Sarah: So anybody who’s got a neck node that’s been there for three weeks or more, should be referred on a suspected cancer pathway because they have up to a 40% chance of having a cancer, which is really high. 

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.  

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 we’re back! New series two and, like series one, we’re going to be talking about new cancers. We’re going to be bringing in some specialists and we’re going to have some shorter and longer form episodes. How excited are you, Sarah? 

Sarah: Oh, I’m looking forward to it. We’ve got some really interesting topics to discuss. We’ve got some great specialists coming in, and I might even let you have a few minutes on cervical screening at some point! 

Rebecca: Yay. So… As well as in most episodes, we’re going to be talking about a few cases and what we’ve learned from them. And today we’re going to be focusing on head and neck. Let’s crack on. 

So, to start things off, I’m gonna throw some stats at you. Head and neck cancers are the eighth most common cancer. They are most commonly diagnosed in patients aged 70 to 74. 

In terms of gender, it’s the fourth most common cancer in men. While it’s the 13th most common in women. 7.7% of diagnoses are made in the emergency settings.  

Rebecca: So are you able just to talk about the first case for us, Sarah? 

Sarah: Yep, yeah, so the first case today is taken from the Gateway C course. This is a case of a 45-year-old man who presented… He didn’t actually come and see me first off, but he presented to a GP with a lump in his neck. He’d had, I can’t remember the details as to how long he’d had the lump, but the first GP he saw before he’d moved to our practice, wasn’t particularly concerned, reassured him, and sent him on his way basically. He didn’t have any symptoms apart from the lump in his neck at that time. He then said he was very reassured by the whole process, and it was about four or five months down the line that his wife said, ‘that lump in your neck hasn’t gone’. And he said, ‘Hmm. Yeah’. She said, she said, ‘you need to go back and see the GP. You need to go back’. So, so he made an appointment to come back and he, you know, he had a sort of two-centimetre lump in his neck. So, he was referred on the, on the suspected cancer pathway, referred to head and neck, had a biopsy, found to have a head and neck cancer. 

I spoke to him a little bit afterwards about the whole process and he was saying that actually he felt very reassured by the first GP he’d seen who he actually said to him – ‘I don’t think this is cancer’. And he said that that’s all he heard after that, he didn’t really listen after that point. And he was sort of saying, well, actually, if they’d said, come back, if it doesn’t get better, come back if it gets bigger. He didn’t hear any of that because he’d been so reassured by the fact that this lump wasn’t cancer. So, I think he was quite, he was sort of saying, when he was with us, that actually he felt that the advice he’d been given should have been a bit less reassuring. 

Rebecca: So, I mean, the reassuring part, the ‘probably isn’t cancer’ that can be detrimental, can’t it? 

Sarah: Yeah, it’s a, it’s a funny phrase, isn’t it? I mean, I, I’ve, I’ve always been a little bit reluctant to make sweeping statements. You know, I remember when, when I was a kid, somebody saying, ‘well, I’ve just been given a clean bill of health’. And I’m thinking, what, what, what does that mean? 

You know, what, what, how can you sort of say that to anybody? And so, I think that that whole very, we, we all know that nothing’s impossible. And so, you have to be a bit more nuanced, I think, in what you say. 

Rebecca: So, if you would’ve been that GP first time round and you would’ve seen the patient, a young patient with a painless neck lump.  

Sarah: Mm-hmm, yeah. 

Rebecca: And… How would you have conducted the consultation? How would you have almost safety netted?  

Sarah: Well, I suppose the first thing is if he’d had it for three weeks or more, I would’ve referred him anyway. And I don’t know how long he’d had it for at that stage, he couldn’t remember. So, I think the first thing is that if he had a lump for three weeks, he needs referring anyway. 

Rebecca: And where would he be referred to? 

Sarah: To head and neck.  

Rebecca: Yeah. 

