Guy: It’s the patient that keeps coming back with the same symptoms. Think about it. And once you’ve thought about it, it’s in your mind and you won’t rest until you make sure they haven’t got it. 

Rebecca: Hello and welcome back to season two of GPs Talk Cancer. I’m Dr. Rebecca Leon and joining me again through this podcast is Dr. Sarah Taylor. We are both practicing GPs and GP leads for Gateway C. We’re 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 diagnoses 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’s really aimed at primary care health professionals. And although all patient cases are based on real stories from clinical practice, they are fully anonymised with no identifiable patient data.  

GatewayC is the free early cancer diagnosis resource funded by the NHS and is based at The Christie NHS Foundation Trust. GatewayC is a national programme across the whole of England, Scotland, and Wales. Register online to gain access to free interactive courses, documentary-style videos, referral maps and more.

So today we’re gonna sit down for a coffee and talk about paediatric cancer with our guest, Dr. Guy Makin. He’s a senior lecturer in paediatric oncology and honorary consultant paediatric oncologist at the Royal Manchester Children’s Hospital.  

Rebecca: Hi everyone. Hello. 

Sarah / Guy: Hello, hi. 

Rebecca: How’s…? How is… How are things? 

Guy: Good. 

Sarah: Yeah, fine. 

Rebecca: Nice week off, Sarah. 

Sarah: Yes. Very nice. Thank you. Yeah, lots of walking and running and stuff. 

Rebecca: Great. And Guy, welcome to the podcast! 

Guy: Thank you very much.  

Rebecca: Did you get here okay this morning? 

Guy: I did. The taxi was very efficient. 

Rebecca: Love that. 

Sarah: More efficient than Rebecca and I were, cause you beat us here! 

Rebecca: I know exactly. We’ve all got drinks and let’s crack on! 

Rebecca: So before we talk about the cases, we’re going to introduce some statistics. Cancer in children accounts for less than 1% of new cases in the UK and a GP is likely to come across approximately one to two cases every 10 years. Leukaemia is the most common, and brain and lymphoma and leukaemia account for two thirds of all childhood cancers. 45% of childhood cancers occur in the ages of 0 to four. 46% are seen in girls with a slightly higher 54% in boys. And there’s no known cause or unclear risk factors and many thought to arise during embryonic or foetal life. So I’m gonna bring you in here, Guy. Can you just explain a little bit more about that? 

Guy: So, if you think about adult cancers, adult cancers are epithelial. They arise in the bit of your body that interacts with the outside world, and they get more common the older you get, because the longer your body’s been in contact with the outside world, the greater the burden of mutations in cells and the greater is the likelihood that those mutations will cause cells to proliferate and form a tumour. And so children don’t get those kind of cancers cause they haven’t been around for long enough. So they get tumours that arise in tissues that were present early in development, embryonal tumours, and the cause for them is very different. So children are… They have mutations that drive malignancy, but they don’t have all that other mutational burden. So children are very unlucky. They just happen to have got early on in their life the mutations which will cause perforation. But because they don’t have that other mutational burden that makes their tumours generally very sensitive to chemotherapy and much easier to treat than most adult tumours. So most adult tumours are very resistant to chemotherapy. 

Rebecca: Okay. 

Sarah: We’ve done a bit of talking to one of the genomics experts and talked about mutations and the different sorts. Presumably you are talking about mutations that aren’t going to increase risk for other members of the family on the whole. 

Guy: Yeah, so not mutations in the child’s germline, but mutations that arise within the cell that then becomes a tumour. So somatic mutations. 

Sarah: Yeah. So we’re not talking about… There being a strong family link in the majority of these cancers, presumably. 

Guy: Yeah, exactly. So there are some conditions which predispose children to get cancer, but they are very rare – all of them. And all even put together, they account for a very small proportion of childhood cancer. 

Rebecca: There you go. Told you he could answer that question really well! 

Sarah: Yeah, I know it was, yeah, really interesting. 

Rebecca: When I sat down with Guy a few weeks ago, I asked the same question and it’s just almost put all my medical school knowledge with, with embryology and all these things together and… 

Sarah: Embryology is a very distant memory, isn’t it? For most of us. 

