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GPs TALK CANCER

Lower GI

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Published on: 15th August 2023

Lower GI

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

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

This episode covers:

  • Statistics
  • Patient cases
  • Safety netting
  • FIT and differences between screening and symptomatic tests
  • Bowel cancer in younger patients
  • Family history
  • NICE guidelines
  • Referral

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

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

 

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Dr Sarah Taylor

A few years ago, I spoke to Deborah James, and what she says very significantly is if somebody had ever said to her, are you passing more or less than a teaspoonful? She would’ve said, it’s way more than a teaspoonful, and she would’ve done something about it.

Dr Rebecca Leon

Hi, this is GPs Talk Cancer, brought to you by GatewayC.

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

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

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

So, official bit done and dusted kettle is on, and joining us today is Ellen, who is a junior doctor working alongside us at GatewayC. She is joining us from rainy Scotland. Is that right? How are you doing today?

Dr Ellen Macpherson

I’m good, thank you. Yep. Definitely still raining here, but I’m good, thank you very much.

Dr Rebecca Leon

Good. Lovely to have you. And have you got yourself a drink?

Dr Ellen Macpherson

I do, yeah, I’m drinking Pepsi Max, which, I’m mildly embarrassed about as I feel it’s a bit of a childish drink.

Dr Rebecca Leon

That’s absolutely fine. And Sarah, how are things with you? How was, how was your morning so far?

Dr Sarah Taylor

It’s good. The traffic was bad, parking was easy, and I remembered my coffee this time, so it’s all good.

Dr Rebecca Leon

Excellent. And big question, have your cases arrived?

Dr Sarah Taylor

I think it’s now on its way from Heathrow to Manchester. Hasn’t [00:02:00] quite made it home, but you know, that’s progress.

Dr Rebecca Leon

Okay. For listeners out there, Sarah was on holiday last week and cases are still at that said destination.

Okay, so today, we’re talking about lower GI cancer or colorectal cancer and, some interesting statistics, regarding this particular cancer. It is the fourth most common cancer with over 45% of cancer diagnosis in patients over the age of 75. We’ll be talking a lot about bowel screening or FIT testing. And actually I reviewed the data from the CRUK website and the uptake of people invited and completing or doing the FIT testing is now up to 70% in England. And in Scotland and Wales it is, slightly below that at 67% and this is on the rise, so it’s all very exciting.

So, let’s talk about the couple of cases. Can you please talk about the first one, Sarah?

Dr Sarah Taylor

Yeah. I think this, this isn’t actually a patient, this [00:03:00] is somebody I know personally who I was talking to about, I think one of the things that we probably both get is, because they know, people know what our jobs is you tend to get a lot of people talking to you about cancer diagnoses and concerns and all of these sorts of things. And this was somebody I know who’s a man in his early forties who had, some fairly vague symptoms. I think it was rectal bleeding that he had initially, went to see the GP. GP was quite reassuring. I don’t honestly know whether or not he was examined, but he was told that he had haemorrhoids and he felt massively reassured, and as far as I know, there was no clear safety netting. There may have been some safety netting, but it wasn’t absolutely clear. And I think that I’ve spoken to a few men like this who are so reluctant to go and see the doctor in the first place, and this probably happens with women too, but they’re so keen to go, so reluctant to go in the first place, and so keen to be reassured, that if you don’t get the balance [00:04:00] of your safety netting right, all they hear is, I’m not worried about this.

They don’t hear anything else. As I say, I don’t know whether or not it was said, but then didn’t do anything for the next 10, 12 months. Went back when things had got quite a lot worse and was then put on a, you know, had investigations, had a FIT test, had blood tests, and was diagnosed with quite an advanced colorectal cancer.

And I think, you know, it just, there’s other people that we’ve spoken to, we spoke before about a woman who worked for Bowel Cancer UK who was told to go back if her symptoms got worse, and actually her symptoms didn’t get worse, but they didn’t get better. So, she similarly didn’t go back for another 10 or 12 months and, and has now subsequently died.

And actually a few years ago I spoke to Deborah James, who again was told that she probably had haemorrhoids and [00:05:00] wasn’t given any safety netting advice. And what she says very significantly is if somebody had ever said to her, are you passing more or less than a teaspoonful? She would’ve said it’s way more than a teaspoonful, and she would’ve done something about it.

So, I think there’s a bit of a pattern because it’s difficult, isn’t it, with these younger patients, because IBS is common, haemorrhoids are common, to safety net and to take the symptoms seriously without causing undue concern and without over investigating people. Because none of us want a colonoscopy at the end of the day.

Dr Rebecca Leon

No, absolutely. And it’s almost that one more question thing, isn’t it Sarah? Like that one more question of saying, is it worsening or if it worsens or persists, that word persists. And I very much use that because we talked about this before. And also, something that’s, I think I need to do more of asking the amount. And with patients who are presenting frequently, we do need to really think about is there [00:06:00] something else going on? So, this is almost going to be a common theme when we’re going to be talking all these different cancers. Not every patient that comes to see us is going to have cancer. Actually, we talked about that when we refer in, only 3%, if we do it right, will actually have a diagnosis of cancers. Actually, 97% of patients will have other diagnosis.

