Optional banner to alert visitors of an upcoming event. You can link the event here.
Optional banner to alert visitors of an upcoming event. You can link the event here.
In episode 10 we cover gastro and oesophageal cancers. Our GPs question how we can best ‘think cancer’ when patients present with vague symptomology. Weight loss, difficulty swallowing, and abdominal pain are some of the key areas covered – with useful safety netting questions shared to provide our listeners with increased confidence when considering cancer as a differential. This episode also covers Barrett’s oesophagus, the impact of radiotherapy from other cancer groups and key risk factors.
If you loved this episode and would like to hear more like this, please leave a review, a rating and share the episode.
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.
Produced by Louise Harbord from GatewayC, and Jo Newsholme from Rethink Audio.
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. All featured statistics are accurate at the time of recording. All views expressed by guest speakers are their own.
Sarah: Weighing people is an… probably an undervalued skill in general practice. I think we probably don’t weigh people as often as we should do.
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 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’s really aimed at primary care health professionals. And although all patient cases are based on real stories from clinical practice, they are fully anonymized with no identifiable patient data.
Gateway C 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, we are back!
Sarah: Yep!
Rebecca: This episode is gonna be about oesophageal and gastric cancers.
Sarah: It sort of follows on quite nicely from the last one, doesn’t it? On head and neck.
Rebecca: Down the body. Nice! And have you got your coffee?
Sarah: Yep, we’re all ready to go.
Rebecca: I bought mine from the cafe downstairs.
Sarah: Is it nice?
Rebecca: Yeah, they, they were quick – oat lattes.
Sarah: Ah, yeah. I thought you’d stopped on those.
Rebecca: Did I? Did I tell you that?
Sarah: You did say that in the last series.
Rebecca: Oh right. What did I say I was going down?
Sarah: I think you said that you felt that oat lattes were a bit pretentious and you’re going to go for something more straightforward.
Rebecca: Yeah. And then if you do this intermittent fasting thing, you shouldn’t have milk before 12 anyway. So maybe I’ll just go straight black coffee.
Sarah: Okay.
Rebecca: That’ll be next time.
Sarah: We’ll see.
Rebecca: We’ll see. So oesophageal and gastric cancers. We’ll start off with some statistics. Throw some at you. So oesophageal cancer is the 14th most common cancer in the UK with 9,200 cases diagnosed each year while stomach cancer is the 17th most common cancer with around 6,500 each year in the UK. It is most common for both cancer groups in people aged between 80 to 84. It is more common in men than women for both cancers, and unfortunately, there is a high proportion of both cancers diagnosed in the A&E department with 18.9% of oesophageal cases and 29.6% for stomach cancer.
Sarah: That’s a lot of stomach cancers diagnosed as emergency presentations, isn’t it?
Rebecca: It really is. So again, this is why it’s important to be doing podcasts and other modules for GPs to be picking up these cancers earlier.
Sarah: I think stomach, I think there’s some stats as well, isn’t there? That stomach cancers tend to be diagnosed quite late and it’s a difficult one, isn’t it? Which we’ll come on to, but yeah, that’s, that’s a high percentage.
Rebecca: Yeah. So, a third of stomach cancers are picked up in the emergency department. Okay. So, our first case, are you able just to talk about our patient?
Sarah: Yeah. So, this patient’s a man in his early seventies who had been a lifelong smoker who came in with difficulty swallowing. And I think, you know, it’s, it’s one of those things, isn’t it, where you just have to really get, we talked about this in the head and neck module before, but you have to get a really clear history about exactly what people mean and what we are looking for is persistent and progressive difficulty swallowing. So somebody who has changed their diet, so has stopped eating bacon or steak or anything, things like that and has gone more towards soup or you know, just having mashed potato rather than roast potatoes, all of that sort of thing. Very specific things that, so you look at. So, I think the concern is persistent progressive symptoms, and again, the feeling of whether or not food’s getting stuck, which comes in some people and not others. And then also weight loss, which obviously comes if you’ve had to alter your diet because you can’t eat as well.
Rebecca: So, if we break that down, I love the progressive and the persistent. I think it’s really important. So, it’s ongoing and it’s there all the time and often it will start with solids…
Sarah: Yeah.
Rebecca: And then liquids kind of later on down the line as well. And again, this is something that I’ve not thought of actually really pinpointing and asking about their diet. So you mentioned…
Sarah: Asking what the people have had for breakfast.
Rebecca: I love that. And it can work for other, for children when they come in with sore throats and if they’ve had the corn flakes and they’ve had their, their hard toast, then you know that it’s not as bad as if they can only just have soft Weetabix. And the weight loss, we’ve talked about that in other ones. I find that if you say to somebody, ‘have you lost weight?’ They’re like, ‘oh, I don’t know, doctor, I never weigh myself.’ So, for women. Again, I can’t be too gender specific, but I’m gonna be – women, they’ll say ‘I’ve, I’ve dropped a couple of dress sizes’, and for men it will be that they’re either now needing to use braces to hold up the trousers or that their belts needing a couple more notches. So, it’s just these kind of things, or you weigh them…
Sarah: Yeah
Rebecca: And then you weigh them again two weeks later and see if there’s been any weight loss.
Sarah: I think it weighing people is an… probably an undervalued skill in general practice. I think we probably don’t weigh people as often as we should do to get a baseline so that you know what’s happening. Because I think there’s, you know, people often don’t weigh themselves and, and why should they? They don’t need to weigh themselves at home, but I think it would be, it is something that we should probably, you know, we talked last time about how we were going to have this New Year’s resolution of asking about family history in everybody, maybe we should start a sort of…
Rebecca: Campaign of weighing?!
Sarah: Campaign of weighing!
Rebecca: There we go. Hashtag campaign of weighing! So, what would you do with our first case?
Sarah: I mean, I think the first case, if he’s got persistent, progressive dysphagia, not swallowing, you know, having changed diet, weight loss, it’s an absolutely classical red flag symptom, isn’t it? I think most people, I think dysphagia is one of those things that springs up in people’s minds as a red flag symptom and you refer on a suspected cancer pathway. In fact, I had a student a couple of years ago came audited our upper GI cancer referrals and we hadn’t missed any oesophageal cancer patients. They all were referred as soon as they were seen. What we did find is that we were referring quite a lot of people who had, who didn’t have persistent, progressive dysphagia and that we probably needed to be a bit more thorough in our questioning. And so actually…
Rebecca: Over…
Sarah: Possibly over, yeah. Never want to talk about over referring because I think if people are concerned, they should refer. But actually, I think being quite clear that this is a persistent, progressive problem is important. But I think, you know, this is, this is a red flag patient, isn’t it? NICE guidance, everything. The Scottish guidelines, everybody’s guidelines will say somebody with progressive dysphagia, refer them.