Rebecca: I quite enjoyed it at the time, but it’s not in our day-to-Day general practice. Is it, Sarah?! We’re gonna start with with case study one and this is a three-year-old girl who presented to general practice complaining of increasing fatigue, pallor, bruising, unexplained bleeding, and nosebleeds. On closer questioning, she was having frequent infections and also had lost some weight. She’d gone down, I think she was in two to three. And understandably the parents were very anxious about the child. Guy, are you just able to explain a few of those symptoms and… And what should be going through our heads then? 

Guy: So the first thing that you should worry about is a child that’s losing weight without obvious cause. So if they’ve got acute gastroenteritis, obviously that’s gonna make them lose weight. But if there isn’t that kind of acute history and their weight is either static or going down, so they’re crossing centiles downwards, then there’s clearly something seriously wrong there and needs to be investigated more thoroughly. The other things in this child that worry me would be easy bleeding. So a child that’s bruising, particularly if they’re getting bruises on places which don’t come into contact with the outside world. So, you know, kids run into things, they get bruises on their shins, but children that get bruises on soft parts of their body, you know, buttocks, that kind of thing, the same kind of thing that would make you worry for non-accidental injury, you know. And nosebleeds, again, kids get nosebleeds, but if they’re getting lots of nosebleeds and they’re difficult to stop, again that makes you worry that the platelet count’s low. And then the child that’s getting tired, increasingly tired, not being able to do things that they were doing before ’cause they’re too tired, it makes you worry that they’re getting anaemic and particularly if they look pale as well. 

Sarah: And if you’ve got a child like this, I mean, some of these, presumably some of this is talking about time span, isn’t it? 

Guy: Absolutely. 

Sarah: You know, if, if a child’s got an acute viral illness, you said that they might lose weight. What, what sort of… And weight loss is quite a, a difficult one… What sort of time span would you be concerned over? 

Guy: Well, if a child’s had acute gastroenteritis and they’ve lost weight over the course of a week. Because they’ve not been eating and they’ve had vomiting and they’ve had diarrhoea. That’s not gonna concern you. But if you’ve seen the child two weeks ago and you’ve seen them again two weeks later and they don’t have any of those symptoms and yet their weight’s dropped, that’s, you know, you need a cause for that ’cause children don’t really do that. 

Sarah: Mm-Hmm. Yeah, probably we just need to weigh them in the first place as well, don’t we? 

Rebecca: And I think also with the centiles as well, plotting the centiles is really important. We always do it on the six to eight week baby check and we’re making sure, but actually maybe we need to do that for longer. 

Guy: Yeah, I mean every time you see a child really they should be weighed and that centile, they should be plotted in the the red book. You know? That’s what it’s there for, isn’t it? 

Sarah: Yeah, it’ll give you a lot of background information then, wouldn’t it? That would… 

Guy: Yeah. It forces you to look and see what centile they’re on before, doesn’t it? 

Sarah: Yeah, absolutely. And well, it just makes you think about the sort of duration of symptoms and changes in symptoms, doesn’t it? Because the problem with case one is that, you know, it’s like there’s a lot of symptoms in there that make you worried, but actually our experiences that probably a lot of children will only have two or three of those symptoms. And some of them are really… You know, lethargy in a 3-year-old is quite a subjective, well lethargy in anybody’s quite subjective, isn’t it? But it’s quite a subjective symptom. And, and so all of these things are… And getting real context from parents, particularly if they are language barriers and things on what you understand by tiredness and lethargy and pallor can be quite difficult. 

Rebecca: We also talked Sarah, didn’t we? That we see a lot of children in general practice and that almost like a typical 3 to 4-year-old started preschool, every other week picking something up. So that question of, of the… of the parents saying they’ve been ill for six weeks, actually saying, ‘well, have they?’ and actually no, they were ill for a week. They were fine for two and then they pick something else up and they’re tired because they’ve started a full day at preschool. So… 

Guy: Yeah. Context is all, isn’t it? 