However, we do need to be thinking, is there something more serious going on? And safety net them. And actually, with some patients who you think may or may not make the appointment themselves actually say, right, I’m going to look at my diary, let’s see what’s going on at the end of May, please come see me and if you are completely better, please cancel your appointment.

And that’s what I do with, with patients of different ages if I’m a bit concerned. So, this is a really good learning point.

Dr Sarah Taylor

Yeah, and I think it is that, it’s that balance, isn’t it? Between, you know, I think we will both tell patients if they’re on a suspected cancer pathway, that they’re on a suspected cancer pathway and that’s what we’re trying to exclude. But it’s that balance between making people [00:07:00] aware of their symptoms and some level of concern and overly reassuring. And I think we do have this natural desire to make people feel better, that’s probably why we’re GPs, because we want people to feel better.

But actually, if you over reassure, some people will just hear the reassurance and you need to be quite clear.

Dr Rebecca Leon

Absolutely, and I, and I like to be quite open and honest with my patients and almost say, if I am concerned there’s something, I want to actually say, I do have concerns. I want to almost rule out this, because I don’t want them leaving the consultation room saying, I think Dr Leon’s actually not telling me something and actually cause anxiety in a different way. Because I’m, I’m almost saying, yeah, you’ll be fine. So, I try and be honest and say I’m talking to you how I’m, I’m being honest with you. And there is a chance this could be something more serious.

Can you, because, from a previous podcast I called you Mrs. NICE. And what I mean by that, I mean, [00:08:00] she’s a very nice person, but also from the NICE guideline point of view. And you know, you’ve done a lot of work with your cancer research hat on, looking at this kind of 3%. Are you able just to talk a little bit more about that?

Dr Sarah Taylor

Yeah, I mean I think that, you know, the, I think in some ways the NICE guidance for lower GI cancer is quite complicated. And I think the introduction of FIT has made things quite a lot easier. So, in the past I almost felt that you, on any given day, you could refer almost everybody or nobody with lower GI symptoms.

You know, there’s a, obviously the key things you’re looking out for are rectal bleeding, change in bowel habit, abdominal pain. You’re concerned if somebody’s got iron deficiency anaemia. There’s the link with high platelets, weight loss, all of these things can be signs of, of bowel cancer. The guidelines have actually, The British Society of Gastroenterologists did a whole review of colorectal referrals and the use of FIT [00:09:00] and the guidelines have now changed. And what we’re encouraged to do now is to refer patients to do a FIT in any of those patients with rectal bleeding, change in bowel habit, abdominal pain, and only refer if the FIT is positive or if they’ve got anal rectal mass, anal ulceration, or if they’ve got an abdominal mass, which is obviously a slightly different scenario.

So, in some ways, I think from a primary care point of view, things are quite a lot easier because now you’ve got a patient with symptoms. And you can do a FIT test. Now, obviously like every test, it’s not a hundred percent reliable, but it’s pretty reliable. And you can still go ahead and refer patients if they have a negative FIT, either on an urgent pathway or a routine pathway, and they will still get investigated.

And one of the things that I think was quite useful when we were talking, we did the last face-to-face event training. Roger Prudham, who’s the consultant who was there, who was [00:10:00] talking to us, was saying that the doubling time for colorectal cancer is quite a long time. So actually, you’ve got time, if the FIT is negative and you, the symptoms can, persist still to refer and for the patient to be investigated and not worry about it.

So, I think the, the old NICE guidance was incredibly complicated. You know, if they were over 60 and they had this and they were under 60 and they had that, you just, whereas now do the FIT, safety net the result, or if they’ve got the other symptoms, just refer straight away.

Dr Rebecca Leon

So, um, I want to talk to you about the FIT test.

Dr Sarah Taylor

Everybody does.

Dr Rebecca Leon

Yeah. This is, this is your, specialist interest.

Dr Sarah Taylor

Oh, it’s a mastermind today. I’ve got master, mastermind today.

Dr Rebecca Leon

Sarah, you’ll be Dr FIT. Just tell us a bit about FIT testing because it really has, as you say, made the whole two week colorectal investigations and, and who to send and what, and if you’ve got a 58 year old, can you, can’t you, it makes it a lot clearer. Just talk to us a little bit about [00:11:00] FIT testing and the difference between screening and again, and diagnostic, and then we’ll bring in the next case. Cause that’s part of, that’s something slightly different.

Dr Sarah Taylor

So, the FIT was brought in. So, the initial NICE guidance, used FOB tests, and the initial screening program used FOB.

Dr Rebecca Leon

What, what does FOB stand for?