Sarah: And I think then so, if he’d got it, if, if say he’d had it for two weeks and you were thinking, this is probably related, bit like you, he’d got a bit, you know, he’d got, he’d had a cold and he’d had a bit of a cough and… 

Rebecca: Felt sorry… 

Sarah: And felt sorry for himself, yeah! If he, if he had a lump associated with that and it’d been there for two weeks, I would then say, ‘I would expect this to settle in the next 2/3/4 weeks’. And I think we’ve actually talked about this, and we got a little bit of guidance, didn’t we, saying that somebody who’s got a lump, I suppose if he’d got, firstly, if he didn’t have any recent infection, you might be a little bit more concerned anyway. So, if he’d had a cold, particularly a younger person with a sore throat, tonsillitis, you’d be much more likely to say, come back in four to six weeks if, if this hasn’t gone down. If he’d had it for a couple of weeks and you didn’t really have a particular cause for it, I think you’d say, I would expect this to have gone or be getting smaller in the next two weeks. And if it hasn’t, then I want to see you again. I think I would not be saying, I don’t think this is cancer. I suppose if, if pushed and somebody asked me, I would say I think it’s probably not, but if it doesn’t settle in this time… And I think it’s that specific guidance. 

Rebecca: Absolutely. It’s that very much saying – you’re saying that he just heard ‘it isn’t cancer’. The word probably isn’t cancer. He probably didn’t even hear the probably. And I think you’re absolutely right with these younger patients, if they’re saying that they’ve not had a recent infection, we’ve gotta think about glandular fever, don’t we in these cases? Then if it’s a painless lump with no preceding illness, I’d probably wanna see them personally in the next kind of 10 to 14 days probably. And then we would say that it should be getting smaller over the next four to six weeks. If they come in without any illness with a lump, I’d want to see them sooner. And if it’s been three weeks or more, we’d actually refer straight in. Why head and neck, Sarah? 

Sarah: Because they can do the biopsy, they can do the ultrasound. And that’s one of the things that when we spoke to the specialists they were saying is that, yes, we can, you know, as GPs, we can access ultrasound, but actually if they’ve, if anybody with a persistent neck node needs a biopsy, there’s, so there’s not really any benefit for us referring for an ultrasound. If we’re concerned, we should just refer straight to head and neck on the suspected cancer pathway where they’ll have, most places now have one-stop clinics organised where the patient will have an ultrasound and probably an ultrasound guided biopsy at the time. So, it’s, it, it’s quicker and easier for everybody. Takes a step out, doesn’t it? It takes an extra investigation out. 

Rebecca: And that, and that’s something I’ve definitely learned. I think I would’ve automatically just sent them for an ultrasound. And actually, it’s important that, that if, if you do suspect something to send them there. You, you spoke to, one of our head and neck surgeons as part of the modules that we organised through GatewayC and she actually gave a very interesting statistic. 

Sarah: Slightly alarming statistic really, isn’t it? I think she said that patients over the age of, we couldn’t quite get the absolute age limit, but between about 35 and 40 with a persistent neck lump have a 40% chance of having some sort of cancer. So really scary. Head and neck cancers, lymphomas, obviously some, sometimes lung cancers. But yeah, very high statistic. So actually, we really do need to be taking these things seriously. And I think this, a lot of this is down to the increase in HPV driven cancers, which is a completely different type of head and neck cancer from the ones that we got used to seeing. Well, certainly I got used to seeing as a a, as a medical student and junior doctor, don’t know if it’s same, you’re a bit younger. 

Rebecca: You love to say that! 

Sarah: I do. It’s true! 

Rebecca: I won’t say how much. But I think, there’s two things I want to say there – I want to talk about HPV, because I think this is a, this is the, the big thing from this case. In the introduction, I talked about statistics, and it was 7.7% being picked up in emergency setting. And when we were off camera or off, I said, oh, that’s quite good. And you said, no, no it’s not. And I’m understanding now why you, why you’re saying that we should be improving the 7.7. 

Sarah: Yeah, I can’t think of why… Of many instances, and there’s always a few aren’t there? 

Rebecca: Yeah. 

Sarah: Why somebody with a head and neck cancer, if the main symptoms are lump in the neck, hoarse voice, maybe an ulcer in the mouth or something like that would have something so acute that they needed an emergency appointment, where as opposed to patients with brain tumours who might have a fit or a possible stroke, or bowel cancers who might have a bowel obstruction, and therefore you start to think that actually is some of the reason that a) they’ve struggled to get an appointment in primary care, which we all know is, is really difficult and, and I’m not sure that’s gonna be solved anytime recently or is,… or have they not recognised the symptom or you know, what is it that’s taking them to the emergency department? Cause I don’t think it’s something… it’s not a fit or a TIA, is it? 

