually, we were told that it is safer to have chemotherapy than actually a glass of wine from the second trimester onwards, which is an amazing thing to almost think about, but it is getting the head round and getting a proper MDT discussion. And I, I think the other thing that you mentioned earlier is actually you being involved in the MDT, I think’s really special and really important that that can happen.

Pete Wallroth

Yeah. It’s not something that I think many patients are aware of and, and quite often in cases like this, because it is so specialised and you have, disciplines of obstetrics and oncology that should never otherwise have any reason to discuss things with each other, suddenly have to come together. And because they are nine times out of ten, it’ll be an MDT just for that [00:20:00] patient.

It is possible to ask that family whether they would like to be involved. It’s not to say they all will be. Some, some families over the years that we’ve supported, they don’t want anything to do with the MDT, but they want to just be informed what’s happening, because it’s too traumatic actually hearing it being spoken about in real time.

For us, we found it quite a reassuring process we found very involved even if we didn’t necessarily understand all the medical jargon. But the point was we were given the opportunity to be, you know, to be involved in it. And you know, when you, when you have a body of emerging specialists, I suppose, who’ve, you know, treated people like oncologist Richard Simcock, who’s been part of the cancer conversation that we previously recorded.

There is that reassurance that, you know, people are looking at this as a subject and wanting to know more about it, to reassure others out there. You know, Richard, to quote him from a conference a few years ago they did for us, said, you know, we’re paranoid beyond rationality to medicate people during pregnancy.

So, when you add something as extreme as chemotherapy into that same breath, you can see why people have this rabbit in the headlights response to, [00:21:00] how on earth is that possible? But yet, the facts are there, that it is.

Dr Sarah Taylor

Yeah. I can think too, if I prescribe anything for anybody…

Dr Rebecca Leon

Antibiotics, yeah.

Dr Sarah Taylor

The computer springs up all of these things saying medium severity warning, high severity warning, low severity warning.

Dr Rebecca Leon

No, it’s exactly, you’re absolutely right. Can I just talk to you a little bit about family history, Sarah? Because breast cancer in particular, there is a link with certain family histories, certain genes.

You talked about a patient that you saw, in her eighties, concerned about her, her granddaughter.

Dr Sarah Taylor

Oh, she was concerned about her granddaughter having a family. I, I think breast cancer’s difficult, isn’t it? Because the, it’s so common. So, a lot of people will have somebody in the family who’s got a, who’s had breast cancer.

Dr Rebecca Leon

So, age is really, age is really important.

Dr Sarah Taylor

Age is really important. Yes, so I mean if you’ve got somebody who’s had breast cancer young, then I think that’s important. Then obviously it is numbers of people, age of diagnosis and whether they’re on the same side of the [00:22:00] family or not. And male breast cancer is a, an important thing to record as well because that is, does have a high genetic link and so, and I think it’s not necessarily something unless you ask specifically, you know?

Dr Rebecca Leon

So, when you’re talking about age, Sarah, what you talking?

Dr Sarah Taylor

We’re talking about basically about premenopausal women.

Dr Rebecca Leon

Premenopausal. So, kind of 50 and below?

Dr Sarah Taylor

Yeah. Really, yeah. I tend to say twenties, thirties, and early forties. But yeah, you know, just as a rough guide.

Dr Rebecca Leon

Okay.

Dr Sarah Taylor

And I think, but I think it’s important, but I, I don’t know, and I don’t know whether Ellen can check with that, whether the male breast cancer risk is, I think that’s at any age.

Dr Rebecca Leon

Okay.

Dr Sarah Taylor

I think that adds at any age.

Dr Rebecca Leon

Okay. So, we’ll, we’ll, we’ll put that in the show notes at the end.

Dr Sarah Taylor

Yeah. And we’ll learn, we’ll all learn.

Dr Rebecca Leon

But, but BRCA is also a, a big thing that we see in the, the Angelina Jolie effect when she was, found to be BRCA positive. And actually, it was, we saw a surge of people asking for genetics tests and things because she made it very public. I’m putting you on the spot here, [00:23:00] Sarah. Pete, you may, can jump in here as well.

I mean, the BRCA genes is, there’s a BRCA1, BRCA2. It, it’s, that’s again, we ask about family history.

Dr Sarah Taylor

We need to remember about the family history, that it’s not just breast cancer for BRCA, don’t we? We need to, we, we might talk about this in another podcast, but obviously it’s related to prostate cancer and ovarian cancer. So, I think we need, it’s one of the I think, you know, we have these key messages that we, that I have. So, my key one from today is definitely going to be Pete’s thing about making sure that you look at the symptoms in isolation from the pregnancy. Because I think that is really, really important. But yeah, I think that’s, I think recording of family history is, needs to be on everybody’s PDP to get better at it.

Dr Rebecca Leon

Yeah. So, PDP is what we have to do every year as part of our appraisal. We have to, kind of come up with three or four.

Dr Sarah Taylor

That’s quite good. I think actually I had not thought about it, but it’s going to be on mine next year.

Dr Rebecca Leon

Yeah. There we go.

Dr Sarah Taylor

Record family history.

Dr Rebecca Leon

Record family history, pedigree diagrams, the whole lot. [00:24:00] So, it’s really important to ask about family history and certain groups also, I think we did discuss it when we did the ovarian cancer module. Certain groups, there’ll be a high risk of, BRCA positive, so that’s something to always be aware of.

Okay. Are we ready for our fun facts?

Dr Sarah Taylor

Have we got some fun facts?

Dr Rebecca Leon

We’ve got one fun fact, and it’s not really fun.

Dr Sarah Taylor

It’s not really fun, is it? No.

Dr Rebecca Leon

It’s your elbow.

Dr Sarah Taylor

It’s my elbow pain fact. Well, yeah, it is that the, that if you look at women with elbow pain, you are as likely to pick up a breast cancer as you are if you look at women with breast pain. Assuming that you have made sure and examined that the woman with breast pain does not have other changes or symptoms.

Dr Rebecca Leon

So, in a nutshell

Dr Sarah Taylor

A nutshell.

Dr Rebecca Leon

So, we’re really talking kind of cyclical breast pain or breast pain with no other examination findings in isolation.

If you compare that to all the elbow pains that we see in general practice… [00:25:00]

Dr Sarah Taylor

I don’t think elbow pain’s a really common one really, is it? You know, but, back pain maybe.