Rebecca: It’s absolutely context, and I’m sure people listening to this will be thinking, oh gosh, like I’m seeing children – particularly during the winter –  with a lot of these symptoms, but it’s just keep- keeping your eyes open, safety netting, and I think the big thing that, that I wanted to mention was ideally asking them to come back if concerned and see the same clinician because continuity will be really good to actually compare. Has that child improved, got worse, stayed the same. 

Guy: Yeah, it makes your job a lot easier as well. You know, you can do a lot more as you’ve seen the child before, than if you have to start from the beginning again, and then do all of the evaluation of the history and try and decide in your own mind whether it’s serious. You’ve done all that before. So much easier to see the child again. 

Rebecca: Absolutely. And I just wanted to pick up on parent anxiety. I’m a parent myself and, and you are anxious about if your child’s unwell. Tell me the role of the parent and how important it is to listen to them. 

Guy: Yeah, so the parent obviously knows their child much better than you do, and you know, most of the time you’ve never seen this child before. You know nothing about them. You don’t know what their normal state of, of, of being is, whereas the parent knows all of that. But obviously the parent is also anxious and that’s why they’ve brought the child to see you. So when you’re doing that history, the really important thing is to try and remove as much emotion from it as possible. So the parent will want to tell you the history in emotional terms, but what you want is actually how many days has it been going on for? How many times has the child been sick? The precise nature of it, rather than the emotional bit of it. And obviously the most important part of this consultation is that the parent leaves the consultation feeling reassured or not reassured ’cause you’ve made the diagnosis of a serious illness, but with answers to their questions. 

Rebecca: And I think it’s important also parent anxiety is not labelled, in a way. 

Guy: Yeah, it shouldn’t be dismissed. 

Rebecca: … Shouldn’t be dismissed because yes, that it is going to be emotionally charged. They are going to be concerned. But, you say that your ‘three strikes and you’re in’ type thing, you need, you need to be listening and taking note of what they’re saying and not saying, oh, it’s, it’s, it’s a, a nightmare parent. They’re bringing their child in again. It’s actually, you know… 

Sarah: Yeah. It’s actually part of the NICE guidance, isn’t it? Um, persistent parent, parental concern is an indication for a suspected cancer referral. Now, obviously that has to be taken in context because you’d be… We know all the paediatric services would be incredibly busy, but actually I think something that is unexplained and, and recurrent viral illnesses when a child starts nursery are explained, aren’t they? But actually something that adds to that because most of these children, in my experience, don’t lose weight. They, and in between they’re back to their normal selves, and, and they, and maybe that’s a question we should be asking, you know, in the days that they were well, were they just doing everything that they normally did? And, and that gives you a bit more context, doesn’t it? 

Guy: Yeah. And if it’s a first child, it’s different to subsequent children, isn’t it? Because once the parent’s had two other children, they’re comparing to those and they know that when the child starts nursery or starts preschool, that they get illnesses. So they’re not so worried about that. 

Sarah: Yeah. Yeah. 

Rebecca: I just wanted to mention I know particularly with case one, we didn’t talk about neck lumps, but we do see swelling in the neck. Possible lymph node enlargement when we do our examination. Lymphadenopathy in children. Can you just talk about the differences between when we should be worried versus something that’s more benign? 

Guy: Children get a lot of respiratory infections, a lot of upper respiratory infections, which are often gonna cause lymphadenopathy, and particularly in winter I will… I’d reckon most children that you examine the neck of will have symmetrical, relatively small but palpable lymph nodes. The important things are symmetry. So if… Malignant lymph nodes don’t tend usually to be symmetrical, they’re on one side and not the other. Site’s important. So benign lymphadenopathy is usually upper cervical, whereas lower cervical supraclavicular lymphadenopathy is much more concerning. And then things like, is there a reason for it? So has the child got upper respiratory tract infection symptoms? Have they got a cough and a runny nose? In which case they’ve got mild cervical, bilateral, symmetric cervical lymphadenopathy – it’s not so worrying as the child who’s got no upper respiratory tract symptoms, who’s got a lump lower down, just on one side, and then of course, the history of what’s been happening to that lump. So your reactive lymphadenopathy that’s that’s caused by a viral infection is gonna be relatively short-lived, it’s gonna come up, it’s gonna go down. Whereas malignant lymph nodes in lymphoma, they just get gradually bigger and bigger and bigger. They might grow and stop and grow and stop, but over time they will get bigger. 