Dr Sarah Taylor

Faecal Occult Blood. And FIT is Faecal Immunochemical Test. So, the old test was FOB. It looked for any type of haemoglobin and it wasn’t particularly accurate. And it was also less acceptable to patients because it required three tests. You had to do a test on three consecutive days.

Dr Rebecca Leon

So, compliance.

Dr Sarah Taylor

So, compliance was poor. About, probably about five or six years ago, FIT was introduced into the screening program. Resulted in an increased uptake because it’s now only one test and it’s more reliable, and then it’s been gradually introduced into diagnostic pathways over the last few years as well.

So [00:12:00] quite a lot of pilots initially just doing a FIT alongside the referral. And now the guidance is that the FIT is done before the referral. One of the key things to remember is that the FIT for symptomatic patients and screening patients is at a very different level. So, for symptomatic patients, you’re looking for a FIT greater than 10. For screening patients in England, at the moment. The levels are slightly different in Wales and Scotland. And England, you’re looking at a level of greater than 120. So, your screening patient might have a level of 115 and it will come back as negative for screening, but they would obviously be well into the positive symptomatic.

So, it’s something, it’s like all screening. It’s a screening procedure and it shouldn’t be used if you’ve got a symptomatic patient.

Dr Rebecca Leon

So that’s really interesting. So actually, if I bring in case two, because this is, one of mine, a 66 year old gentleman who’d actually came [00:13:00] in with new onset, rectal bleeding. But came in, don’t worry, doc. I’ve had a, a bowel screening, kind of 10 weeks ago and, and it all came back clear, so I’m not worried about that it’s anything serious, but I’ve, but I’ve got rectal bleeding. I’ve never suffered from haemorrhoids. So, and, and then actually because of the learning, the teaching that I’ve had, regarding the, the different FIT levels, from screening and diagnostic, I realised that actually he could still have something. And so, repeated the FIT test, from a non-screening point of view, and he came back positive and it went on to have a colonoscopy and, and has bowel cancer. So, this is a really interesting thing that actually just because somebody’s had bowel screening, don’t think, well, they can’t have, and then they present with symptoms. You need to potentially repeat the FITs.

Dr Sarah Taylor

Absolutely. Yeah. To a different level.

And I think the, you know, there’s been a lot of concern as to whether you can do a FIT in somebody [00:14:00] who’s got rectal bleeding.

Dr Rebecca Leon

Oh yes.

Dr Sarah Taylor

And all the research seems to suggest that you can because rectal bleeding is often intermittent, so suggest that they do it on a day when they’re not bleeding. Or you suggest they take it from a part of the stool sample where there is no blood. And that’s, and the other thing that I think is really important that we remember that, the FIT is part of the referral guidance, but actually anal rectal mass and anal ulceration and abdominal mass are also part of it. And also, a patient with iron deficiency anaemia, you might have increased concerns of.

So, I think, you know, I think it’s really important that we examine our patients because if you don’t examine the patient, you don’t know if they’ve got a rectal mass. And if you don’t do the blood tests, you don’t know if they’re iron deficient. So, I think the whole assessment of these patients with rectal bleeding, with new onset abdominal and changing bowel habit, and that can be either, not just looser bowel [00:15:00] habit but becoming more constipated. I think it’s really important that these patients are examined and we do some blood tests. And I think, you know, so you’d obviously do the full blood count and some iron studies to check whether they’ve got an iron deficiency anaemia.

The other thing, just to help the referral pathway, if you’re doing further, if you are going to be referring on, is to do renal function. They don’t necessarily need it for CT now, but they do need it if they’re going to go ahead and do a colonoscopy. So just on a practical basis, you might as well do it all at once.

Dr Rebecca Leon

And we all work in different areas, but my, my lower GI two week wait actually will say, have you examined the patient, yes or no? If not, why? Have you done a PR? Have you done, an abdominal examination, the findings of that? So just to bring Ellen in, were you aware that there were different, I suppose, ranges when it came to FIT testing with screening and diagnostic? [00:16:00]

Dr Ellen Macpherson

I was aware from having worked with GatewayC, but I would imagine a lot of my colleagues wouldn’t necessarily be aware of that. And I think what I was thinking when you were talking about it is I, I do wonder if there would be patients for whom they might not know themselves. They might have symptoms, do the screening and it comes back negative and they’d never tell a GP they’ve got symptoms because they, they themselves also think, oh, well that’s fine, we’ve ruled that out. So yeah, it’s, it’s worth something that I think patients should know as well, that even if they’ve got a negative FIT, if they have symptoms, they need to see their GP about that as well.

Dr Sarah Taylor

I think that’s quite, that is part of the bowel screening stuff is it that that information is shared with patients.

Dr Rebecca Leon

I think also, when we organise a FIT test, actually the lab sends it directly to the patient. That’s how it works in, in our area.

Dr Sarah Taylor

Not in ours.