Rebecca: And then you’ve got the older patient, the male, and the lifelong smoker…
Sarah: Yes. So, he’s got, you know, he’s got… If he had a Bingo card, he would do quite well on that, wouldn’t he?!
Rebecca: I don’t wanna go to Bingo with you!
Rebecca: So, I mean, I, I’m quite happy to move to case two really because I think that’s pretty Barn door.
Sarah: It’s more difficult, isn’t it? Case two…
Rebecca: Yeah, case two I think picks up a, a few other things. We’ve got a patient, in their early fifties and presents with quite a short history of abdominal pain, dyspepsia, reflux, and a bit of nausea. When I see a patient like that, I start to think, you know, could this be H. pylori?
Sarah: Yeah, absolutely.
Rebecca: So, H. pylori is a, a, a common presentation of a bug that is quite an easily, investigated primary care through a stool sample. How would you tell a patient how to do that?
Sarah: This is just you want me to get me back onto FIT. I’m not talking about FIT today!
Rebecca: Not talking about FIT today. It’s a FIT free zone!
Sarah: It’s just producing, getting your stool sample. I think people worry about this and so I always say a plastic container that you might get chicken or strawberries or mushrooms or something like that in. Put some toilet paper in it. Do your poo in there, and then you can get your sample.
Rebecca: Easy. Yeah. The important thing is with these, with a patient presenting with these kinds of symptoms a proton pump inhibitor is a really good medication that we can give for a certain amount of time to see if things improve. However, when we’re considering H. pylori, it can actually mask.
Sarah: Yeah. It it, it affects the result, doesn’t it?
Rebecca: It does.
Sarah: So, so, so you, so you don’t… may get a false negative.
Rebecca: So, what we suggest is that they do the sample first and then potentially commence.
Sarah: Yeah. But that’s really difficult with this patient, isn’t it? Because this patient obviously ended up, because of, you know, we, we, we wouldn’t be talking about him if he hadn’t ended up having a stomach cancer. But he’s got symptoms that we see really frequently, and would normally set, assume that there was a benign cause for. But actually, we’ve already said that 30% of stomach cancers present in A&E, that it’s a late-stage diagnosis. What would you do with that sort of patient to… What would make you more concerned about him? More likely to do something apart from the H. pylori? Because we need to…
Rebecca: It’s a really good, it is a really good question. And as I was almost jumping into PPIs, and we are talking about gastric cancer. So, this is a man who, is not a regular attender, so it’s a, it’s a man who’s presented with some fairly, as you say, common, potentially benign symptoms. We’d first have to ask about the red flag symptoms as well. So, we’d have to ask about the swallowing, we’d ask about any weight loss. The other thing that I think we need to ask is about his general health. Has he got any fatigue? Is he got any breathlessness? Is he unable to do things that he would normally, be able to do? So, you mentioned about a patient that saw…
Sarah: Oh, the patient that we, that we spoke to. In fact, we didn’t speak to the patient. We spoke to his widow after… When we did the stomach cancer module. And he had, he was a very keen triathlete and his first symptom that he noticed was that he became, he, he noticed he’d got slower, and he was getting more tired after doing things. And he was then found to be anaemic and then subsequently went on and had a gastroscopy was found to have a stomach cancer. But he, he was a, a fit patient who had a change in symptoms. Obviously, you know, if we’ve got 80-year-old patients, and you were saying the common age is between 80 and 85, who are quite limited because of other comorbidities, their change in function could be very different, couldn’t it? So, I suppose it is, it’s that clear questioning is, is really important to try and pull out which of these patients you would be particularly concerned about. The other thing we’ve got down here is the difference between you know, just clear questions about weight loss, but also about appetite loss, which again is something I don’t think we necessarily…
Rebecca: Yeah, absolutely.
Sarah: Ask about in a really clear manner. We, you know, we will ask, I most of the time I’ll ask patients if they’ve lost weight. They may or may not know whether they’ve lost weight, but I rarely ask them whether that’s because they don’t feel like eating.
Rebecca: Yep. Or do they feel sick?
Sarah: Yeah. Yeah. So, I think, I think both things. You know, it’s, it’s, we, we talk about this all the time, don’t we? That actually getting lots of information from people gives you more bits of a jigsaw puzzle to try and work out…
Rebecca: Yeah.
Sarah: Where you should go next.
Rebecca: It’s that one more question, isn’t it?
Sarah: Yeah. Yeah.
Rebecca: So, I think, listen, I, I think I almost confused myself by going down this, this patient has got H. pylori, so I want just to apologise to you Sarah, and also to everybody that’s listening! But I suppose, this is a patient who’s presenting with, with fairly common GP symptoms. We are doing a podcast about cancer. However, there are lots of other things that can be. So, let’s now just focus so… One potential differential is H. pylori. Okay. We’ve talked about the H. pylori can be picked up on a stool sample, and you’ve talked very nicely about how to pick that up.
Sarah: Literally!
Rebecca: Literally! We then, we then ask those extra questions to see, are you actually worried? If we think this is just almost a barn door, this patient could have a H. pylori. We’re going to do a stool sample. We’re gonna give them a prescription for a PPI. We’re gonna tell them to do it, me personally, I would say I’d like to see you in about three weeks just before your prescriptions run out and you tell me how, how you are.
Sarah: Yeah.
Rebecca: Okay. And the results be better. This patient comes back after three weeks, or we’ve got, almost got two prongs to this. If they’ve got other worrying symptoms, other red flag symptoms, we might send them down a different route. Or at that first consultation I might send them for some blood tests.
Sarah: Yeah, and I think blood tests help, don’t they?
Rebecca: Yeah. So, let’s talk about blood tests. We do a full blood count. What, what could be picked up?