Sarah: So measuring would be a useful thing to do if you can… 

Rebecca: Yeah. So measuring, sight, the feel of it, is that going to be an issue? 

Guy: I mean, people say that they feel rubbery, but to be honest, by the time you can feel that texture of them, they’re kind of obviously malignant ’cause they’re so big anyway. 

Rebecca: And again, it’s what I said before. Continuity of clinician is helpful for the same clinician to then reexamine. 

Sarah: It’s the same thing I do with young women with breast lumps. If I see a 21-year-old with a breast lump, I always book them back to come and see me four weeks later if I think it’s a hormonal change rather than a discrete lump ’cause I know what I’ve felt the first time round. 

Guy: Yeah, that’s exactly what I’d… When we, we, when I get sent lymph nodes and it’s like, I’m not sure about this. I bring them back in a month’s time and have another feel. And if it’s, if it’s malignant, it will have got bigger. And if it’s not, it’ll have disappeared. 

Sarah: And presumably there’s no benefit… I know we, we’ve talked to the head…, spoken to the head and neck specialist about ultrasound. Is there any benefit in a, in us organising ultrasounds? 

Guy: It depends how worried you are. I mean, if, if you are just thinking this is probably reactive, then I wouldn’t, if you’re thinking towards this is more likely to be malignant then ultrasound is really useful. Ultrasound will distinguish between reactive and malignant lymph. 

Sarah: But pre, but presumably at that stage we’re better off referring to… 

Guy: I would say it’s in that middle bit. So the ones where you see them and they’ve got, you’re confident, it’s reactive. You don’t need to do an ultrasound. The ones you see where there’s a great big thing and it’s supraclavicular, and it’s obviously malignant, you don’t need to do an ultrasound. The ones in the middle where you’re not quite sure, you’ve brought them back, it’s not disappeared, you’re a little bit concerned. It reassures you to get an ultrasound done because then the ultrasound comes back and says normal reactive lymph nodes. You can reassure the family. You don’t have to worry about the patient anymore. 

Sarah: So if we were gonna organise an ultrasound in a child, what age can children have ultrasounds relatively straightforwardly? 

Guy: You can do them even in babies. Most people who, most sonographers and radiologists are used to examining children, it doesn’t really matter if they wriggle. Obviously if you’ve got a 2-year-old that’s just screaming the place down and not entertaining anything, it’s gonna be very difficult. But you know… 

Sarah: Okay. I mean, I was just saying it’s a bit like listening to the heart in the child, isn’t it? You know, that if this child’s screaming, you can’t really, you know, you can’t do that very easily then either. Okay. No, that’s really helpful 

Rebecca: Guy, so there’s a, a child that we’ve brought back, we’re still a little bit concerned. What would we do next in primary care? 

Guy: So we talking about this child who’s got the pallor and… 

Rebecca: Yeah. So the 3-year-old who we’ve, we were thinking is this just a viral illness but still something, bring them back two weeks later. Still losing weight…. What, what would we do next? 

Guy: So this child needs a blood count, doesn’t it? You know, you’ve got symptoms that are making you worry, it’s anaemic, that it’s got low platelets. You’re worrying that it might have got, it’s getting recurrent infections. You need a full blood count that’s gonna reassure you one way or the other. 

Rebecca: And how easy – I’m gonna ask Sarah this – how easy is it to get a paediatric blood test? Because it’s not easy in my surgery… 

Sarah: No, nor mine. Yeah, yeah. And you have to refer them to the hospital. They have to have an appointment. You have to sort of prescribe all the EMLA stuff for them to, and, and it, it’s not quick. 

Rebecca: No. 

Sarah: So I think if I, if I was worried, it wouldn’t be quick enough for me. 