Dr Rebecca Leon

So, so what that means is that we’re, we’re actually not giving the pot, they, we put the form [00:17:00] into the lab box that gets picked up every day. It goes lab and then they send it directly to the patient and then they send it back to the lab.

I think the worry that we have, because it’s actually our responsibility as clinicians, if we organise the test, if it’s not done. So there also might need to be, particularly if you are concerned about compliance, that maybe a bit of a diary entry or something to actually almost check-up this patient has actually done the test.

If you do, if they don’t do it and there’s something further down the line, you could potentially be blamed, couldn’t you?

Dr Sarah Taylor

Yeah. I think we know, I think practices have had over the last few years have got really good systems in place now to track two-week waits and make sure the patient go on two week waits.

And actually, you’re right, the FIT is now replacing that two week wait. So actually, you need to treat it in the same way and make sure the patient has A returned the test and B, somebody’s acted on the result. We use a [00:18:00] safety netting template and one of our admin staff then does a weekly search and will notify the doctor if the sample has not been returned.

One of the issues, and I don’t know whether this is a countrywide issue, but it’s something worth checking for everybody, is that if you request via an automated system, I know in Greater Manchester people use ICE and tQuest, the request isn’t coded, so you can’t search for the request, you can only search on the result.

There’s no, so if you want to actually search for it, you have to put a separate code in to say that you’ve requested the FIT test, which I think is a sort of logistical thing. I told you I spend too much time of my life thinking about FIT. But actually, it’s a really important thing that you can’t just go in and search how many FITs you’ve done.

You have to have that diary entry of FIT requested, and then you can search, and then you can act on the results.

Dr Rebecca Leon

That’s very interesting. I think that’s something I’m going to look at in implementing into [00:19:00] my own practice. Just want to go away from FIT. You okay Sarah?

Dr Sarah Taylor

Yeah. Okay. I can cope, yeah.

Dr Rebecca Leon

Okay. So, we’re now going to be, one of the things you mentioned was about iron deficiency anaemia, which is something when, when we’re actually investigating a patient for potential lower GI cancers, iron deficiency is something that we very much want to look at, or raised platelets is the other thing as well.

There’s a cool acronym, isn’t there? Can you tell us about that?

Dr Sarah Taylor

Oh, I can, yes. So the, so this is just for the platelets.

Dr Rebecca Leon

Oh, okay.

Dr Sarah Taylor

Yeah. So, it’s not for the iron deficiency.

Dr Rebecca Leon

Apologies. It’s, yeah. Okay.

Dr Sarah Taylor

So, the raised platelets, I think we, we discussed this on the lung cancer module, raised platelets are an indicator of cancer, new onset raised platelets obviously. If somebody’s had it for years, you would be far less concerned. And actually, the main cancers that you’re concerned about are lung and colorectal. The significance is more in men than in women. But LEGO-C is the acronym for what cancers you would be concerned about, and [00:20:00] it’s lung.

Dr Rebecca Leon

So L is lung.

Dr Sarah Taylor

E is endometrial, G and O, gastroesophageal, and C is colorectal.

Dr Rebecca Leon

Great. And that was the big thing that I learned when, when we were putting these podcasts together and doing our GatewayC modules, is that raised platelets, you should be, think properly, and as you say, a new onset high platelets, and if you want to repeat them, they were still high, I’d probably do a chest x-ray and a FIT test.

Dr Sarah Taylor

Yeah.

Dr Rebecca Leon

And that’s something that my colleagues in the practice are now doing. And regarding iron deficiency anaemia, ‘cause this is when it, it gets a little bit complicated in a way. Would you, would you start the patient on iron while they’re waiting for the investigations?

Dr Sarah Taylor

That’s a really good question. I think it depends on symptoms, doesn’t it? I think that if you’ve, on level of iron deficiency and on symptoms, I think the advice that we’ve had, I think we have spoken to one of the specialists about this and [00:21:00] the advice was that probably yes, because it can, they’re unlikely to have, well they’re going to have to have bowel prep anyway if they’re going to have a colonoscopy, aren’t they?

So, they’re not going to have a colonoscopy, if I say, refer a patient today, Tuesday, they’re not going to have a colonoscopy on Friday. So, there’s time for the hospital teams to stop their iron if they’re concerned about it for the colonoscopy. So, I think I’ve got a symptomatic patient probably yes. Do I routinely do it?

No, but I think it’s probably something that we should do, particularly with all the emphasis on prehab and getting patients as healthy as possible before they have cancer treatments, then probably yes.

Dr Rebecca Leon

Yeah. And also diet as well. Ellen, are you aware of any iron rich dietary modifications that people can have?

Dr Ellen Macpherson

Spinach is the one that comes to my mind.

Dr Rebecca Leon

Absolutely, spinach with everything. Kale is another good one. It’s all quite fancy.

Dr Sarah Taylor

Breakfast cereals are all reinforced with irons.