Dr Rebecca Leon

Yeah. So, it, so breast pain in isolation, we should think about other measures, maybe safety net, maybe bring them back. I often put a date in the diary for somebody to come back if I, if I’m just got that slight inkling that I want to see them again, but it’s not in isolation a reason for an urgent diagnosis. Okay.

Pete Wallroth

I think just to pick up on that point, I think from what we’ve been talking about with, with symptoms and being checked and people visiting as well from a pregnancy context is that’s what we’d love to see more of as well, is if there is a reassurance that’s given, but there’s just that niggling doubt that you want to have that person again, is, is place the appointment in your diary to get them back.

Dr Rebecca Leon

Absolutely.

Pete Wallroth

I think because sometimes where people have been told to come back, if it persists, you end up in such a wide realm of subjectivity, people then think, oh well, do I bother them again? And it, we enter that, that area of, I you know, I don’t want to take up somebody’s time, but we want, we want them to [00:26:00] know that they’re being watched and, and you know, we’re proactively wanting to seek the reassurance for yourselves as professionals, as much as it the person in, in question as well.

Dr Sarah Taylor

Yeah. And I think that links into the one that, that probably Jo and Louise are now quoting to people too, that we always say that the patient who was told to come back if it got worse, rather than to come back if it persists.

Pete Wallroth

Yeah.

Dr Sarah Taylor

And actually nothing got worse, but over the next year, 18 months, it didn’t get better. It didn’t change, but it didn’t go. I think, you know, that, that wording and that safety netting and probably in pregnancy as things are changing anyway, is even more important, isn’t it?

Pete Wallroth

Yeah, absolutely.

Dr Rebecca Leon

So, we’re going to do a, we’re just going to quickly just talk about case two, just because it’s something very different and it does bring up some learning points that we want to talk about.

So, Sarah, can you just, just talk about.

Dr Sarah Taylor

Yeah, so I think we’re just talking about the issues of recurrence of breast cancer, particularly in older women. It’s something we talked about on, on the GatewayC module that actually, [00:27:00] recurrence of breast cancer is relatively common, not in everybody. And, but obviously it is, it is fairly common, but the biggest problem is that it can happen quite a long time after the initial diagnosis.

So, we’ve, we’ve got patients who’ve been diagnosed five, 10 years after the initial diagnosis. Obviously, breast cancer can spread to bones, to lungs, to the liver, and to brain. And obviously there’s local, local recurrence and, all of those can have quite vague symptoms. So, a lot of the patients who have bone recurrence will have vague pains, particularly back pains.

But lots of people have vague pains. And similarly, you know, the breathlessness, the lung patients may have a little bit of cough or breathlessness. Again, they’re often non-specific symptoms. And I think that the, the key when we’ve spoken to patients, and you know, Jo Taylor, who does, does a lot of work with a local [00:28:00] charity on awareness for patients of recurrence of breast cancer is really keen that women are aware of their risk of recurrence so that they can articulate it when they come to see us. But not all women will be, and I think it’s really key for us to make sure that we’ve got particularly good coding.

Because you know what GP notes can be like if you’ve got something that’s sunk 10 years ago.

Dr Rebecca Leon

Do you, do you actually get, we get a flash up to say history of neoplasm.

Dr Sarah Taylor

You do for bone pain, but you don’t for anything else.

Dr Rebecca Leon

That’s interesting. So, if, so for the, so if there is, as you say, dizziness or breathlessness or something, I don’t know, abdominal pain, which could be kind of liver capsular pain. None of that comes up.

Dr Sarah Taylor

Yeah, I think it’s just back pain actually. I don’t think it’s other bone pain. I don’t think it covers, come up.

Dr Rebecca Leon

It’s like shoulder pain. Yeah, which is an obvious one. That’s really interesting. So, it’s almost the coding that can get deepened from 10 years ago.

And just from a terminology point of view, Sarah, this breast recurrence, the word kind of secondary breast [00:29:00] cancer, are they all meaning the same thing?

Dr Sarah Taylor

Yes. Yeah.

Dr Rebecca Leon

So just because I know that these words are used…

Dr Sarah Taylor

Yeah. And people talk about, and obviously local recurrence can be slightly different. Yeah. And a lot of women, and some women will get local changes after they’ve had surgery.

Dr Rebecca Leon

I had a, I had a patient in recently who, in her mid-eighties, who actually, had it in 2017 and literally came with kind of fullness, in the upper arm axilla area, but she had lymphedema in that arm as well. And, but I could feel that it was, it felt different, and she actually had a recurrence.

And it’s unfortunate now, metastasized further, but that’s how she presented with, as I say, this, this fullness, which I think if it would’ve been a telephone remote consultation in the same area as her lymphedema and she was getting treatment for that, it would’ve just been discounted. So again, examine, examine, examine.

Dr Sarah Taylor

I think the other issue with this is that [00:30:00] you, like all of these things, some of the investigations that we use aren’t, and it’s just the way it is, they’re not particularly helpful. So, you can have liver metastases and have normal liver function tests. You can have bone metastases and have normal plain film X-rays, and you can have lung metastases and have normal chest X-ray.

Dr Rebecca Leon

25% of chest x-rays are normal, which is…

Dr Sarah Taylor

So, I think that what we need, what we should be able to do, is if you’ve got a patient who has a history of breast cancer and has symptoms of concern, is refer back to the initial treating team so that they can organise the most appropriate investigations. So, ultrasounds, bone scans, CT thorax, MR brains. Because I don’t think CT brain is a particularly good test for picking up brain metastases if they’re quite small as well. So, I think. It’s not something that it’s like, it’s like lots of things we talk about. It’s having that awareness, understanding the [00:31:00] limitations of the investigations that we can access and then sending on to somebody who can

Pete Wallroth

From a resources perspective as well, you mentioned Jo Taylor, she’s produced some fantastic infographics around, how you pick up the early signs and symptoms of recurrence and I think that stemmed from conversations and concerns that when people are given the all clear and no evidence of disease, that they’re not at the same time, always given a raft of information about what to keep an eye out for.

Dr Sarah Taylor

Yeah.

Pete Wallroth

And because if it is given, it’s given in the same conversation that somebody is perhaps really joyful or, you know, relieved at good news that they don’t necessarily pick up the things to, to necessarily take forward. And, and that’s the message that Jo’s been talking about for years.

Dr Sarah Taylor

She has hasn’t she.

Dr Rebecca Leon

Yeah.