Rebecca: So, in a hospital you can get them with a snap of your fingers. For us it’s more difficult. When we last talked Guy, you, you came up with something I thought was really helpful to actually say. I work in a big practice, so it’s, it may, it may be I cover four, four surgeries that actually training up one of our HCAs in paediatric bloods could be really helpful and maybe running a paediatric clinic once a fortnight or something. So that was something that I took away and is on my to-do list. 

Guy: Yeah. 

Sarah: One thing we talked about before we started as well, with children like this who have got fairly non-specific symptoms that could be explained by a variety of things is the problems of labelling, ’cause we were talking about where there are delayed diagnoses. Can you just tell us what you were meaning by that? 

Guy: So if, if children get labelled with a diagnosis, then what people tend to do is, that’s the first thing they write down when they see the child again, is the diagnosis that they’ve been labelled with. And then what they tend to do is fit all the subsequent symptoms into the diagnosis. So they’ll, they’ll focus on the symptoms that fit with the diagnosis and ignore the ones that don’t fit. 

Sarah: Yeah. Okay. So, so I suppose that whole, well, they’ve just, they’re tired because they’ve started school and because they’ve got the recurrent infections ’cause they’ve started, school fits into that. But they shouldn’t be losing weight because they’ve just started school. But you could… 

Guy: Yeah, it’s, I mean it’s amazing the number of symptoms that people attribute to constipation in children! 

Sarah: Oh yeah, I know. Yes. 

Guy: You know, in my experience, constipation stops you pooing, and it gives you tummy ache, but it’s amazing. 

Sarah: And teething! 

Guy: Yeah. And growing pains is the other one, isn’t it? 

Sarah: Yeah, yeah. There’s a few things. Yeah. 

Rebecca: And the other one was a fussy eater, which I thought was a good one because actually they, they haven’t got, a huge variety of diet, therefore that’s why they’re losing weight. But actually a fussy eater shouldn’t be the cause of gradual weight loss. 

Guy: No. 

Sarah: And fussy eaters tend often to eat… 

Guy: … Eat enough. They just eat weird things. Yeah. 

Sarah: Yeah. Beige food. 

Rebecca: Beige food, yeah. Okay. So, just going back to the bloods, if the bloods are normal and you’re, you’re still concerned, would you repeat these? 

Guy: I mean, it’s reassuring obviously in this case with the, the bleeding and the bruising and the, the worry about anaemia. If you’ve got a full blood count that’s perfectly normal, it’s gonna make you feel pretty reassured they haven’t got leukaemia. But if the symptoms persist, yeah, you need to do it again. 

Sarah: And presumably if they’ve got a neck node, it doesn’t reassure you massively that they haven’t got a lymphoma. Do you see… Would you… You wouldn’t see…? 

Guy: Yeah, less likely. I mean often say Hodgkin’s disease in children blood count will be perfectly normal. 

Sarah: Yeah. So it’s helpful, but it is what we say about a lot of tests, isn’t it? It’s helpful… 

Rebecca: … But it’s not completely reassuring. Well, it is reassuring, but it’s not the, the answer. You’ve gotta keep looking. 

Guy: If it’s abnormal, you are ‘Great, it’s abnormal that accounts for everything’. If it’s normal, you’ve still gotta bear in mind it might not remain normal two weeks down the line. 

Sarah: And presumably as well with kids who’ve got some of these symptoms, there are a whole host of other things that need to be treated and investigated that aren’t cancer. Um, you know, if you’ve got slightly older child, presumably a new onset coeliac could have very, very similar symptoms. And there are quite a lot of other things that we should be taking seriously as well. 

Guy: And your blood count’s useful for all of those, isn’t it? Because if your child’s got ITP or something, the platelet count will be abnormal. You say if they’ve got coeliac disease and they’ve got significant iron deficiency anaemia, the haemoglobin will be low. So that normal blood count just makes you generally feel a lot less anxious about the patient. 

Sarah: Yeah. Maybe we should change it ’cause I think as GPs we have a fairly high threshold. You know, you have to have a quite… To get bloods done on a child and maybe we should be just rethinking that. 