Dr Rebecca Leon

Yeah, fortified iron, like Special [00:22:00] K and stuff. Yeah. So, kind of a bit of both. Okay. So, with patients that have either got a positive, well, who have a positive FIT and then sent for a colonoscopy, bowel prep is always a bit of a headache for patients. And, I mean, what are the challenges around bowel prep and what, what do you tell your patients to do?

Dr Sarah Taylor

Oh, well, I actually, most of the bowel prep is organised from the hospital, so I do little of that. But actually, that’s quite a relief. I think that it is, I think it’s just a bit miserable.

Dr Rebecca Leon

What quantities? It’s a couple litres or something?

Dr Sarah Taylor

I don’t know how much you have but I, yeah, I’ve had a couple of friends who’ve had, who’ve used bowel prep recently and it does incapacitate you for a day or so beforehand and I think you do need to do it, but I think it is, suppose GPs will always have patients and people in primary care will always have patients coming in saying, I’m a bit worried about this, what should I do? I suppose the advice would always be just to do it as [00:23:00] well as you possibly can, because actually, a colonoscopy is a bit grim, isn’t it? And actually, having a failed colonoscopy is really not, is not what you want. So, I suppose it’s just complying with the regime, whichever, when they use, and I suspect different hospitals use different regimes of bowel prep, and probably accepting that the day before you’re not going very far from your toilet.

Dr Rebecca Leon

Absolutely. And it’s quite trendy these days for people to have colonic irrigations as well. So, they actually, people choose to have that as a bit of a, so it’s, it’s almost a way just to clear yourself up, but you’re absolutely right. A colonoscopy, patients often dread.

So, it would be a shame for them to psych themself up for that and actually have a failed one. Just going back to your, the patient we discussed earlier, which I know is, you didn’t see from, you were, you gave advice because you know the person. I mean, instance of bowel cancer in younger patients is on the rise and, it’s been highlighted because of Bowelbabe, [00:24:00] because of Deborah James and, and what she went through. And, I mean, regarding bowel cancer in younger patients, what, what kind of numbers are we talking?

Dr Sarah Taylor

I just, I don’t, I think that the, the incidence is going up, and in 20 to 29 year olds, there’s been nearly an 8% increase over the last few years, which is, is, is quite significant.

I think it probably, I mean, there’s a variety of things that you, that makes you think about then, I don’t know how much of that is dietary related? It might be, don’t know how much of it is genetic? And we’ve talked previously about the importance of asking about a family history and I think, you know, there are quite a lot of links between in familial family history, links with bowel cancer. So, I think probably for us to start asking more routinely in anybody with new onset bowel symptoms, whatever age, whether they do have any family history, that’s really probably quite important. And I think it is quite a difficult one, isn’t it?

Dr Rebecca Leon

It’s really difficult and I, and I [00:25:00] think it’s just opening your mind to potential diagnosis when, when you see a patient that something isn’t quite right. And, and I think we talked about this off mic earlier, with, with Ellen and Sarah about, that the screening age is actually coming down. Ellen, I mean, regarding the screening age, what is it currently?

Dr Ellen Macpherson

So currently 60 to 74 years. And that’s, every two years they’ll get a kit. But the program is expanding to include people 50 to 59 years old. But this is apparently happening gradually. The expansion is happening gradually over the four years and started in April 2021. So, I think it’ll be a bit of time before nationwide, all 50 year olds and up are included. But yeah, in some areas, yeah.

Dr Rebecca Leon

So, 50 and above. And that’s, that was very much what, Deborah James, never too young campaign.

Dr Sarah Taylor

Although, [00:26:00] you know, Deborah, um, the patient we’re talking about, under 50. Well under 50 and would not have been screened. But actually, they were all. Deborah was before FIT was being widely used. The patient that we spoke to at Bowel Cancer UK was similarly before FIT was widely used. Actually, if you’ve got somebody back to what, Richard Roope had said to us, if you’ve got a sort of three strikes and you’re in policy, so if the same patient comes back to you three times with symptoms that you can’t explain and you haven’t got a really good explanation for, and I think that, haemorrhoids, you know, that aren’t really obvious, or IBS and possibly not a good symptom for somebody coming back three times. You should think about doing a FIT test and you, because it is so much easier, isn’t like, you’ve got to think, am I going send a two week wait referral? Have I got to put that patient through that anxiety?

You know, what will they think? You know, I, I’ve gone past worrying about what people think about my referrals. I [00:27:00] sort of, if I think I need to refer somebody, I refer them. But, you know, all that sort of thing. It’s not such a big thing just to say, do this FIT test.

Dr Rebecca Leon

Absolutely. It’s, it’s, it’s a good and easy test. And that’s when investigations are, I suppose, are at their best because, they’re easy to, to be organised, they’re easy to be done by the patient and now that they just need one sample rather than three like the FOB. So compliance is better. And I understand, the reason why they want a FIT test alongside a potential two-week wait is because then they can triage, which ones need to be done sooner, is that correct as well?