Sarah: I suppose the first, well, like with the patient we were just talking about, you could pick up an iron deficiency anaemia, couldn’t you? And stomach cancer particularly is a reasonably common cause, well, it’s not common, but it does cause iron deficiency anaemia. The other thing is, the one that we all love to talk about is the raised platelets. So you know, our LEGO-C cancers, and actually they are, you know, raised, a new onset, raised platelets, particularly in men, but also in women, is quite a strong indicator of a cancer, and we’re talking about the LEGO-C cancers.
Rebecca: Let’s talk about LEGO-C again.
Sarah: Yes.
Rebecca: Talk me through the L, the E, the G, the O, and the C.
Sarah: So L is lung…
Rebecca: I’m like, I’m like, a cheerleader!
Sarah: Yeah.
Rebecca: Okay. Gimme an L.
Sarah: Lung.
Rebecca: Gimme an E.
Sarah: Endometrial.
Rebecca: Give me a G.
Sarah: Gastric.
Rebecca: Gimme an O.
Sarah: Oesophageal.
Rebecca: And give me a C.
Sarah: Colorectal.
Rebecca: There we go. So actually, the G and the O is all part of this.
Sarah: So, I think that, you know, if you’ve got it, it’s two ways with this, isn’t it? So, if you’ve got a patient who comes in with new onset raised platelets, questions about upper GI cancer. So gastric and oesophageal should be part of your questioning because that’s what you’d be concerned about. And conversely, if you’ve got a patient with symptoms that you’re concerned about if you’ve got raised platelets on their full blood count. That’s another thing that would make you think that actually I should probably be referring this patient on a suspected cancer pathway. The other thing that, you know, we talk about frequently is obviously if this patient has an epigastric mass when you examine them, that would also make you concerned and we, you know, if you don’t feel the tummy, you will never know whether they’ve got an epigastric mass.
Rebecca: So, as well as taking a very good history, asking those extra questions – always examine.
Sarah: Yeah.
Rebecca: And consider primary care investigations as well that we’ve talked about.
Sarah: Yeah.
Rebecca: So, at the moment we’re gonna do an H. pylori test for this patient. We’ll do a stool sample. If there’s a change in bowel habit, you do your FIT test, plus or minus you do microbiology also on a, on a stool sample. And then you also do some routine blood tests, including a full blood count.
Sarah: You probably do liver function as well, wouldn’t you? But again, I think, and the other thing to stress is that if the full blood count, and the liver function tests are normal that doesn’t mean the patient doesn’t have an upper GI cancer, it doesn’t mean anything. It just, you know, the, the normal tests don’t, aren’t reassuring and we just need to remember that.
Rebecca: We do.
Sarah: Always.
Rebecca: It makes our lives so difficult!
Sarah: I know, I know!
Rebecca: Okay, so this, this patient, whether we refer when we first see them or whether when we, when they come back, we refer them, you would send them and they would be getting an OGD.
Sarah: Yeah. And I think that’s the other thing, isn’t it? That actually sending for an ultrasound for some – We do sometimes ultrasound patients with abdominal pain, but it’s not going… It might tell you if they’ve got gall stones, which may give similar symptoms, but again, it’s not gonna tell you that they have or haven’t got a stomach cancer or an oesophageal cancer. So, if they go for, yeah, you need to do a, if you’re concerned you need to do a referral for a gastroscopy, and if you’re very concerned, you know, if they fit the guidelines, they need to be sent on a suspected cancer pathway.
Rebecca: Yeah. And actually, if a patient has been confirmed to have H. pylori, it’s actually one of those general practice diagnoses that are quite satisfying because it’s the triple therapy and people, people often feel a lot better once they’re treated. And that’s a,…
Sarah: Like pulled elbows!
Rebecca: Yeah. And also like PMR as well, I find that quite… so polymyalgia rheumatica, they come in, you give them the steroids and they feel a lot better quite quickly. This, they get the, the, the double whack of antibiotics with the high dose PPI and they feel better quite quickly. So a pulled elbow, tell me about that…
Sarah: Did you not used to do pulled elbows in kids, you know, kids who’ve been…
Rebecca: As in, if you pull an elbow and they feel better quite quickly?
Sarah: You can, you can actually re-, it’s, you can put it back into place very easily in a little kid. It’s very satisfying because they come in not using their arm and then they go out using it.
Rebecca: There you go.
Sarah: There you go. Life saved!
Rebecca: I do love my job!
Sarah: Do you think we should just go back to summarising exactly what we should be concerned about with stomach cancers.
Rebecca: Yes.
Sarah: Because I think it’s, I still think it’s quite a difficult one, isn’t it? So, I think that you’ve got a symptom that’s quite common and you’ve got a patient, you know, you’ve got a patient who may or may not be high risk because the risk factors are less clear than they are for oesophageal cancer. So, what, what are we concerned about? We’re concerned about new onset symptoms. We’re concerned about making sure we’ve checked for red flag symptoms. We’re concerned about things that are worsening rather than getting better, weight loss, checking for abdominal masses and abnormal blood tests. I think even at the end of that, it’s still making me feel that this is really difficult and I think that’s probably reflected in the figures, isn’t it? That actually this is, it’s not…
Rebecca: I think it’s also reflective on our faces right now!
Sarah: Yeah, yeah.
Rebecca: We we’re, we’re almost thinking like, actually we see so many patients with so many of, of these, kind of, a few of these symptoms and on the whole, they have got straightforward dyspepsia, or they’ve got straightforward acid reflux. So, in that point of view, it is really, really tricky.
Sarah: So, I suppose, it’s what we talk about all the time. It’s all of those bits of the history, examination and investigations together, and which you were talking, and then what we were talking about before, just being really clear about what you would expect to happen and safety netting. So, if you start the patient, you assume this is reflux. You give the patient a PPI, then how long would you expect them to take to get better? You know, would they, you know? Yeah. How long would they, when would you want to see them again? What circumstances would you want to, would you consider things? So, I suppose it’s, it’s that key to… really because a lot of this early cancer diagnosis stuff is quite difficult, isn’t it? It’s clear history, examination, investigations and then really, really specific safety netting.
Rebecca: And reassess.
Sarah: And reassessing, and that whole… Stuff that we talked about with the colorectal, the ‘come back if it doesn’t get better’, rather than ‘come back if it gets worse’. Because actually if you’ve given somebody a PPI, you would expect them to get better on with symptoms. So, you, you don’t, you sort of, you can’t just say come back if it gets worse. You want to know, you want to see them again if it doesn’t get better too, don’t you?