Rebecca: I agree. 

Guy: Just ’cause it’s difficult, isn’t it? 

Sarah / Rebecca: It is. 

Rebecca: Yeah, and also iron deficiency anaemia is more common in children than adults. So we… and, and therefore we need to see why. And it might be dietary, but it might be something else. Is it dietary? Have I said… Is that right? 

Guy: Yeah, usually it’s in children. 

Rebecca: Normally it’s dietary related. 

Guy: Fussy eaters! 

Rebecca: You can’t label them! Are you happy for me to go on to case two because I think this is completely… This is different and, and brings up new discussion points. This is an 8-year-old child who presents to general practice with a headache, persistent sickness over a long period of time. This child is a fussy eater. What would you be concerned about Guy? 

Guy: I’d be worried about headache in an 8-year-old. Children don’t usually complain of headache. Older children, you know, when they’re teenagers, yes they do, but eight-year-olds don’t. If they’ve got a headache that’s bad enough that they’re complaining about it, that’s, that’s a symptom I would be taking seriously. And then associated with sickness, that makes you worried. And the fussy eating, well, you know, are they a fussy eater because they know if they eat, they they’re gonna be sick? 

Rebecca: So almost a history of have they always been fussy? Is, is this a new thing that they’ve suddenly gone off things, particularly with an 8-year-old. ’cause actually an 8-year-old will, will know what they like and, and dislike at this age. I mean, as far as headaches, when we think about red flags with adults, Sarah, we think about the headaches, the nausea and vomiting, the… any visual symptoms, the early morning wakening. Are they similar questions that we’d be asking? 

Guy: Yeah, exactly the same symptoms in children. Once the skull bones are fused, they get headache, morning vomiting, lethargy… 

Sarah: How often do they get other… because when we’ve spoken to Catherine McBain, and we are gonna speak to her in a couple of weeks as well about adult brain tumours, she was saying that new sort of headache plus, so headache with other neurological signs is, is very, very common so bumping into things, visual field disturbances, maybe change in handwriting, forgetting words, how often do these sorts of things happen in kids? 

Guy: Well, the, the, the quoted figures are that 90% of children with brain tumours have neurological abnormalities. 

Sarah: Oh, okay. 

Guy: But the problem is, particularly in little children, is actually being able to detect those. 

Sarah: Of course.  

Guy: So if you can imagine that you’ve got subtle visual field loss in a 3-year-old, I mean, they won’t even notice it themselves, let alone you be able to detect it. So that’s the problem. It’s a kind of false reassurance. People look at it and go, well, that’s fine. I’ll be able to pick that up. But actually, it’s usually quite subtle. 

Sarah: So what about in an 8-year-old? Obviously if you know, if they’ve had more… if they’ve fallen off the bike more or that sort of thing, would that be something that would start, is it worth sort of thing worth asking about or…? 

Guy: Yeah. And school performance has, have the teachers noticed any issues? 

Sarah: Yeah, ’cause handwriting in adults is one of the things that they notice if things have got worse, that… 

Guy: Yeah. People think things like the child’s moved closer to the front of the class ’cause they can’t see properly. 

Sarah: Right. Okay. 

Rebecca: Do you see behavioural changes with children? 

Guy: Absolutely. 

Sarah: Right.  

Rebecca: So you mentioned school. I suppose that would be really good to get a collateral history from the school ’cause… 

Guy: Yeah. School teacher knows that child. They know how they’ve been performing over the time they’ve been in that class, and of course they’ve got a room full of 29 other kids of the same school age to compare to, so it’s easy to spot that things have changed 

Sarah: And what sort of time span are you looking at for some of these things to develop? 