Dr Sarah Taylor

Yeah. Yeah, yeah.

Dr Rebecca Leon

Yeah. So, the, the higher the, the FIT test results. Just wanted to just mention just one other thing was about family history and, and something that we are both, wanting to improve in our consultation skills. There is a genetic link with certain kind of genetic syndromes. Lynch is the one, that is the one that I think about.

Dr Sarah Taylor

Yeah. Familial Adenomatous Polyposis is the [00:28:00] one that we all remember.

Dr Rebecca Leon

Yeah, HNPCC, yeah.

Dr Sarah Taylor

Yeah. From medical school, remember.

Dr Rebecca Leon

Yeah.

Dr Sarah Taylor

But I don’t ever remember hearing about Lynch at medical school. I don’t know, that they probably didn’t, haven’t found it when I was at medical school.

Dr Rebecca Leon

No. So Lynch is, there’s a connection. And again, Ellen, there’s a connection I think with it’s endometrial cancer.

Dr Ellen Macpherson

Got it. Here. Yeah. It is Lynch syndrome increases the risk of developing colon cancer, endometrial cancer, ovarian cancer, as well as brain tumours. And is something to consider any, in anyone presenting under the age of 50, or with family history of multiple cancers at young age.

Dr Sarah Taylor

I think it just highlights, doesn’t it, the importance of asking, because I think that, if we’ve got patients who were diagnosed, who had family members who were diagnosed with bowel cancer 20, 30 years ago, the samples won’t have been tested for Lynch. They probably don’t know about it. They won’t know that there’s a possibility of Lynch or any other, any other syndromes or genetic [00:29:00] problems within the family.

So, the likelihood is that, if you don’t ask, they won’t volunteer it because they won’t have thought about it. So, whereas actually if you’ve got, if you speak to somebody and they’ve got bowel and they just say, well, yeah, my, you know, my uncle did die when he was 42, of bowel cancer. Then you start to think, oh yeah.

Dr Rebecca Leon

So it’s that extra question of asking. Okay. So, I think what we’ve learned from these particular cases is, FIT testing is a new investigation in primary care that we can use and it’s effective. And the difference between somebody presenting with symptoms versus screening and the ranges, that’s something we’ve got to take into account.

The other thing I also wanted to mention was the importance of family history and that the instance of bowel cancer, unfortunately, is rising in younger patients. Always safety net. If you’re concerned, get them back, re-examine and, refer if necessary.

Dr Sarah Taylor

I think the other thing is we just need to share all [00:30:00] of the ways in which FIT tests can be rejected, which there are…

Dr Rebecca Leon

Fun facts

Dr Sarah Taylor

There are plenty.

Some of them are our fault. So sometimes GPs are, but patients are given the wrong bottle, they are quite specific bottles. They’ll be different in different areas, but they are quite specific. They’re not the same as the ones that are sent for, culture, in patients with diarrhoea. So, you need to get the right one.

We need, I label all my patient samples for them because I’m a bit of a control freak, and they just feel better having actually labelled it myself. And then I know the sticker is put on in the right way. But there are, and I give quite specific information and details about how to collect the sample.

Dr Rebecca Leon

Tell me how you collect the sample.

Dr Sarah Taylor

Well, we’ve had a discussion as to whether or not meat containers or mushroom containers are best, but any sort of container like that, you put some toilet paper in poo into the, the receptacle and then use the stick within the sample to [00:31:00] collect it. Now there are lots of rejected samples. I think the result number of rejected samples is up to about 10%.

Dr Rebecca Leon

Wow.

Dr Sarah Taylor

Which is quite high. And reasons for this are partly because patients overfill the sample. One of the consultants recently was saying that patients use the wrong end of the sample, which it actually

Dr Rebecca Leon

Wrong end of the sample stick.

Dr Sarah Taylor

Stick. Yeah. There’s, it’s a little stick. it’s, it’s sort of very difficult to understand quite how that can happen, but it does. So, I think it’s really important, you know, there’s, there’s quite a lot of, certainly Bowel Cancer UK, Cancer Research UK have produced quite a lot of leaflets to help patients do that.

There are texts that you can send with leaflets attached to encourage patients to do it. The texts have been produced, you know, we, we are working with Greater Manchester. There’s, they’ve been produced in loads of different languages to try and encourage people from different, backgrounds to do the test and support them in doing it. There will still be people who won’t do it and who will get it wrong, and I think that, actually, if you get to that stage and you’ve [00:32:00] asked a patient, a symptomatic patient two or three times and you’ve given them the support to do it, I think it is acceptable to refer the patient without the test and just explain that you’ve tried.

And it might be that a call from the hospital will actually mean that the patient will try a little bit harder again, because it, it really needs to be done. But some of the, yeah, the, the wrong end of the sample is, stick, is just still something I can’t quite get my mind around.