Rebecca: Yeah. And often we give the PPI for a certain amount of time, often a month’s course, and tell them to come off it and if their symptoms return after two weeks, that’s again, you want to see them because it’s, it is…
Sarah: It is a difficult one.
Rebecca: It is a difficult one.
Sarah: And I’m, I’m feeling a bit… Dissatisfied,
Rebecca: I’m feeling a bit dissatisfied as well because the oesophageal, we feel a little bit more satisfied with that.
Sarah: Yeah. I think you’ve got clear questions that you can ask. You’ve got clear symptoms you can sort of…
Rebecca: Yeah. And that, and that’s okay because it’s almost…
Sarah: That’s just acknowledging what everybody else, what we’re having to do on day by day…
Rebecca: Yeah, and by doing this podcast. Yeah. And, and almost just picking up what we can and reevaluating and reassessing.
Sarah: And again, I think that it’s when, I don’t know we are, we are going to do a bit more on genomics as we go forward, but again, I think it’s probably worth asking about, generally about family histories because it’s another little bit of a jigsaw. It might only be a tiny little bit, but it might…
Rebecca: A tiny corner?!
Sarah: A tiny corner. Yes. The corner’s important!
Rebecca: So important. Do you start with the corners? Do you go all the way around?
Sarah: Yeah.
Rebecca: You do. You are one of those. I do an area. So, it just shows again, it’s important. So yeah, A tiny corner – family history. Can I talk about Barrett’s oesophagus now?
Sarah: You can now. Yes.
Rebecca: Okay. So, I think that that was really important Sarah to actually say we struggle with this.
Sarah: Yeah.
Rebecca: So Barrett’s oesophagus is, this is something that is caused by a change in the lining of the oesophagus. And interestingly, it’s, it’s from a, a squamous cell to a columnar-lined epithelium, that’s what the histology is. So, these are often picked up when you…
Sarah: Could you recognise that under a microscope? Because I couldn’t, no.
Rebecca: No, it’s what’s written on the report that’s sent to us. But often we send patients for an OGD for, for an endoscopy, a gastroscopy, and actually this is picked up and, and then we’re told that they’ve got Barrett’s oesophagus and they’re put on an… Kind of a formal surveillance program, which is often depending on the area, between two to three yearly. 3 to 13% of patients with a Barrett’s oesophagus can go on to develop oesophageal adeno carcinomas. And that’s why it’s really important that they’re, they’re part of a surveillance program, but there are issues when people move, change addresses, change practices that they’re not, that they don’t stay on the surveillance program.
Sarah: I think Covid has also caused problems with that, hasn’t it? The people have a delay, and then they get lost to follow up. And yeah, so I think there is a, a problem with that. And certainly, I think we need, we as primary care professionals, if we see somebody who has had Barrett’s in the past, we probably need to… Be checking up with them that they are being… having surveillance and referring them back if it seems to have gone awry, which I think it does quite frequently.
Rebecca: Yeah. So, it’s really important that if you see somebody with Barrett’s and you feel that they haven’t been seen because of Covid, because of a change of practice, that we as GPs, as we as, in primary care write to the local department and get them back on the surveillance. And we also need to make sure that they’re on long-term, high dose, acid suppression, that they’re not smoking, that they’re on a good diet…
Sarah: Which, some of which, is easier to do than others.
Rebecca: Of course, it is! So, it’s all those kinds of things but…
Sarah: Yeah. Yeah. But certainly, we can do the high dose PPI and advise on the others, can’t we?
Rebecca: Yeah. Yeah. Because another fact, just kind of going back to H. Pylori as well, which I think shocked us both when we were preparing for this podcast, was that around 40% of stomach cancers in the UK are caused by H. Pylori infection. But the good thing is that the prevalence of H. pylori is falling, but it still remains a problem in developing countries. So it’s about education.
Sarah: Yeah. And the tests are presumably, availability of tests, and treatments as well. So onto our interesting facts.
Rebecca: Okay. So, very hot drinks. I think we’ve been talked about this for a long time. You shouldn’t actually drink freshly brewed hot drinks. So actually, by putting a bit of milk or by letting cool down a bit, because burning, it’s all to do with burning the oesophagus, isn’t it, can increase your risk of oesophageal cancer.
Sarah: So we said with head and neck cancers, you’d need to drink more coffee. But it doesn’t have to be hot coffee, does it?
Rebecca: No. It’s just the caffeinated bit.
Sarah: Yeah.
Rebecca: And this is don’t have burning, burning hot food. So hot, spicy food and scorching food as well, which can burn.
Sarah: Right.
Rebecca: I think that’s all to do with ulceration and burning.
Sarah: Probably, yeah.
Rebecca: So that’s our interesting facts. Okay. So, we’ll start off with the key clinical points. So, risk factors for, I’m going to put gastric and oesophageal together because they, they kind of work together. So, age is common in older people. 40% of these are over the age of 75 and we’ve actually talked that a high proportion are over the age of 80. Weight is another one, with obesity being an increasing problem, it’s an increased risk. Smoking, alcohol, particularly with those people who drink over 14 units weekly have an increased risk. And the other one is radiotherapy as well from other cancer groups.
Sarah: Okay. The second one is the progressive, persistent dysphagia is a red flag. I think most people are aware of that, but it’s just being clear exactly what patients mean when they say they’ve got difficulty swallowing and being clear and making a referral if needed.
Rebecca: The next key clinical point is as we’ve just been talking, that stomach cancer is often really difficult to diagnose. The symptoms are often vague and also where the stomach is, the anatomy, it could cause lots of other benign symptomology. So just think about it as part of your differentials.
Sarah: Yeah, I think that’s right, isn’t it? I think if you see the patient and you think, could this be a stomach cancer? Rather than automatically assuming it’s a dyspepsia problem, it’s related to a benign condition, then if you’ve thought about it, you’ll have it at the back of your mind. You’ll think about it, you’ll talk about it in your safety netting. So, I think that’s it, isn’t it? It’s just thinking about it in the first place and not making an assumption that it’s benign.
Rebecca: Yeah.
Sarah: And then the last one is that patients who’ve got Barrett’s should be on a formal follow-up program. And if they’re not, make sure you refer them in.