Pete Wallroth

To make that point and to have it heard, so that that secondary breast cancer community are, listened to and it’s, you know, it’s the chances are things being picked up earlier.

Dr Sarah Taylor

Yeah. And like lots of patient infographics and information leaflets, actually Jo’s leaflets and infographics are really, really good for primary care [00:32:00] professionals as well.

Pete Wallroth

Yeah, and it’d be good one to have, you know, for any surgery to have copies of that, not just for patients, but for, you know, for any GP as well to look at it because it’s so, it’s so easily digestible, but it sticks with you.

Dr Rebecca Leon

But I think, and, again, we’ll put those in the show notes at the end, but again, it’s, as you say, when somebody’s been given almost the all clear, the last thing they want to hear is it may come back and this is what you need to look out for. And it’s understanding the nature of the disease, as you’re saying, both of you, that unfortunately can stay latent, it can just stay there, and then actually it can rear its ugly head later on.

Pete Wallroth

Yeah. It’s not to say that there won’t be situations where sadly, like I explained earlier, there isn’t any outward sign that there is something else going on, and then by the time it suddenly takes effect, sadly it’s, you know, it’s far too advanced. But I think what, what we are talking about and what Jo makes the point of is where the symptoms are clearly there and they could be listened to and picked up on, but people either aren’t aware of them themselves or health professionals maybe aren’t that commonly in touch with people who are being diagnosed [00:33:00] with secondary or living with, you know, ongoing impact of, of secondary cancer.

Dr Rebecca Leon

Absolutely. Okay. Well, I have really enjoyed this.

Dr Sarah Taylor

I have and I’ve got my…

Pete Wallroth

Yeah, indeed.

Dr Sarah Taylor

Take away a message from today, which I always like…

Dr Rebecca Leon

Always, and she’ll be quoting that forever.

Pete Wallroth

Brilliant.

Dr Sarah Taylor

Forever, you’ll all know.

Dr Rebecca Leon

And Pete, thank you so much and, and thank you for sharing your story, your experience, and for the fantastic work that you’re doing ongoing. And I hope that we continue to work together…

Pete Wallroth

Likewise.

Dr Rebecca Leon

And share the wonders of Mummy’s Star.

Pete Wallroth

Thank you.

Dr Rebecca Leon

So, Sarah, thank you again. Thank you all for listening today. We’ve got a free breast cancer module that you can find on the GatewayC website.

We’ve put all the references to the studies and guidelines that we mentioned and all the extra stuff, that we’ve picked up. And also, we’ll make sure we’ll put a link to Mummy’s Star website as well, and these will all be on our show notes. Thank you for Ellen. [00:34:00] who again, she’s waving, she’s remote, but, and silent, but, she is still providing us with wonderful information.

And news just in from Ellen, that what Sarah was saying earlier, that the…

Dr Sarah Taylor

Male breast cancer is a risk at any age. So female breast cancer, you’re worried in younger women, but male, it’s at any age.

Dr Rebecca Leon

Thank you very much. And I also want to thank our producers, Louise Harbord from GatewayC and Jo Newsholme from ReThink Audio.

Before we go, I wanted to just clear up and discuss the positive predictive value, which is something that we touch on in a few of the episodes. The positive predictive value was used to determine the threshold to encourage clinicians to refer on for a suspected cancer pathway or for urgent tests. And this was agreed at 3%. For more information, we have attached the link via the show notes, and this [00:35:00] is through the NICE guidelines, and I would encourage all listeners to have a look at this and understand this in more detail. You can also get this podcast direct to your feed if you press the follow button, and we’d love it if you share this podcast with your friends or colleagues. It really does help spread the wor

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Dr Rebecca Leon

[00:00:00] It just seems crazy and actually we were told that it is safer to have chemotherapy than actually a glass of wine from the second trimester onwards. Which is an amazing thing to almost think about, but it is getting the head round and getting a proper MDT discussion.

Hi, this is GPS Talk Cancer, brought to you by GatewayC. I’m Dr Rebecca Leon, and joining me through this podcast is Dr Sarah Taylor. We are both practicing GPs and GP leads for GatewayC. We are both passionate about diagnosing cancer early, and in this podcast, we want to share our clinical experiences with you, so you can make better, faster, and more confident cancer diagnosis in primary care.

So, there’s some official stuff to make you aware of. We know this podcast might be of interest to anybody, but it is really aimed at primary care health professionals. And although all patient cases are based on real stories from our clinical practice as GPs, they are fully [00:01:00] anonymised with no identifiable patient data.

GatewayC is funded by the NHS and is part of The Christie NHS Foundation Trust.

So, the official stuff out the way, kettle’s on, it’s time to talk about today’s podcast and we’ll be talking about breast cancer. I’m here alongside Sarah and Ellen is working up north today. Ellen is a junior doctor who works with us at GatewayC. But we are joined by my friend and colleague, Pete Wallroth, from the charity, Mummy’s Star.

Pete, I think you do a better job of actually telling us why you’re here and a bit about yourself.

Pete Wallroth

Thank you. I will of course. So, I’m the founder and CEO of a charity called Mummy’s Star, that’s been going 10 years and we focus our support on families where they get a cancer diagnosis during pregnancy or any time up to 12 months postnatally. And we’ve been supporting families all [00:02:00] over the UK and Ireland in that time to be able to support, be able to raise awareness of what the impact is of cancer and pregnancy, and how it challenges families in what should otherwise be a really exciting and celebratory time.

Dr Rebecca Leon

Well, thank you and it’s lovely to have you here. So, Sarah, how are you today? And have you had a nice weekend?

Dr Sarah Taylor

Yes, very nice, thank you. Yeah, my husbands on call so we couldn’t do very much, but yeah, it was, yeah, we did bits and pieces, walked the dog went for a run, which I won’t mention to Pete because I know he’s injured, but, you know. It’s all good.

Yeah, and Pete, how are you since I last saw you, what have you been up to?

Pete Wallroth

We’re good, yeah. Just busy celebrating 10 years as a charity, which is a massive milestone. And it’s, yeah, it’s been full of reflections and celebrations and you know, obviously looking back on, you know, sad times as well, but it’s, you know, looking at the positive difference we’ve been able to make in conversations just like this.

Dr Rebecca Leon

Fantastic. We’ll be talking about breast cancer today, and I’m going to be throwing some stats at you coming straight from CRUK [00:03:00] one in seven UK females will be diagnosed with breast cancer in their lifetime. But the good news is that 75% of women will survive breast cancer for 10 years or more following a diagnosis.