Dr Rebecca Leon

I think one of the other, things we heard was somebody actually put it on the outside of the bag, and I know that a sample arrived in a, in a Tesco bag, not in a…

Dr Sarah Taylor

Sample bag.

Dr Rebecca Leon

Not in a sample bag, in a Tesco bag.

Dr Sarah Taylor

Oh, dear.

Dr Rebecca Leon

Not even in a pot. And it was landed on our reception desk. So, I mean, I suppose the fun facts today really was try and encourage your patients to, do the FIT sample properly. [00:33:00] And there are aids and videos and leaflets that can support that.

And the new thing I learned today is a mushroom box. I presume that’s the same as like a strawberry punnet.

Dr Sarah Taylor

Yeah. Any of those. You could, I think.

Dr Rebecca Leon

Okay. Yeah. Any of those. But on kind of on a serious note, we have to also think that certain patients may find it difficult to do the test for mobility issues, for understanding issues.

You know, it, it actually takes quite a lot to do the sample and then actually, do everything else that comes with it. So, as, as much support as possible.

So, we go onto our, final key clinical points. I’ve really actually enjoyed this podcast. I enjoy all the podcasts, but I, I think this has been, a podcast rich in information. So, iron deficiency, anaemia, something that we see regularly in primary care. Iron deficiency anaemia is a reason to refer and particularly to organise a FIT test. The other one, which is something from blood results [00:34:00] are raised platelets, and we’ve talked about the acronym, and this should increase the index of suspicion for colorectal cancer.

Dr Sarah Taylor

But I think it’s important to remember as well, isn’t it the flip side of that, that actually if the investigations are normal, it shouldn’t reassure you because actually normal platelets and normal haemoglobin are not, you know, they don’t, they don’t rule…

Dr Rebecca Leon

They don’t rule out

Dr Sarah Taylor

No, they don’t rule out at all normal LFTs. And you know, the FIT stuff is that we, the new guidance is now that all that FIT should be done for all colorectal referrals and patients only referred if they have a FIT greater than 10, anal or rectal ulceration or an anal mass, but obviously to know that you have to have examined your patient.

Dr Rebecca Leon

Absolutely. And an abdominal mass as well. Regarding rectal bleeding, which again, we see a lot of in general practice, it will come up and saying if they’ve got rectal bleeding, you can’t do a FIT test. You can do a FIT test. You can do it on the, the days when they aren’t bleeding, or you can do a mid-sample. [00:35:00] Which again needs to be explained to the patient.

Dr Sarah Taylor

And going back to the FIT test, I think the other thing to remember is that a negative FIT is quite reassuring for a colorectal cancer. But you know, we’ve discussed ovarian cancer previously. It doesn’t, that can also cause abdominal pain, altered bowel habit.

A negative FIT doesn’t exclude any of those cancers, and therefore you have to think about other things and you might want to refer your patient on a non-specific pathway if they’ve got a negative FIT, and ongoing symptoms.

Dr Rebecca Leon

So, any negative test, but you still are concerned. Keep digging. Keep looking for a possible reason for this.

It’s not just a reason to say you haven’t got bowel cancer. Thank you very much. Goodbye.

And finally, communication, essential. Don’t over reassure. Don’t under reassure. And take a family history because we’re seeing more and more that actually family history is key and ask the question and learn how to do a good pedigree diagram as well. [00:36:00]

So that is for today. Thank you to both Sarah and Ellen, and thank you for listening today to this podcast from GatewayC. Alongside this podcast, we have a free colorectal module, which is available on the GatewayC website, for healthcare professionals. All our references to the studies and guidelines we’ve discussed will be in our show notes and we really look forward to seeing you next time on our next podcast on non-specific symptoms.

And thank you to Ellen Macpherson for joining us today from Scotland. And our producers, Louise Harbord from GatewayC and Jo Newsome from ReThink Audio.

Before we go, I wanted to just clear up and discuss the positive predictive value, which is something that we touch on in a few of the episodes. The positive predictive value was used to determine the threshold to encourage clinicians to [00:37:00] refer on for a suspected cancer pathway or for urgent tests, and this was agreed at 3%. For more information, we have attached the link via the show notes, and this is through the NICE guidelines, and I would encourage all listeners to have a look at this and understand this in more detail.

And we’d love it if you share this podcast with your friends or colleagues. It really helps spread the word. Bye bye.

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Dr Sarah Taylor

A few years ago, I spoke to Deborah James, and what she says very significantly is if somebody had ever said to her, are you passing more or less than a teaspoonful? She would’ve said, it’s way more than a teaspoonful, and she would’ve done something about it.

Dr Rebecca Leon

Hi, this is GPs Talk Cancer, brought to you by GatewayC.

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

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

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

So, official bit done and dusted kettle is on, and joining us today is Ellen, who is a junior doctor working alongside us at GatewayC. She is joining us from rainy Scotland. Is that right? How are you doing today?