Rebecca: So that’s it for today, and thank you as ever to my co-host, Sarah. We have fun and thank you all for listening to this podcast from GatewayC. We really hope you have enjoyed the episode and would appreciate a rate and review. We’ve got a free stomach and oesophageal cancer module, which is available on the GatewayC website. All reference studies and guidelines are on our show notes.
Thank you to our producers, Jo Newsholme from Rethink Audio and Louise Harbord from GatewayC. And we’d love it if you shared this podcast with your friends or colleagues, it really helps to spread the word. Thanks, and see you again soon.
Sarah: Weighing people is an… probably an undervalued skill in general practice. I think we probably don’t weigh people as often as we should do.
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 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’s really aimed at primary care health professionals. And although all patient cases are based on real stories from clinical practice, they are fully anonymized with no identifiable patient data.
Gateway C 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, we are back!
Sarah: Yep!
Rebecca: This episode is gonna be about oesophageal and gastric cancers.
Sarah: It sort of follows on quite nicely from the last one, doesn’t it? On head and neck.
Rebecca: Down the body. Nice! And have you got your coffee?
Sarah: Yep, we’re all ready to go.
Rebecca: I bought mine from the cafe downstairs.
Sarah: Is it nice?
Rebecca: Yeah, they, they were quick – oat lattes.
Sarah: Ah, yeah. I thought you’d stopped on those.
Rebecca: Did I? Did I tell you that?
Sarah: You did say that in the last series.
Rebecca: Oh right. What did I say I was going down?
Sarah: I think you said that you felt that oat lattes were a bit pretentious and you’re going to go for something more straightforward.
Rebecca: Yeah. And then if you do this intermittent fasting thing, you shouldn’t have milk before 12 anyway. So maybe I’ll just go straight black coffee.
Sarah: Okay.
Rebecca: That’ll be next time.
Sarah: We’ll see.
Rebecca: We’ll see. So oesophageal and gastric cancers. We’ll start off with some statistics. Throw some at you. So oesophageal cancer is the 14th most common cancer in the UK with 9,200 cases diagnosed each year while stomach cancer is the 17th most common cancer with around 6,500 each year in the UK. It is most common for both cancer groups in people aged between 80 to 84. It is more common in men than women for both cancers, and unfortunately, there is a high proportion of both cancers diagnosed in the A&E department with 18.9% of oesophageal cases and 29.6% for stomach cancer.
Sarah: That’s a lot of stomach cancers diagnosed as emergency presentations, isn’t it?
Rebecca: It really is. So again, this is why it’s important to be doing podcasts and other modules for GPs to be picking up these cancers earlier.
Sarah: I think stomach, I think there’s some stats as well, isn’t there? That stomach cancers tend to be diagnosed quite late and it’s a difficult one, isn’t it? Which we’ll come on to, but yeah, that’s, that’s a high percentage.
Rebecca: Yeah. So, a third of stomach cancers are picked up in the emergency department. Okay. So, our first case, are you able just to talk about our patient?
Sarah: Yeah. So, this patient’s a man in his early seventies who had been a lifelong smoker who came in with difficulty swallowing. And I think, you know, it’s, it’s one of those things, isn’t it, where you just have to really get, we talked about this in the head and neck module before, but you have to get a really clear history about exactly what people mean and what we are looking for is persistent and progressive difficulty swallowing. So somebody who has changed their diet, so has stopped eating bacon or steak or anything, things like that and has gone more towards soup or you know, just having mashed potato rather than roast potatoes, all of that sort of thing. Very specific things that, so you look at. So, I think the concern is persistent progressive symptoms, and again, the feeling of whether or not food’s getting stuck, which comes in some people and not others. And then also weight loss, which obviously comes if you’ve had to alter your diet because you can’t eat as well.
Rebecca: So, if we break that down, I love the progressive and the persistent. I think it’s really important. So, it’s ongoing and it’s there all the time and often it will start with solids…
Sarah: Yeah.
Rebecca: And then liquids kind of later on down the line as well. And again, this is something that I’ve not thought of actually really pinpointing and asking about their diet. So you mentioned…
Sarah: Asking what the people have had for breakfast.
Rebecca: I love that. And it can work for other, for children when they come in with sore throats and if they’ve had the corn flakes and they’ve had their, their hard toast, then you know that it’s not as bad as if they can only just have soft Weetabix. And the weight loss, we’ve talked about that in other ones. I find that if you say to somebody, ‘have you lost weight?’ They’re like, ‘oh, I don’t know, doctor, I never weigh myself.’ So, for women. Again, I can’t be too gender specific, but I’m gonna be – women, they’ll say ‘I’ve, I’ve dropped a couple of dress sizes’, and for men it will be that they’re either now needing to use braces to hold up the trousers or that their belts needing a couple more notches. So, it’s just these kind of things, or you weigh them…
Sarah: Yeah
Rebecca: And then you weigh them again two weeks later and see if there’s been any weight loss.
Sarah: I think it weighing people is an… probably an undervalued skill in general practice. I think we probably don’t weigh people as often as we should do to get a baseline so that you know what’s happening. Because I think there’s, you know, people often don’t weigh themselves and, and why should they? They don’t need to weigh themselves at home, but I think it would be, it is something that we should probably, you know, we talked last time about how we were going to have this New Year’s resolution of asking about family history in everybody, maybe we should start a sort of…
Rebecca: Campaign of weighing?!
Sarah: Campaign of weighing!
Rebecca: There we go. Hashtag campaign of weighing! So, what would you do with our first case?
Sarah: I mean, I think the first case, if he’s got persistent, progressive dysphagia, not swallowing, you know, having changed diet, weight loss, it’s an absolutely classical red flag symptom, isn’t it? I think most people, I think dysphagia is one of those things that springs up in people’s minds as a red flag symptom and you refer on a suspected cancer pathway. In fact, I had a student a couple of years ago came audited our upper GI cancer referrals and we hadn’t missed any oesophageal cancer patients. They all were referred as soon as they were seen. What we did find is that we were referring quite a lot of people who had, who didn’t have persistent, progressive dysphagia and that we probably needed to be a bit more thorough in our questioning. And so actually…
Rebecca: Over…
Sarah: Possibly over, yeah. Never want to talk about over referring because I think if people are concerned, they should refer. But actually, I think being quite clear that this is a persistent, progressive problem is important. But I think, you know, this is, this is a red flag patient, isn’t it? NICE guidance, everything. The Scottish guidelines, everybody’s guidelines will say somebody with progressive dysphagia, refer them.