Rebecca: Absolutely right. And I think it’s probably all those things you discussed and also maybe lack of pickup from the GP as well. 

Sarah: Yeah. 

Rebecca: And that’s, and that’s what we are trying to do is… 

Sarah: Yeah. 

Rebecca: To improve knowledge, improve skills so that, so that can be done. 

Sarah: So, if the, if our patient had gone to the GP and seen, and somebody said, oh, I don’t think this is… the first time… I don’t think this is a cancer. And they thought, well this, I’m not really happy about that, people go to A&E for second opinions. 

Rebecca: Yeah, they do. They do. So just, I interrupted you talking about HPV. 

Sarah: Oh well… I don’t think that’s necessarily a bad thing! 

Rebecca: So, HPV now is, is driving a lot of these head and neck cancers and other cancers as well. But, but we’re gonna talk about head and neck today. We’re not, we’re not gonna talk about cervical because we know that’s my specialist interest. So, the, the interesting thing about HPV is part of the vaccination program that’s happening, are you just able to, to talk a bit about that? 

Sarah: Yeah, so the vaccination program’s been going for quite some time, hasn’t it? For for girls, and they’ve also started now vaccinating boys in the first two or three years of secondary school. They have the, the, the, the vaccines and it’s to prevent cervical, I think anal cancers, it makes a difference to penile cancers and, and, and also head and neck cancers. So, I think there’s, it’s… A lot of cancers are HPV driven, and this is to try and prevent it. The problem is that we’re probably not going to see the benefits of the vaccine program because for… In some of the head and neck cancers for about 20 years. So, there’s been an increase in HPV driven cancers over the last 10 or 15 years, and we’re probably not going to see the benefits from the vaccine program for another 15 to 20 years. So… 

Rebecca: Because it can actually, the HPV can lie dormant for 20 years plus can’t it before actually causing cancers. I heard an interesting statistic, that HPV was often seen as, as an STD and you know, a lot of it is, it is part of the sexually transmitted disease cohort, however… Most people, they’re saying eight out of ten will have been affected at some time, some point in their lifetime. And… 

Sarah: So that means that we, that really, we should assume that everybody who has a neck lump is at, is at risk of having an HPV driven cancer and investigate them according to that rather than thinking about sexual history. Taking any sort of in, asking anything else at all, just assume that anybody who has a neck lump has been exposed to HPV and, and is therefore at a risk of an HPV driven cancer. One of the things that’s quite encouraging, ’cause it is a bit alarming, isn’t it, this sort of big increase in, in head and neck cancers is that they actually have a better prognosis. And I think that sometimes they, they’re quite difficult to find these cancers. So you, so if we see somebody with a neck lump, I mean, I don’t know what you are like, I’m not particularly good at looking at mouth and gums and, you know, I think, but actually even if you are, you often don’t see anything. And I think often even on nasoendoscopy and similar investigations, they don’t see things but they get the histology, which shows what type of cancer it is, which I can’t remember ’cause histology was never my strong point! 

Rebecca: Great. And, and, and we also have to rely on our dentists as well to help. 

Sarah: Yes.  

Rebecca: Because they’re often the first to, to pick up abnormalities on the tongue, as you say in the mouth that we’re not as good at. Dentists, as part of the general checkup, will also look out for any suspicious, potential symptoms of a mouth cancer. So, any red and white patches on the tongue or actually in the mouth and they can refer themselves to the urgent care pathway directly. And there is actually NICE guidance for dentists. 

Sarah: Yeah. And I suppose sometimes we see people with persistent ulcers, don’t we? Where again, we should probably be concerned and thinking about, I actually thinking about it, I did see a patient probably about three or four years ago who had a persistent ulcer who I referred who turned out to have a mouth cancer. So, I think. Probably I, I don’t, I can’t remember the guidelines specifically, but I would imagine we’re on about anything that goes on for more than about three weeks we should be becoming concerned about. 