Guy: Well brain tumours, it depends upon the point at which they develop raised intercranial pressure. So if they, if, if it’s growing somewhere where it’s gonna obstruct CSF flow and the child’s gonna get raised pressure very early on, the symptoms will be there from very early on. But if it’s somewhere where it’s gonna only cause obstruction of CSF flow later on, those symptoms of headache and vomiting and stuff won’t be there at the beginning. So it’ll only be later on when it obstructs the flow then, then you’re gonna get raised pressure. But obviously, the other thing is if you’ve got tumours growing in places where there are critical structures, like the brainstem, the tumour doesn’t have to get very big before it starts causing cranial nerve signs, facial nerve palsy, sixth nerve palsy, that kind of thing. 

Sarah: Mm-Hmm. Yeah. The two children that we’ve had diagnosed with brain tumours at my practice over the last sort of 15-20 years have both presented… the first presentation we’ve been aware of has been a fit. So they’ve been diagnosed in A&E. 

Guy: Well that, yes. So fits are a very common way that childhood brain tumours in the cerebral hemispheres present, and particularly low-grade tumours which are very slow growing. And have been there for a long time, don’t really cause pressure science, but then cause a local… But on the other hand, childhood epilepsy is very common, isn’t it? The vast majority of children with new seizures won’t have brain tumours. 

Sarah: It’s all very difficult. 

Rebecca: So difficult! There was a new campaign by Head Smart, which ran in 2011. Do you know anything about that? 

Guy: Yeah, that was a very good campaign that was looking at making people aware of the signs and symptoms of brain tumours in children. Very, very good at getting out lots of information to primary care to help with people picking up these kids as early as possible. 

Rebecca: And we just read before we came on air that there’s a new project called Child Cancer Smart, which is currently running on all childhood cancers. And it looks like it’s a four-year project. And looking at faster diagnosis with these cancers and, and things like this. What we are doing here is to make people aware and just to make it a consideration. 

Sarah: I suppose. It’s, it’s that thing, isn’t it? If, if you don’t, if you, you know, if you see a child with a fever and the parent says that they’ve got a rash, we have all being absolutely correctly trained to check whether or not they’ve got meningitis, and the parents are used to doing it. And we go through other spells – there’s a big measles outbreak at the moment, isn’t there? And, and so we’re constantly checking whether children have got measles. It’s just having that thought at the back of your mind in that child, not the one that you know, who you’ve seen once, who’s got a cough and a runny nose, but the one who’s got other symptoms as well, or who’s infrequently in and just thinking about it. And I suppose that that’s the difference, isn’t it?  

Guy: Absolutely. 

Sarah: And that’s the problem. 

Guy: Think about it. 

Sarah: Yeah.  

Guy: And then you won’t… you… once you’ve thought about it, you won’t just put it away ’cause you’ll have to reassure yourself that it’s not what’s going on. 

Sarah: Yeah. I find it really difficult to reassure myself, once I thought that a young person might have a pneumothorax… once I’ve thought it’s really quite difficult to reassure yourself that you, that it’s wrong, isn’t it? And… 

Guy: Well this is why being a GP is so tough, isn’t it? 

Sarah: Yeah. And, and, and, and it’s fine. But actually if you don’t think about it, you’ll just carry on and as you say, go on the last label or… 

Rebecca: Yeah, and I think it’s getting harder now with continuity in general practice. The demand has gone through the roof, so it’s important, particularly with these cases that we ourselves make the appointment or actually say, please do come and see me. And, and just, just to get, almost, wipe this slate clean, start again, look at the child again, and compare and contrast from last time. 

Sarah: Mm. Can I ask one more? What about you, you talked about the development of childhood tumours… What about things like melanoma particularly? I know that the number of referrals has gone up to childhood melanoma services. How common is it? And… 

Guy: Really rare. 

Sarah: Yeah, that’s what I would’ve thought. 

Guy: I’ve seen one in 30 years. 

Sarah: Right. Okay. 

Guy: And it was, you know, one that had been excised from the scalp and then it had come back as metastatic disease in the lymph nodes. 

Sarah: Right. 

Guy: And that’s the only one in 30 years of doing paediatric oncology. 

Sarah: Okay. That’s quite reassuring then, isn’t it? So, so, and I suppose it just ties into that basis of what you’re saying that all of these cancers that actually have… need a sort of external stimulus to make a difference. 

Guy: Yeah. 

Sarah: You are less likely to have. 