Rebecca: And then you’ve got the older patient, the male, and the lifelong smoker…
Sarah: Yes. So, he’s got, you know, he’s got… If he had a Bingo card, he would do quite well on that, wouldn’t he?!
Rebecca: I don’t wanna go to Bingo with you!
Rebecca: So, I mean, I, I’m quite happy to move to case two really because I think that’s pretty Barn door.
Sarah: It’s more difficult, isn’t it? Case two…
Rebecca: Yeah, case two I think picks up a, a few other things. We’ve got a patient, in their early fifties and presents with quite a short history of abdominal pain, dyspepsia, reflux, and a bit of nausea. When I see a patient like that, I start to think, you know, could this be H. pylori?
Sarah: Yeah, absolutely.
Rebecca: So, H. pylori is a, a, a common presentation of a bug that is quite an easily, investigated primary care through a stool sample. How would you tell a patient how to do that?
Sarah: This is just you want me to get me back onto FIT. I’m not talking about FIT today!
Rebecca: Not talking about FIT today. It’s a FIT free zone!
Sarah: It’s just producing, getting your stool sample. I think people worry about this and so I always say a plastic container that you might get chicken or strawberries or mushrooms or something like that in. Put some toilet paper in it. Do your poo in there, and then you can get your sample.
Rebecca: Easy. Yeah. The important thing is with these, with a patient presenting with these kinds of symptoms a proton pump inhibitor is a really good medication that we can give for a certain amount of time to see if things improve. However, when we’re considering H. pylori, it can actually mask.
Sarah: Yeah. It it, it affects the result, doesn’t it?
Rebecca: It does.
Sarah: So, so, so you, so you don’t… may get a false negative.
Rebecca: So, what we suggest is that they do the sample first and then potentially commence.
Sarah: Yeah. But that’s really difficult with this patient, isn’t it? Because this patient obviously ended up, because of, you know, we, we, we wouldn’t be talking about him if he hadn’t ended up having a stomach cancer. But he’s got symptoms that we see really frequently, and would normally set, assume that there was a benign cause for. But actually, we’ve already said that 30% of stomach cancers present in A&E, that it’s a late-stage diagnosis. What would you do with that sort of patient to… What would make you more concerned about him? More likely to do something apart from the H. pylori? Because we need to…
Rebecca: It’s a really good, it is a really good question. And as I was almost jumping into PPIs, and we are talking about gastric cancer. So, this is a man who, is not a regular attender, so it’s a, it’s a man who’s presented with some fairly, as you say, common, potentially benign symptoms. We’d first have to ask about the red flag symptoms as well. So, we’d have to ask about the swallowing, we’d ask about any weight loss. The other thing that I think we need to ask is about his general health. Has he got any fatigue? Is he got any breathlessness? Is he unable to do things that he would normally, be able to do? So, you mentioned about a patient that saw…
Sarah: Oh, the patient that we, that we spoke to. In fact, we didn’t speak to the patient. We spoke to his widow after… When we did the stomach cancer module. And he had, he was a very keen triathlete and his first symptom that he noticed was that he became, he, he noticed he’d got slower, and he was getting more tired after doing things. And he was then found to be anaemic and then subsequently went on and had a gastroscopy was found to have a stomach cancer. But he, he was a, a fit patient who had a change in symptoms. Obviously, you know, if we’ve got 80-year-old patients, and you were saying the common age is between 80 and 85, who are quite limited because of other comorbidities, their change in function could be very different, couldn’t it? So, I suppose it is, it’s that clear questioning is, is really important to try and pull out which of these patients you would be particularly concerned about. The other thing we’ve got down here is the difference between you know, just clear questions about weight loss, but also about appetite loss, which again is something I don’t think we necessarily…
Rebecca: Yeah, absolutely.
Sarah: Ask about in a really clear manner. We, you know, we will ask, I most of the time I’ll ask patients if they’ve lost weight. They may or may not know whether they’ve lost weight, but I rarely ask them whether that’s because they don’t feel like eating.
Rebecca: Yep. Or do they feel sick?
Sarah: Yeah. Yeah. So, I think, I think both things. You know, it’s, it’s, we, we talk about this all the time, don’t we? That actually getting lots of information from people gives you more bits of a jigsaw puzzle to try and work out…
Rebecca: Yeah.
Sarah: Where you should go next.
Rebecca: It’s that one more question, isn’t it?
Sarah: Yeah. Yeah.
Rebecca: So, I think, listen, I, I think I almost confused myself by going down this, this patient has got H. pylori, so I want just to apologise to you Sarah, and also to everybody that’s listening! But I suppose, this is a patient who’s presenting with, with fairly common GP symptoms. We are doing a podcast about cancer. However, there are lots of other things that can be. So, let’s now just focus so… One potential differential is H. pylori. Okay. We’ve talked about the H. pylori can be picked up on a stool sample, and you’ve talked very nicely about how to pick that up.
Sarah: Literally!
Rebecca: Literally! We then, we then ask those extra questions to see, are you actually worried? If we think this is just almost a barn door, this patient could have a H. pylori. We’re going to do a stool sample. We’re gonna give them a prescription for a PPI. We’re gonna tell them to do it, me personally, I would say I’d like to see you in about three weeks just before your prescriptions run out and you tell me how, how you are.
Sarah: Yeah.
Rebecca: Okay. And the results be better. This patient comes back after three weeks, or we’ve got, almost got two prongs to this. If they’ve got other worrying symptoms, other red flag symptoms, we might send them down a different route. Or at that first consultation I might send them for some blood tests.
Sarah: Yeah, and I think blood tests help, don’t they?
Rebecca: Yeah. So, let’s talk about blood tests. We do a full blood count. What, what could be picked up?
Sarah: I suppose the first, well, like with the patient we were just talking about, you could pick up an iron deficiency anaemia, couldn’t you? And stomach cancer particularly is a reasonably common cause, well, it’s not common, but it does cause iron deficiency anaemia. The other thing is, the one that we all love to talk about is the raised platelets. So you know, our LEGO-C cancers, and actually they are, you know, raised, a new onset, raised platelets, particularly in men, but also in women, is quite a strong indicator of a cancer, and we’re talking about the LEGO-C cancers.
Rebecca: Let’s talk about LEGO-C again.
Sarah: Yes.