Right, back to the cases. And actually I’m going to start with Pete to talk about a case that’s very close to home.

Pete Wallroth

Sure. Yeah. So my, I guess, introduction to cancer and pregnancy as a, as a topic came from a personal experience 11 years ago. My late wife Mair was, 19 weeks pregnant with our second child, and she started to develop a dull ache in her left breast at about 19 weeks. We proceeded to have a sonography appointment about a week later, had a scan, found out that we were going to have a little boy, and then in the midwifery appointment that followed that it was just mentioned, in passing that this, this ache had, you know, had surfaced over the last week or so.

It wasn’t particularly worrying her. She [00:04:00] wasn’t, you know, staying awake at night with concern or anxiety. But nonetheless, the midwife that we, we disclosed this to, said, you know, yes it probably won’t be anything serious, but, we’ll, nonetheless, we’ll make the referral, we’ll put a referral through to the breast clinic, and that was it.

We carried on with, you know, for the next couple of weeks that appointment came and went. And sadly with it came a diagnosis that she had a six centimetre tumour in her left breast. And as a family with a relatively limited experience of cancer that’s, it’s quite an eye-opening and scary traumatic time.

But when it’s framed with, you know, a continuation of a, you know, growing pregnancy and all the excitement is, then it’s just that it’s that perfect storm that you know, that nobody would really, you know, sort of be able to imagine, you know, never mind be able to work out how to actually step through it.

And, from that point, we, you know, we had a, a really good team, very reassured, very quickly, MDT convened, we were involved in our MDT as a family. We actually sat there, you know, with all these different oncology and obstetric and midwifery, you know, professionals talking and making a [00:05:00] plan for us as a family.

We proceeded with chemotherapy, had four rounds of chemotherapy while Mair was pregnant, and then we had our baby by induction. He was born safe and well. And then she proceeded with treatment, you know, postnatally, the impact as a family trying to raise a, a little baby when somebody is so fatigued and, you know, and all the onset of chemotherapy side effects, especially when you’ve got that, that post labour, you know, physical and, and, you know, and psychological tiredness as well is a real challenge, you know, for any family.

And it was from that, that it I guess it spurned the idea of why wasn’t there a tailored support out there for families in our situation? Or what if more to the point, what if families weren’t as fortunate as us? What if they didn’t have the, the nature of support networks, friends, family close by that would’ve softened the blow.

And you could have planned, you know, around your, the rigors of treatment and then subsequent surgeries. And from that, I guess that seed was kind of planted. But, you know, ultimately it didn’t really turn, turn into Mummy’s Star until about nine months later. What sadly [00:06:00] happened for us, despite the initial cancer, you know, responding really well to treatment, the cancer had actually very silently spread with no, you know, outward signs to the meningeal lining of her brain.

And about eight weeks after Merlin’s birth, she presented with quite severe dehydration. She started to lose her balance, was losing her sight in one of her eyes, hospital admission. And then a subsequent lumbar puncture revealed that the nature of the spread and how rapid it was. And she sadly then died at 10 weeks postnatally as a result of that cancer.

Dr Rebecca Leon

And you mentioned that it was the midwife who actually was instrumental in picking up the lump in the first place. This was something, so you actually never visited a GP. It was a different line of diagnosing and, and subsequently, everything that went with that.

Pete Wallroth

Yeah. For, for us, when that symptom arose, you know, for her and she started, you know, to feel it [00:07:00] and, you know, mention it to me the next, the next juncture in our health journey, if you like, was that we just happened to have this appointment coming up anyway. So it seemed like the natural course of action. So well, why make another appointment when we’ve got that one next week? And it was just mentioned very casually. We didn’t go into that appointment fraught with, you know, concern or worry. It was just, you know what, we’re going to see the midwife, let’s mention it to them.

And then they said, right, do you know what? I’ll just make the referral that you’re here anyway. There’s, you know, there’s no point in delaying any further. And granted, that could have caused, you know, some you know, temporary anxiety in somebody to think, oh, well why are you referring me? What, you know, you must be worried about something.

But for us it was better that than to go away and think, should we have said something? Should we have not said something? And ultimately, it led to what was a very rapid diagnosis. And that’s what you’d hope, any other family would, you know, would be able to receive in that kind of situation?

Dr Sarah Taylor

Did Mair notice a lump herself?

Pete Wallroth

She, yeah, she first noticed it when she was sleeping and she just said, you know, just there’s a soreness. And I think because we’d breastfed our daughter for, you know, for well [00:08:00] over a year, the natural position for us as a couple was, it’ll be something to do with, with milk production. It’ll be a, possibly a blocked milk duct, a bit of, you know, massage or, you know, warm pads on the breast tissue might, you know, might help ease it out. We didn’t, you know, Google symptoms, we didn’t look it up because it just wasn’t a concern for her. And because we didn’t have a long wait to another medical appointment of any, of any discipline, it just felt easier to just say, well, we’ll just mention it there. But it wasn’t keeping her awake. It wasn’t a, it wasn’t a physical lump that she could feel, for example. It was just this dull ache is how she always described it.

Dr Rebecca Leon

I mean, Sarah, we, we talk about an ache, a pain, a discomfort, which we see a lot in general practice. What do you think about breast pain and, how is the best way to manage this? Particularly hearing about Pete’s story and, and things like that.

Dr Sarah Taylor

I think breast pain is very common, isn’t it? I think that’s the first thing, and I think that [00:09:00] there’s, you know, we’ve just done quite a lot of talking and research about it. I’ve just spoken to one of the consultants and we’ve been designing a local breast pain pathway. It, it is very common. There’s lots of causes for it. You know, a lot of women who have pain actually, it’s cyclical, which is related to hormones in their periods. I think a lot of people have pain that is actually chest wall pain rather than actual breast pain.

I think it’s really important to have a, like we always say, we say this every week, don’t we? It’s important to have a clear history, and it’s really, really important to examine a patient because obviously if somebody has a breast pain that’s related to a lump or any other changes in the breast, any physical changes in the breast, then that has to be taken really seriously.

The evidence is that breast pain alone is not an, a symptom of breast cancer, but in association with a lump, or with other breast changes, and it has to be taken seriously. And I think the key thing at the moment, well, not at the moment, there just generally, [00:10:00] is to make sure you assess the patient thoroughly.