Rebecca: Yeah, and I think also patients will come and see a GP about any changes with their tongue, probably more than a dentist, so any pain they might say ‘I burnt it on some hot soup’. And then again, it’s the safety netting saying if it doesn’t get any better, take a good history, look for any risk factors – alcohol, smoking, all these other things as well, because there is higher risk in smokers with, with mouth cancers as well. So, it’s important. 

So that, that’s really interesting. So, I think in a nutshell, this is a, a, a new cohort of patients, these younger patients who are picking up head and neck cancers, and we need to be open-minded to neck lumps and they could be HPV driven and to refer appropriately. 

Let’s talk about case two. 

Sarah: Yeah, so case two is probably the one that we both remember being taught about at medical school or seeing probably as junior doctors. 68-year-old man who is a long-time smoker. Also, you know, relatively heavy alcohol intake, who developed symptoms of sort of pain and discomfort on swallowing. Not, again, it’s difficult sometimes, isn’t it, to work out with patients whether or not they’re having actual difficulty swallowing, particularly if it’s something quite high up and whether they can get food down or not. It was a bit difficult to work that out. Change in the voice. So again, just sort of coming and saying it didn’t, voice, didn’t seem the same, and a little bit of a, a, again, a neck lump, which was a little bit more alarming. And then just over the, these symptoms had been going on for about six to eight weeks. And over the last week or so before coming in to see, see me just had a little bit of intermittent pain in the ear as well. So, it was just sort of a much more typical picture of… Particularly, you know, hoarse voice I think is a red flag that most people will pick up on. Neck lumps, similarly, but then there’s sort of pain on swallowing and ear pain, which were also a little bit alarming. 

Rebecca: Absolutely. And I think we know that a risk factor for all cancers is older age. 

Sarah: Yeah.  

Rebecca: And then you add in alcohol and smoking, and then all the red flag symptoms that you’ve discussed. 

Sarah: Yeah, and I think one of the things that I’ve not really, and it’s not actually in the NICE guidance, but again speaking one of the… We often say one of the things that’s really quite nice about this job is we get to speak to lots of specialists about things as well, and Susi Penney, who’s the specialist we’d spoken to, was saying that actually ear pain, intermittent, unexplained ear pain, not intermittent, unexplained ear pain is a concern. 

Rebecca: So, when you say unexplained ear pain. So we often, we, we see a lot of ear pain in general practice. 

Sarah: Mm-Hmm.  

Rebecca: Is it more that it does come and go, or is it that it’s not related to other symptoms of an ear infection? 

Sarah: Yeah, I think it’s more the latter that it… So, I think, and, and, and actually if you think about it, I don’t know how often I see older people with ear pain unless they’ve got something like an otitis externa or something like that. Yeah, but actually you see lots of kids, don’t you, with ear pain. but as people get older, you see… 

Rebecca: Yeah, we see hearing loss. 

Sarah: Yeah.  

Rebecca: And we obviously see wax and things but, you are right, do we actually see… And we see otitis externa. So if they’re saying that they’ve actually got earache, ear pain, so I suppose it’s… 

Sarah: And it’s, it is length as well, isn’t it? So, if somebody’s got an infection as sort of otitis media type ear pain, it tends to be fairly short-lived, doesn’t it? 

Rebecca: And they’ve often got other symptoms with it as well.  

Sarah: Yeah.  

Rebecca: Okay. That’s really interesting. So really from case two, it’s very much kind of the more typical patient that we’d expect. An older male patient, a long-term smoker with red flag symptoms. And the interesting one that we’ve picked up on as well as the neck lump, which is, should be a real alarm bell, is, is this new kind of ear pain. 

Sarah: And I don’t know what you found out. I, I think that swallowing problems and voice changes are one of those slightly difficult to pin down symptoms, a bit like dizziness. You know, there are some things, aren’t there, some things you can say to patients? Cough tends to be a bit easier, doesn’t it? You can say to a patient, how long have you had the cough for? Are you coughing anything up?  

Rebecca: Yeah. 

Sarah: Difficulty swallowing or pain on swallowing is, is much more, and changes in voice often seem to be a bit more vague. 