Guy: Yeah. I mean, you do, in children, you do every now and then see what you would consider to be typical adult cancers. You know, you see… I’ve seen a child with colon cancer, but it’s really rare. And similarly, you’d sometimes see young adults who’ve got typical childhood cancers. But again, it’s pretty uncommon. 

Rebecca: Gosh. Okay, so I think we’re ready for the key clinical points, but before we do that, I have an interesting fact. 

Sarah: Oh, tell me 

Rebecca: Children that drink tea. It’s been found that this is related to iron deficiency anaemia as it reduces the absorption of the iron from foods. 

Sarah: Oh, that’s… I remember that from a medical school lecture! 

Guy: Yeah! 

Sarah: You’ll have to ask Matt whether he remembers it too. 

Rebecca: I will! I hadn’t heard that. I hadn’t heard that before. 

Sarah: Oh, yes. 

Rebecca: Do you have to drink a lot of tea, do you think? 

Guy: I think it’s kids who have it in a bottle. 

Rebecca: Oh gosh! 

Guy: A bottle of tea! 

Sarah: Yeah, because it’s one of the things you’re told about people taking iron tablets. They’re not supposed to take them with their cups of tea, are they? 

Guy: Yeah, it’s the tannin in the tea collates iron. 

Rebecca: Supposed to take it with orange juice, aren’t you? 

Sarah: Yeah. Much better. 

Rebecca: Okay. So that’s my interesting fact. Just going onto some key clinical points, but please do add any that I’ve missed. Luckily childhood cancer is rare. However, primary care need to consider it as a potential differential. Just put it on your list. Monitoring and safety netting, so see the child again if you’re unsure. Best course of action if you are concerned is a simple blood test. I say simple, we’ve got… but it’s a blood test. 

Guy: Simple test, but hard to do! 

Rebecca: There we go! And if you’re still concerned, maybe booking another appointment for four weeks’ time to repeat the blood test. 

Sarah: Mm, and I think the ‘three strikes and you’re in’ works quite well for these kids as well, doesn’t it? You know, if you’ve not got a good explanation after three visits with the same sort of thing, you should be thinking harder.  

Rebecca: Absolutely. And my three Ps, I just got the nod. I made this up and it kind of stuck. It’s – if it’s progressive, if it’s persistent, and listen to the parents. 

Sarah: Oh, very good! 

Rebecca: Do you like that? Yeah. It’s gonna be like the Krebs cycle. It’s gonna, it’s gonna be the Leon Ps! Guy, do you have any other key clinical points that I’ve missed that we need to mention? 

Guy: No, I think we’ve summarised it, that it’s the, the, the patient who keeps coming back with the same symptoms. Think about it and once you’ve thought about it, it’s in your mind and you won’t rest until you’ve made sure they haven’t got it. Which obviously makes your life difficult, but it’s probably better for the family. 

Sarah: Mm-Hmm. And the ones who are really ill, will just be really ill and we’ll be dealing with them in that way. 

Guy: You know how to deal with really ill patients. 

Sarah: We do, yeah, yeah. Ill kids, you know, ill kids we are used to deal dealing with. It’s the ones that are rumbling along that are different. Difficult, aren’t they? 

Rebecca: In the middle. Okay. Well thank you very much. It’s been fascinating. 

Sarah: Yeah, that was really good. 

Rebecca: So, that’s it for today and thank you to Sarah and Guy. Thanks for listening to this podcast from GatewayC. We hope you’re enjoying this series. Please do support this podcast by leaving us a review or rating wherever you get your podcasts. And if you’ve got any topic suggestions for future episodes, we’d love to hear them. Please do include these in your review. If you’ve found this or other episodes interesting and helpful to your practise, please do share it with a friend or colleague. It really does help to spread the word. We’ve got two free Childhood and TYA cancer courses available on the GatewayC website. TYA that stands for teenagers and young adults. All reference studies and guidelines are in our show notes. Thank you again for listening and thank you to our producers, Jo Newsholme from Rethink Audio and Louise Harbord from GatewayC. See you again soon.