And I think, you know, it’s part of what, we’ll, we’ll talk, we’ll come onto this again in a minute, I’m sure, but part of that assessment I think for breast cancer also, particularly in younger women, has to be a really clear family history. Because if you’ve got a positive family history and you’ve got symptoms, then you become, you become more concerned.

Dr Rebecca Leon

Yeah. And, and I think it’s examine, examine, examine and off air Pete, you, you said something that will, will definitely stick with Sarah and I about symptoms not being in isolation.

Pete Wallroth

Yeah, I think from, from the, I think what we’ve seen with, you know, with the charity over the last 10 years, we’ve supported nearly 1,600 people in that, in that time.

So we’ve seen how people have presented and how they’ve described their initial symptoms. And what the emerging theme has been is that when people are presenting that the symptom is seen in isolation of whatever stage of pregnancy they are, or even whatever stage they are postnatally because there’s so much body change, you know, postnatally as well. And that sometimes gets missed when people are, [00:11:00] are presenting with symptoms is that, you know, if we, if we did have, you know, two or three women sat in front of us and one of them was pregnant and then the other two weren’t, and they all presented with the same symptom, there is the possibility that the person who is pregnant may not necessarily have their symptoms elevated in terms of the concern.

And it’s, and the only way around that is to just almost put aside the, the fact that they’re pregnant or post and say, right. How do, how do we see that symptom in independence? How concerning is it? Does it match the red flags when we’re going through that safety netting process? And then step forward from there in terms of referral and the next stages.

Dr Rebecca Leon

Because with Covid and with us now doing more remote consultation, particularly telephones, it, we can imagine getting a phone call from a pregnant woman saying that she’s got breast changes. And as Sarah and I talked about last week about we don’t want to overly reassure. In some ways patients almost just ring up and say, it’s nothing, doctor, is it?

So again, back to the point that we, that actually, I think with [00:12:00] any breast changes, we should be inviting the patient in for a face-to-face and a, and an examination, but keeping the pregnancy and the symptoms separate.

Pete Wallroth

Yeah, absolutely. And I think for that, for that patient, if that initial call is a, you know, a phone call assessment or even a video call, it’s about making sure that not, don’t be afraid to elevate your symptoms.

If it’s a concern to you, it will be a concern to the health professional that’s seeing you as opposed to playing down your symptoms or thinking that you’re, you’re taking somebody’s time up. We, you know, there’s this constant reiteration that the NHS is open and if you’re, you know, if it, if it doesn’t feel or function right, go and get it checked. Go and make an appointment. Don’t be afraid to make the phone call because it’s better for your own reassurance to have an intervention, either to diagnose that it isn’t something you’re worried about, and been able to go through the different stages of tests to be able to ascertain what is causing the problem.

Or in the worst case scenario, if it does turn out to be a cancerous, in, you know, instance, then at least earlier intervention that net of options and treatment options and [00:13:00] surgeries remain, you know, is, is much wider from the, from the starting point.

Dr Sarah Taylor

I always make a point of if I see somebody who comes in with a lump that for a variety of reasons I’m not concerned about, of saying, I’m really not concerned about this. But I absolutely think that you did the right thing in coming in to see me about it because it’s my job to know all of the things to be concerned or not concerned. And if you get something like this and you’re concerned in the future, so sometimes you do see people with lumps that are, or symptoms that I’m really not concerned about. And I, and just to, to add to them, because I don’t want them to think, oh, she wasn’t worried last time. When they’ve got something different the next time to think, oh, she wasn’t worried about that or she made me feel like I was wasting her time. I want them to know that actually, I’m perfectly happy to assess because that’s my job.

And if they’ve got another concern in the future, they should come back.

Pete Wallroth

Yeah, absolutely. And I think what also matters with that is, ensuring that the, the body vigilance messages that we’re sharing with people

Dr Sarah Taylor

Yeah.

Pete Wallroth

That they have to remain during pregnancy and postnatally. I think there is, there is this [00:14:00] I guess a, an approach that, you know, when the, when the, the body goes through so much change during pregnancy and what we’re advised is going to happen and what you expect yourself, either from previous pregnancies or from friends or families, you know, notions of what they have experienced themselves is, oh, you know, I’m going to have so much change, how would I tell the difference between a concerning symptom versus something that’s normal anyway? And it’s just reiterating that message that keep checking yourself, keep doing the, you know, whether it’s a monthly breast check, you’ve got a reminder on your phone or any other, you know, issues that come up in and around pregnancy.

It’s making sure that you’re just body vigilance remains high just as it would outside of pregnancy.

Dr Sarah Taylor

I think we were talking about the common cancers in pregnancy being just the common cancers in people of that age. Cause the other thing that’s springing to mind is the idea that women, a lot of women have rectal bleeding, don’t they? And it’s always.

Dr Rebecca Leon

Haemorrhoids.

Dr Sarah Taylor

You’ve got haemorrhoids. But actually again, that, I don’t know whether you see many women with haemorrhoids.

We do. We, it’s the, the common things that we hear are around breast [00:15:00] complaints, abdominal discomfort, gynaecological issues, whether it’s discharge, but where it’s, you know, whether it’s not clearly bleeding, but other types of discharge that could be early signs of other, you know, UTIs, infections, thrush, rectal bleeding, sign of haemorrhoids, early signs of, you know, different types of bowel cancer, breathlessness.

We’ve seen lymphomas, lung cancers diagnosed, but, but the narrative that surrounds it is, this is to be expected in pregnancy and it’s just that consideration of yes, it probably will, it could happen and it is something to look out for, but if it’s concerning, you go and get it checked and don’t ignore symptoms.

And I think even with all the awareness we’ve had over the last 12 months, especially just because you’ve used the example around rectal bleeding, bowel cancer, check your poo, all of those symptoms, there’s still that element of taboo around it. And we’ve got to keep continuing those conversations. People say, get it checked.

Dr Rebecca Leon

Because Pete with women being older now, now that they’re conceiving older, women are having babies later. Do you think that’s going to also increase the chances of cancers being [00:16:00] seen in pregnancy and generally cancers?

Pete Wallroth

I think because we’ve got these birth trends and they’re not showing any change in, you know, in families leave it until later into the thirties, early forties, there’s going to be that overlap into higher risk categories around, around age. And it’s, it’s important to, to clarify that there’s not causation between breast cancer and pregnancy, but people are just going to overlap and they’re, you’re going to have these coincidental diagnosis. So, you know, when, when we talk about this subject, yes, we are probably only more likely to see cases over the next, you know, 10 to 15 years while those birth trends stay.