Rebecca: Talk me through the L, the E, the G, the O, and the C.
Sarah: So L is lung…
Rebecca: I’m like, I’m like, a cheerleader!
Sarah: Yeah.
Rebecca: Okay. Gimme an L.
Sarah: Lung.
Rebecca: Gimme an E.
Sarah: Endometrial.
Rebecca: Give me a G.
Sarah: Gastric.
Rebecca: Gimme an O.
Sarah: Oesophageal.
Rebecca: And give me a C.
Sarah: Colorectal.
Rebecca: There we go. So actually, the G and the O is all part of this.
Sarah: So, I think that, you know, if you’ve got it, it’s two ways with this, isn’t it? So, if you’ve got a patient who comes in with new onset raised platelets, questions about upper GI cancer. So gastric and oesophageal should be part of your questioning because that’s what you’d be concerned about. And conversely, if you’ve got a patient with symptoms that you’re concerned about if you’ve got raised platelets on their full blood count. That’s another thing that would make you think that actually I should probably be referring this patient on a suspected cancer pathway. The other thing that, you know, we talk about frequently is obviously if this patient has an epigastric mass when you examine them, that would also make you concerned and we, you know, if you don’t feel the tummy, you will never know whether they’ve got an epigastric mass.
Rebecca: So, as well as taking a very good history, asking those extra questions – always examine.
Sarah: Yeah.
Rebecca: And consider primary care investigations as well that we’ve talked about.
Sarah: Yeah.
Rebecca: So, at the moment we’re gonna do an H. pylori test for this patient. We’ll do a stool sample. If there’s a change in bowel habit, you do your FIT test, plus or minus you do microbiology also on a, on a stool sample. And then you also do some routine blood tests, including a full blood count.
Sarah: You probably do liver function as well, wouldn’t you? But again, I think, and the other thing to stress is that if the full blood count, and the liver function tests are normal that doesn’t mean the patient doesn’t have an upper GI cancer, it doesn’t mean anything. It just, you know, the, the normal tests don’t, aren’t reassuring and we just need to remember that.
Rebecca: We do.
Sarah: Always.
Rebecca: It makes our lives so difficult!
Sarah: I know, I know!
Rebecca: Okay, so this, this patient, whether we refer when we first see them or whether when we, when they come back, we refer them, you would send them and they would be getting an OGD.
Sarah: Yeah. And I think that’s the other thing, isn’t it? That actually sending for an ultrasound for some – We do sometimes ultrasound patients with abdominal pain, but it’s not going… It might tell you if they’ve got gall stones, which may give similar symptoms, but again, it’s not gonna tell you that they have or haven’t got a stomach cancer or an oesophageal cancer. So, if they go for, yeah, you need to do a, if you’re concerned you need to do a referral for a gastroscopy, and if you’re very concerned, you know, if they fit the guidelines, they need to be sent on a suspected cancer pathway.
Rebecca: Yeah. And actually, if a patient has been confirmed to have H. pylori, it’s actually one of those general practice diagnoses that are quite satisfying because it’s the triple therapy and people, people often feel a lot better once they’re treated. And that’s a,…
Sarah: Like pulled elbows!
Rebecca: Yeah. And also like PMR as well, I find that quite… so polymyalgia rheumatica, they come in, you give them the steroids and they feel a lot better quite quickly. This, they get the, the, the double whack of antibiotics with the high dose PPI and they feel better quite quickly. So a pulled elbow, tell me about that…
Sarah: Did you not used to do pulled elbows in kids, you know, kids who’ve been…
Rebecca: As in, if you pull an elbow and they feel better quite quickly?
Sarah: You can, you can actually re-, it’s, you can put it back into place very easily in a little kid. It’s very satisfying because they come in not using their arm and then they go out using it.
Rebecca: There you go.
Sarah: There you go. Life saved!
Rebecca: I do love my job!
Sarah: Do you think we should just go back to summarising exactly what we should be concerned about with stomach cancers.
Rebecca: Yes.
Sarah: Because I think it’s, I still think it’s quite a difficult one, isn’t it? So, I think that you’ve got a symptom that’s quite common and you’ve got a patient, you know, you’ve got a patient who may or may not be high risk because the risk factors are less clear than they are for oesophageal cancer. So, what, what are we concerned about? We’re concerned about new onset symptoms. We’re concerned about making sure we’ve checked for red flag symptoms. We’re concerned about things that are worsening rather than getting better, weight loss, checking for abdominal masses and abnormal blood tests. I think even at the end of that, it’s still making me feel that this is really difficult and I think that’s probably reflected in the figures, isn’t it? That actually this is, it’s not…
Rebecca: I think it’s also reflective on our faces right now!
Sarah: Yeah, yeah.
Rebecca: We we’re, we’re almost thinking like, actually we see so many patients with so many of, of these, kind of, a few of these symptoms and on the whole, they have got straightforward dyspepsia, or they’ve got straightforward acid reflux. So, in that point of view, it is really, really tricky.
Sarah: So, I suppose, it’s what we talk about all the time. It’s all of those bits of the history, examination and investigations together, and which you were talking, and then what we were talking about before, just being really clear about what you would expect to happen and safety netting. So, if you start the patient, you assume this is reflux. You give the patient a PPI, then how long would you expect them to take to get better? You know, would they, you know? Yeah. How long would they, when would you want to see them again? What circumstances would you want to, would you consider things? So, I suppose it’s, it’s that key to… really because a lot of this early cancer diagnosis stuff is quite difficult, isn’t it? It’s clear history, examination, investigations and then really, really specific safety netting.
Rebecca: And reassess.
Sarah: And reassessing, and that whole… Stuff that we talked about with the colorectal, the ‘come back if it doesn’t get better’, rather than ‘come back if it gets worse’. Because actually if you’ve given somebody a PPI, you would expect them to get better on with symptoms. So, you, you don’t, you sort of, you can’t just say come back if it gets worse. You want to know, you want to see them again if it doesn’t get better too, don’t you?
Rebecca: Yeah. And often we give the PPI for a certain amount of time, often a month’s course, and tell them to come off it and if their symptoms return after two weeks, that’s again, you want to see them because it’s, it is…
Sarah: It is a difficult one.
Rebecca: It is a difficult one.
Sarah: And I’m, I’m feeling a bit… Dissatisfied,
Rebecca: I’m feeling a bit dissatisfied as well because the oesophageal, we feel a little bit more satisfied with that.