Rebecca: Well, we talked about that, didn’t we? That okay, if we talk about voice, there’s, there’s different things that can happen. It can be hoarseness is a, is a red flag and we often, if I think about hoarseness, I think could this patient, have a lung cancer. But actually, could hoarseness also be, a head and neck related as well. 

Sarah: It’s certainly one of the NICE guidance… 

Rebecca: Absolutely. And then you think about what actually, is it more, is it a neurological thing? Is it slurred speech? Is it all these other things? So, speech itself and, and tone of voice. And so, you’ve got to take a good history. When you’re talking about swallowing – you’re right, is it painful or painless? And then are things getting stuck? And you talked about actually the sternal notch, didn’t you? 

Sarah: Yeah. So, well, certainly I have spent time doing the referral forms locally in work and actually what, what we’ve got done is if you’ve got dysphagia. And people feel that food is getting stuck above the sternal notch, and I realize that me pointing to my neck isn’t helping anybody apart from you! 

Rebecca: I see it! Yeah. 

Sarah: But actually, if it’s, if it’s feeling like getting stuck above the sternal notch, you should refer to head and neck, ENT, on a suspected cancer pathway. If it’s, feels like it’s getting stuck lower down, below the sternal notch, it should be an oesophago-gastric referral. 

Rebecca: And then if you’ve got hoarseness, then you also need to think about lung as well. So it’s all, I mean, I don’t know how we do our job! Okay. No, that, that’s really, really good. So I’m gonna do an interesting fact now. 

Sarah: Okay, go ahead! 

Rebecca: This was quite an interesting one because I do like my coffee and a lot, a lot of this… Well, a lot of these podcasts are around drinking tea and coffee… Is head and neck cancer risk is lower in people with who have a higher intake of caffeinated coffee. So, we’re always told to be drinking decaf, but actually head and neck cancers and uterine cancers, it’s like top, it’s top and tail! It has an up to 39% lower risk in those that drink four cups of caffeinated coffee versus non-drinkers. We couldn’t find any information about whether it has to be, you know, the instant versus the posh brewed stuff! So,… 

Sarah: And we don’t know whether tea and… 

Rebecca: We don’t know about tea and Coca-Cola and, and all these other caffeinated drinks, so coffee is a good thing. And I don’t know whether dogs help in this situation. They’re often, on the, on the interesting facts, I talk about whether dogs can sniff things out. Do you know? 

Sarah: Yeah. I, I don’t know. I don’t know whether they can sniff head and neck cancers. Probably. Probably. Depends what sort of dog. 

Rebecca: Yes, exactly. 

Sarah: My dog… My dog can sniff out hula hoops! 

Rebecca: There you go. 

Sarah: Or any other food to be perfectly honest! 

Rebecca: Any, any food! We do like our dogs. We have Labradors and miniature schnauzers, don’t we? So that’s, that’s our interesting fact for the day and if anybody has got any more information on that, we’d love to know and just want to recap some key clinical points. So, risk factors, I’d call them more so red flag symptoms, are older people, alcohol and smoking. That’s the classical head and neck cancer patient. 

Sarah: Yeah, with symptoms of ulcer in the mouth, hoarse voice, lump in the neck, difficulty swallow, pain on swallowing, and then ear pain as well, although it’s not in the guidance. 

Rebecca: But we’re adding that in. 

Sarah: Yeah. And then I think the real one that we need to be remembering is the increase in HPV driven cancers in head and neck patients, which typically present with a neck node. So, anybody who’s got a neck node that’s been there for three weeks or more should be referred on a suspected cancer pathway because they have up to a 40% chance of having a cancer, which is really high. 

Rebecca: Really high. Next key clinical point is don’t overly reassure. It’s all about using the right language when speaking to our patients, because they’ll often go away with a certain message, and we don’t want to overly reassure that they don’t come back if things persist. 

Sarah: And then just adding to that, it’s being really clear about, which is something we talk about virtually every podcast, being really clear about when you want to see patients again, how they should make the appointment, and very, very clear specific instructions. 

Rebecca: Safety netting. 

Sarah: Safety netting. 

Rebecca: So that’s it for today and thank you to Sarah as always. Thank you 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 head and neck 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.