But that’s not to say that women who are feeling those symptoms at younger age groups in the twenties, thirties, you know, equally, you know, are going to, we’re going to see diagnosis as well, and, I think that’s where some of the issue lies is you don’t expect to be diagnosed with breast cancer at 22, 24, 27. And then all the other issues that come with it.

Dr Sarah Taylor

Yeah. And in terms of treatment, so I, I can imagine, you know, when, when I started as a GP, if you’d seen, diagnosed somebody and [00:17:00] with cancer in pregnancy, the treatments would’ve been very difficult for somebody to tolerate and not possible. And I think that would’ve made me think, oh gosh, what we know, what, what should I do now? Has that changed? And what’s the position in terms of treating?

Pete Wallroth

When, from, from all the, the senior oncologists that treat and have treated people and the, and the, the research that exists from the Institute of Cancer, Infertility and Pregnancy in Belgium, the research shows that there isn’t any adverse impact on the development of baby if chemotherapy is given in the second trimester onwards.

But it’s clear to state that in, in the first trimester, it’s far more complex and it’s not routinely given because of, you know, the period of, you know, fastest foetal growth. But I think the, the issue isn’t necessarily, whether you can or can’t, it’s how people psychologically get their head round the notion that you would have, you would combine chemotherapy, something that we know has side effects as well as you know, as well as ability to, to treat or cure with the growth of a baby and that special, precious time and people hold pregnancy so sacred that the idea of putting the two things together for [00:18:00] medical professionals as well as members of the public, it’s just, if they haven’t come across it, it’s actually quite a difficult thing for people to get their heads around that it’s possible.

And once you do look at the options, like our experience, we were instantly given reassurance because our team, purely by chance had actually treated two other women in, in previous years with, you know, chemotherapy and pregnancy. They knew the safe parameters you could do so, but the, you know, the, the unseen traumas that I think that hides is, you know, for women who were, you know, who were pregnant and being treated is there is that impact on breastfeeding and that is a fundamental, core part of pregnancy for so many people. And it’s, some people get bothered by the cancer diagnosis, but then you lose something like breastfeeding from maternity experience and it’s actually really devastating.

Dr Rebecca Leon

I mean, Sarah, for us, we’ve been in this cancer world for a while and I had the pleasure of speaking to Pete probably about 18 months ago, and we did a cancer conversation as part of GatewayC. And one of the things that I really learned about, was about that chemotherapy [00:19:00] can be given during pregnancy and you’ve put it eloquently that a baby’s growing and then you’re actually giving a toxic substance.

Pete Wallroth

Yeah

Dr Rebecca Leon

You said it better than me, but you know what I’m saying. And that I think to any GPs listening, it just seems crazy. And actually, we were told that it is safer to have chemotherapy than actually a glass of wine from the second trimester onwards, which is an amazing thing to almost think about, but it is getting the head round and getting a proper MDT discussion. And I, I think the other thing that you mentioned earlier is actually you being involved in the MDT, I think’s really special and really important that that can happen.

Pete Wallroth

Yeah. It’s not something that I think many patients are aware of and, and quite often in cases like this, because it is so specialised and you have, disciplines of obstetrics and oncology that should never otherwise have any reason to discuss things with each other, suddenly have to come together. And because they are nine times out of ten, it’ll be an MDT just for that [00:20:00] patient.

It is possible to ask that family whether they would like to be involved. It’s not to say they all will be. Some, some families over the years that we’ve supported, they don’t want anything to do with the MDT, but they want to just be informed what’s happening, because it’s too traumatic actually hearing it being spoken about in real time.

For us, we found it quite a reassuring process we found very involved even if we didn’t necessarily understand all the medical jargon. But the point was we were given the opportunity to be, you know, to be involved in it. And you know, when you, when you have a body of emerging specialists, I suppose, who’ve, you know, treated people like oncologist Richard Simcock, who’s been part of the cancer conversation that we previously recorded.

There is that reassurance that, you know, people are looking at this as a subject and wanting to know more about it, to reassure others out there. You know, Richard, to quote him from a conference a few years ago they did for us, said, you know, we’re paranoid beyond rationality to medicate people during pregnancy.

So, when you add something as extreme as chemotherapy into that same breath, you can see why people have this rabbit in the headlights response to, [00:21:00] how on earth is that possible? But yet, the facts are there, that it is.

Dr Sarah Taylor

Yeah. I can think too, if I prescribe anything for anybody…

Dr Rebecca Leon

Antibiotics, yeah.

Dr Sarah Taylor

The computer springs up all of these things saying medium severity warning, high severity warning, low severity warning.

Dr Rebecca Leon

No, it’s exactly, you’re absolutely right. Can I just talk to you a little bit about family history, Sarah? Because breast cancer in particular, there is a link with certain family histories, certain genes.

You talked about a patient that you saw, in her eighties, concerned about her, her granddaughter.

Dr Sarah Taylor

Oh, she was concerned about her granddaughter having a family. I, I think breast cancer’s difficult, isn’t it? Because the, it’s so common. So, a lot of people will have somebody in the family who’s got a, who’s had breast cancer.

Dr Rebecca Leon

So, age is really, age is really important.

Dr Sarah Taylor

Age is really important. Yes, so I mean if you’ve got somebody who’s had breast cancer young, then I think that’s important. Then obviously it is numbers of people, age of diagnosis and whether they’re on the same side of the [00:22:00] family or not. And male breast cancer is a, an important thing to record as well because that is, does have a high genetic link and so, and I think it’s not necessarily something unless you ask specifically, you know?

Dr Rebecca Leon

So, when you’re talking about age, Sarah, what you talking?

Dr Sarah Taylor

We’re talking about basically about premenopausal women.

Dr Rebecca Leon

Premenopausal. So, kind of 50 and below?

Dr Sarah Taylor

Yeah. Really, yeah. I tend to say twenties, thirties, and early forties. But yeah, you know, just as a rough guide.

Dr Rebecca Leon

Okay.

Dr Sarah Taylor

And I think, but I think it’s important, but I, I don’t know, and I don’t know whether Ellen can check with that, whether the male breast cancer risk is, I think that’s at any age.

Dr Rebecca Leon

Okay.

Dr Sarah Taylor

I think that adds at any age.