Sarah: Yeah. I think you’ve got clear questions that you can ask. You’ve got clear symptoms you can sort of…
Rebecca: Yeah. And that, and that’s okay because it’s almost…
Sarah: That’s just acknowledging what everybody else, what we’re having to do on day by day…
Rebecca: Yeah, and by doing this podcast. Yeah. And, and almost just picking up what we can and reevaluating and reassessing.
Sarah: And again, I think that it’s when, I don’t know we are, we are going to do a bit more on genomics as we go forward, but again, I think it’s probably worth asking about, generally about family histories because it’s another little bit of a jigsaw. It might only be a tiny little bit, but it might…
Rebecca: A tiny corner?!
Sarah: A tiny corner. Yes. The corner’s important!
Rebecca: So important. Do you start with the corners? Do you go all the way around?
Sarah: Yeah.
Rebecca: You do. You are one of those. I do an area. So, it just shows again, it’s important. So yeah, A tiny corner – family history. Can I talk about Barrett’s oesophagus now?
Sarah: You can now. Yes.
Rebecca: Okay. So, I think that that was really important Sarah to actually say we struggle with this.
Sarah: Yeah.
Rebecca: So Barrett’s oesophagus is, this is something that is caused by a change in the lining of the oesophagus. And interestingly, it’s, it’s from a, a squamous cell to a columnar-lined epithelium, that’s what the histology is. So, these are often picked up when you…
Sarah: Could you recognise that under a microscope? Because I couldn’t, no.
Rebecca: No, it’s what’s written on the report that’s sent to us. But often we send patients for an OGD for, for an endoscopy, a gastroscopy, and actually this is picked up and, and then we’re told that they’ve got Barrett’s oesophagus and they’re put on an… Kind of a formal surveillance program, which is often depending on the area, between two to three yearly. 3 to 13% of patients with a Barrett’s oesophagus can go on to develop oesophageal adeno carcinomas. And that’s why it’s really important that they’re, they’re part of a surveillance program, but there are issues when people move, change addresses, change practices that they’re not, that they don’t stay on the surveillance program.
Sarah: I think Covid has also caused problems with that, hasn’t it? The people have a delay, and then they get lost to follow up. And yeah, so I think there is a, a problem with that. And certainly, I think we need, we as primary care professionals, if we see somebody who has had Barrett’s in the past, we probably need to… Be checking up with them that they are being… having surveillance and referring them back if it seems to have gone awry, which I think it does quite frequently.
Rebecca: Yeah. So, it’s really important that if you see somebody with Barrett’s and you feel that they haven’t been seen because of Covid, because of a change of practice, that we as GPs, as we as, in primary care write to the local department and get them back on the surveillance. And we also need to make sure that they’re on long-term, high dose, acid suppression, that they’re not smoking, that they’re on a good diet…
Sarah: Which, some of which, is easier to do than others.
Rebecca: Of course, it is! So, it’s all those kinds of things but…
Sarah: Yeah. Yeah. But certainly, we can do the high dose PPI and advise on the others, can’t we?
Rebecca: Yeah. Yeah. Because another fact, just kind of going back to H. Pylori as well, which I think shocked us both when we were preparing for this podcast, was that around 40% of stomach cancers in the UK are caused by H. Pylori infection. But the good thing is that the prevalence of H. pylori is falling, but it still remains a problem in developing countries. So it’s about education.
Sarah: Yeah. And the tests are presumably, availability of tests, and treatments as well. So onto our interesting facts.
Rebecca: Okay. So, very hot drinks. I think we’ve been talked about this for a long time. You shouldn’t actually drink freshly brewed hot drinks. So actually, by putting a bit of milk or by letting cool down a bit, because burning, it’s all to do with burning the oesophagus, isn’t it, can increase your risk of oesophageal cancer.
Sarah: So we said with head and neck cancers, you’d need to drink more coffee. But it doesn’t have to be hot coffee, does it?
Rebecca: No. It’s just the caffeinated bit.
Sarah: Yeah.
Rebecca: And this is don’t have burning, burning hot food. So hot, spicy food and scorching food as well, which can burn.
Sarah: Right.
Rebecca: I think that’s all to do with ulceration and burning.
Sarah: Probably, yeah.
Rebecca: So that’s our interesting facts. Okay. So, we’ll start off with the key clinical points. So, risk factors for, I’m going to put gastric and oesophageal together because they, they kind of work together. So, age is common in older people. 40% of these are over the age of 75 and we’ve actually talked that a high proportion are over the age of 80. Weight is another one, with obesity being an increasing problem, it’s an increased risk. Smoking, alcohol, particularly with those people who drink over 14 units weekly have an increased risk. And the other one is radiotherapy as well from other cancer groups.
Sarah: Okay. The second one is the progressive, persistent dysphagia is a red flag. I think most people are aware of that, but it’s just being clear exactly what patients mean when they say they’ve got difficulty swallowing and being clear and making a referral if needed.
Rebecca: The next key clinical point is as we’ve just been talking, that stomach cancer is often really difficult to diagnose. The symptoms are often vague and also where the stomach is, the anatomy, it could cause lots of other benign symptomology. So just think about it as part of your differentials.
Sarah: Yeah, I think that’s right, isn’t it? I think if you see the patient and you think, could this be a stomach cancer? Rather than automatically assuming it’s a dyspepsia problem, it’s related to a benign condition, then if you’ve thought about it, you’ll have it at the back of your mind. You’ll think about it, you’ll talk about it in your safety netting. So, I think that’s it, isn’t it? It’s just thinking about it in the first place and not making an assumption that it’s benign.
Rebecca: Yeah.
Sarah: And then the last one is that patients who’ve got Barrett’s should be on a formal follow-up program. And if they’re not, make sure you refer them in.
Rebecca: So that’s it for today, and thank you as ever to my co-host, Sarah. We have fun and thank you all for listening to this podcast from GatewayC. We really hope you have enjoyed the episode and would appreciate a rate and review. We’ve got a free stomach and oesophageal cancer module, which is available on the GatewayC website. All reference studies and guidelines are on our show notes.
Thank you to our producers, Jo Newsholme from Rethink Audio and Louise Harbord from GatewayC. And we’d love it if you shared this podcast with your friends or colleagues, it really helps to spread the word. Thanks, and see you again soon.