Dr Rebecca Leon

Okay. So, we’ll, we’ll, we’ll put that in the show notes at the end.

Dr Sarah Taylor

Yeah. And we’ll learn, we’ll all learn.

Dr Rebecca Leon

But, but BRCA is also a, a big thing that we see in the, the Angelina Jolie effect when she was, found to be BRCA positive. And actually, it was, we saw a surge of people asking for genetics tests and things because she made it very public. I’m putting you on the spot here, [00:23:00] Sarah. Pete, you may, can jump in here as well.

I mean, the BRCA genes is, there’s a BRCA1, BRCA2. It, it’s, that’s again, we ask about family history.

Dr Sarah Taylor

We need to remember about the family history, that it’s not just breast cancer for BRCA, don’t we? We need to, we, we might talk about this in another podcast, but obviously it’s related to prostate cancer and ovarian cancer. So, I think we need, it’s one of the I think, you know, we have these key messages that we, that I have. So, my key one from today is definitely going to be Pete’s thing about making sure that you look at the symptoms in isolation from the pregnancy. Because I think that is really, really important. But yeah, I think that’s, I think recording of family history is, needs to be on everybody’s PDP to get better at it.

Dr Rebecca Leon

Yeah. So, PDP is what we have to do every year as part of our appraisal. We have to, kind of come up with three or four.

Dr Sarah Taylor

That’s quite good. I think actually I had not thought about it, but it’s going to be on mine next year.

Dr Rebecca Leon

Yeah. There we go.

Dr Sarah Taylor

Record family history.

Dr Rebecca Leon

Record family history, pedigree diagrams, the whole lot. [00:24:00] So, it’s really important to ask about family history and certain groups also, I think we did discuss it when we did the ovarian cancer module. Certain groups, there’ll be a high risk of, BRCA positive, so that’s something to always be aware of.

Okay. Are we ready for our fun facts?

Dr Sarah Taylor

Have we got some fun facts?

Dr Rebecca Leon

We’ve got one fun fact, and it’s not really fun.

Dr Sarah Taylor

It’s not really fun, is it? No.

Dr Rebecca Leon

It’s your elbow.

Dr Sarah Taylor

It’s my elbow pain fact. Well, yeah, it is that the, that if you look at women with elbow pain, you are as likely to pick up a breast cancer as you are if you look at women with breast pain. Assuming that you have made sure and examined that the woman with breast pain does not have other changes or symptoms.

Dr Rebecca Leon

So, in a nutshell

Dr Sarah Taylor

A nutshell.

Dr Rebecca Leon

So, we’re really talking kind of cyclical breast pain or breast pain with no other examination findings in isolation.

If you compare that to all the elbow pains that we see in general practice… [00:25:00]

Dr Sarah Taylor

I don’t think elbow pain’s a really common one really, is it? You know, but, back pain maybe.

Dr Rebecca Leon

Yeah. So, it, so breast pain in isolation, we should think about other measures, maybe safety net, maybe bring them back. I often put a date in the diary for somebody to come back if I, if I’m just got that slight inkling that I want to see them again, but it’s not in isolation a reason for an urgent diagnosis. Okay.

Pete Wallroth

I think just to pick up on that point, I think from what we’ve been talking about with, with symptoms and being checked and people visiting as well from a pregnancy context is that’s what we’d love to see more of as well, is if there is a reassurance that’s given, but there’s just that niggling doubt that you want to have that person again, is, is place the appointment in your diary to get them back.

Dr Rebecca Leon

Absolutely.

Pete Wallroth

I think because sometimes where people have been told to come back, if it persists, you end up in such a wide realm of subjectivity, people then think, oh well, do I bother them again? And it, we enter that, that area of, I you know, I don’t want to take up somebody’s time, but we want, we want them to [00:26:00] know that they’re being watched and, and you know, we’re proactively wanting to seek the reassurance for yourselves as professionals, as much as it the person in, in question as well.

Dr Sarah Taylor

Yeah. And I think that links into the one that, that probably Jo and Louise are now quoting to people too, that we always say that the patient who was told to come back if it got worse, rather than to come back if it persists.

Pete Wallroth

Yeah.

Dr Sarah Taylor

And actually nothing got worse, but over the next year, 18 months, it didn’t get better. It didn’t change, but it didn’t go. I think, you know, that, that wording and that safety netting and probably in pregnancy as things are changing anyway, is even more important, isn’t it?

Pete Wallroth

Yeah, absolutely.

Dr Rebecca Leon

So, we’re going to do a, we’re just going to quickly just talk about case two, just because it’s something very different and it does bring up some learning points that we want to talk about.

So, Sarah, can you just, just talk about.

Dr Sarah Taylor

Yeah, so I think we’re just talking about the issues of recurrence of breast cancer, particularly in older women. It’s something we talked about on, on the GatewayC module that actually, [00:27:00] recurrence of breast cancer is relatively common, not in everybody. And, but obviously it is, it is fairly common, but the biggest problem is that it can happen quite a long time after the initial diagnosis.

So, we’ve, we’ve got patients who’ve been diagnosed five, 10 years after the initial diagnosis. Obviously, breast cancer can spread to bones, to lungs, to the liver, and to brain. And obviously there’s local, local recurrence and, all of those can have quite vague symptoms. So, a lot of the patients who have bone recurrence will have vague pains, particularly back pains.

But lots of people have vague pains. And similarly, you know, the breathlessness, the lung patients may have a little bit of cough or breathlessness. Again, they’re often non-specific symptoms. And I think that the, the key when we’ve spoken to patients, and you know, Jo Taylor, who does, does a lot of work with a local [00:28:00] charity on awareness for patients of recurrence of breast cancer is really keen that women are aware of their risk of recurrence so that they can articulate it when they come to see us. But not all women will be, and I think it’s really key for us to make sure that we’ve got particularly good coding.

Because you know what GP notes can be like if you’ve got something that’s sunk 10 years ago.

Dr Rebecca Leon

Do you, do you actually get, we get a flash up to say history of neoplasm.

Dr Sarah Taylor

You do for bone pain, but you don’t for anything else.

Dr Rebecca Leon

That’s interesting. So, if, so for the, so if there is, as you say, dizziness or breathlessness or something, I don’t know, abdominal pain, which could be kind of liver capsular pain. None of that comes up.

Dr Sarah Taylor

Yeah, I think it’s just back pain actually. I don’t think it’s other bone pain. I don’t think it covers, come up.

Dr Rebecca Leon

It’s like shoulder pain. Yeah, which is an obvious one. That’s really interesting. So, it’s almost the coding that can get deepened from 10 years ago.

And just from a terminology point of view, Sarah, this breast recurrence, the word kind of secondary breast [00:29:00] cancer, are they all meaning the same thing?

Dr Sarah Taylor

Yes. Yeah.

Dr Rebecca Leon

So just because I know that these words are used…

Dr Sarah Taylor

Yeah. And people talk about, and obviously local recurrence can be slightly different. Yeah. And a lot of women, and some women will get local changes after they’ve had surgery.

Dr Rebecca Leon

I had a, I had a patient in recently who, in her mid-eighties, who actually, had it in 2017 and literally came with kind of fullness, in the upper arm axilla area, but she had lymphedema in that arm as well. And, but I could feel that it was, it felt different, and she actually had a recurrence.

And it’s unfortunate now, metastasized further, but that’s how she presented with, as I say, this, this fullness, which I think if it would’ve been a telephone remote consultation in the same area as her lymphedema and she was getting treatment for that, it would’ve just been discounted. So again, examine, examine, examine.

Dr Sarah Taylor

I think the other issue with this is that [00:30:00] you, like all of these things, some of the investigations that we use aren’t, and it’s just the way it is, they’re not particularly helpful. So, you can have liver metastases and have normal liver function tests. You can have bone metastases and have normal plain film X-rays, and you can have lung metastases and have normal chest X-ray.

Dr Rebecca Leon

25% of chest x-rays are normal, which is…

Dr Sarah Taylor

So, I think that what we need, what we should be able to do, is if you’ve got a patient who has a history of breast cancer and has symptoms of concern, is refer back to the initial treating team so that they can organise the most appropriate investigations. So, ultrasounds, bone scans, CT thorax, MR brains. Because I don’t think CT brain is a particularly good test for picking up brain metastases if they’re quite small as well. So, I think. It’s not something that it’s like, it’s like lots of things we talk about. It’s having that awareness, understanding the [00:31:00] limitations of the investigations that we can access and then sending on to somebody who can

Pete Wallroth

From a resources perspective as well, you mentioned Jo Taylor, she’s produced some fantastic infographics around, how you pick up the early signs and symptoms of recurrence and I think that stemmed from conversations and concerns that when people are given the all clear and no evidence of disease, that they’re not at the same time, always given a raft of information about what to keep an eye out for.

Dr Sarah Taylor

Yeah.

Pete Wallroth

And because if it is given, it’s given in the same conversation that somebody is perhaps really joyful or, you know, relieved at good news that they don’t necessarily pick up the things to, to necessarily take forward. And, and that’s the message that Jo’s been talking about for years.

Dr Sarah Taylor

She has hasn’t she.

Dr Rebecca Leon

Yeah.

Pete Wallroth

To make that point and to have it heard, so that that secondary breast cancer community are, listened to and it’s, you know, it’s the chances are things being picked up earlier.

Dr Sarah Taylor

Yeah. And like lots of patient infographics and information leaflets, actually Jo’s leaflets and infographics are really, really good for primary care [00:32:00] professionals as well.

Pete Wallroth

Yeah, and it’d be good one to have, you know, for any surgery to have copies of that, not just for patients, but for, you know, for any GP as well to look at it because it’s so, it’s so easily digestible, but it sticks with you.

Dr Rebecca Leon

But I think, and, again, we’ll put those in the show notes at the end, but again, it’s, as you say, when somebody’s been given almost the all clear, the last thing they want to hear is it may come back and this is what you need to look out for. And it’s understanding the nature of the disease, as you’re saying, both of you, that unfortunately can stay latent, it can just stay there, and then actually it can rear its ugly head later on.

Pete Wallroth

Yeah. It’s not to say that there won’t be situations where sadly, like I explained earlier, there isn’t any outward sign that there is something else going on, and then by the time it suddenly takes effect, sadly it’s, you know, it’s far too advanced. But I think what, what we are talking about and what Jo makes the point of is where the symptoms are clearly there and they could be listened to and picked up on, but people either aren’t aware of them themselves or health professionals maybe aren’t that commonly in touch with people who are being diagnosed [00:33:00] with secondary or living with, you know, ongoing impact of, of secondary cancer.

Dr Rebecca Leon

Absolutely. Okay. Well, I have really enjoyed this.

Dr Sarah Taylor

I have and I’ve got my…

Pete Wallroth

Yeah, indeed.

Dr Sarah Taylor

Take away a message from today, which I always like…

Dr Rebecca Leon

Always, and she’ll be quoting that forever.

Pete Wallroth

Brilliant.

Dr Sarah Taylor

Forever, you’ll all know.

Dr Rebecca Leon

And Pete, thank you so much and, and thank you for sharing your story, your experience, and for the fantastic work that you’re doing ongoing. And I hope that we continue to work together…

Pete Wallroth

Likewise.

Dr Rebecca Leon

And share the wonders of Mummy’s Star.

Pete Wallroth

Thank you.

Dr Rebecca Leon

So, Sarah, thank you again. Thank you all for listening today. We’ve got a free breast cancer module that you can find on the GatewayC website.

We’ve put all the references to the studies and guidelines that we mentioned and all the extra stuff, that we’ve picked up. And also, we’ll make sure we’ll put a link to Mummy’s Star website as well, and these will all be on our show notes. Thank you for Ellen. [00:34:00] who again, she’s waving, she’s remote, but, and silent, but, she is still providing us with wonderful information.

And news just in from Ellen, that what Sarah was saying earlier, that the…

Dr Sarah Taylor

Male breast cancer is a risk at any age. So female breast cancer, you’re worried in younger women, but male, it’s at any age.

Dr Rebecca Leon

Thank you very much. And I also want to thank our producers, Louise Harbord from GatewayC and Jo Newsholme from ReThink Audio.

Before we go, I wanted to just clear up and discuss the positive predictive value, which is something that we touch on in a few of the episodes. The positive predictive value was used to determine the threshold to encourage clinicians to refer on for a suspected cancer pathway or for urgent tests. And this was agreed at 3%. For more information, we have attached the link via the show notes, and this [00:35:00] is through the NICE guidelines, and I would encourage all listeners to have a look at this and understand this in more detail. You can also get this podcast direct to your feed if you press the follow button, and we’d love it if you share this podcast with your friends or colleagues. It really does help spread the wor

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