Dr Ellen Macpherson

I’m good, thank you. Yep. Definitely still raining here, but I’m good, thank you very much.

Dr Rebecca Leon

Good. Lovely to have you. And have you got yourself a drink?

Dr Ellen Macpherson

I do, yeah, I’m drinking Pepsi Max, which, I’m mildly embarrassed about as I feel it’s a bit of a childish drink.

Dr Rebecca Leon

That’s absolutely fine. And Sarah, how are things with you? How was, how was your morning so far?

Dr Sarah Taylor

It’s good. The traffic was bad, parking was easy, and I remembered my coffee this time, so it’s all good.

Dr Rebecca Leon

Excellent. And big question, have your cases arrived?

Dr Sarah Taylor

I think it’s now on its way from Heathrow to Manchester. Hasn’t [00:02:00] quite made it home, but you know, that’s progress.

Dr Rebecca Leon

Okay. For listeners out there, Sarah was on holiday last week and cases are still at that said destination.

Okay, so today, we’re talking about lower GI cancer or colorectal cancer and, some interesting statistics, regarding this particular cancer. It is the fourth most common cancer with over 45% of cancer diagnosis in patients over the age of 75. We’ll be talking a lot about bowel screening or FIT testing. And actually I reviewed the data from the CRUK website and the uptake of people invited and completing or doing the FIT testing is now up to 70% in England. And in Scotland and Wales it is, slightly below that at 67% and this is on the rise, so it’s all very exciting.

So, let’s talk about the couple of cases. Can you please talk about the first one, Sarah?

Dr Sarah Taylor

Yeah. I think this, this isn’t actually a patient, this [00:03:00] is somebody I know personally who I was talking to about, I think one of the things that we probably both get is, because they know, people know what our jobs is you tend to get a lot of people talking to you about cancer diagnoses and concerns and all of these sorts of things. And this was somebody I know who’s a man in his early forties who had, some fairly vague symptoms. I think it was rectal bleeding that he had initially, went to see the GP. GP was quite reassuring. I don’t honestly know whether or not he was examined, but he was told that he had haemorrhoids and he felt massively reassured, and as far as I know, there was no clear safety netting. There may have been some safety netting, but it wasn’t absolutely clear. And I think that I’ve spoken to a few men like this who are so reluctant to go and see the doctor in the first place, and this probably happens with women too, but they’re so keen to go, so reluctant to go in the first place, and so keen to be reassured, that if you don’t get the balance [00:04:00] of your safety netting right, all they hear is, I’m not worried about this.

They don’t hear anything else. As I say, I don’t know whether or not it was said, but then didn’t do anything for the next 10, 12 months. Went back when things had got quite a lot worse and was then put on a, you know, had investigations, had a FIT test, had blood tests, and was diagnosed with quite an advanced colorectal cancer.

And I think, you know, it just, there’s other people that we’ve spoken to, we spoke before about a woman who worked for Bowel Cancer UK who was told to go back if her symptoms got worse, and actually her symptoms didn’t get worse, but they didn’t get better. So, she similarly didn’t go back for another 10 or 12 months and, and has now subsequently died.

And actually a few years ago I spoke to Deborah James, who again was told that she probably had haemorrhoids and [00:05:00] wasn’t given any safety netting advice. And what she says very significantly is if somebody had ever said to her, are you passing more or less than a teaspoonful? She would’ve said it’s way more than a teaspoonful, and she would’ve done something about it.

So, I think there’s a bit of a pattern because it’s difficult, isn’t it, with these younger patients, because IBS is common, haemorrhoids are common, to safety net and to take the symptoms seriously without causing undue concern and without over investigating people. Because none of us want a colonoscopy at the end of the day.

Dr Rebecca Leon

No, absolutely. And it’s almost that one more question thing, isn’t it Sarah? Like that one more question of saying, is it worsening or if it worsens or persists, that word persists. And I very much use that because we talked about this before. And also, something that’s, I think I need to do more of asking the amount. And with patients who are presenting frequently, we do need to really think about is there [00:06:00] something else going on? So, this is almost going to be a common theme when we’re going to be talking all these different cancers. Not every patient that comes to see us is going to have cancer. Actually, we talked about that when we refer in, only 3%, if we do it right, will actually have a diagnosis of cancers. Actually, 97% of patients will have other diagnosis.

However, we do need to be thinking, is there something more serious going on? And safety net them. And actually, with some patients who you think may or may not make the appointment themselves actually say, right, I’m going to look at my diary, let’s see what’s going on at the end of May, please come see me and if you are completely better, please cancel your appointment.

And that’s what I do with, with patients of different ages if I’m a bit concerned. So, this is a really good learning point.

Dr Sarah Taylor

Yeah, and I think it is that, it’s that balance, isn’t it? Between, you know, I think we will both tell patients if they’re on a suspected cancer pathway, that they’re on a suspected cancer pathway and that’s what we’re trying to exclude. But it’s that balance between making people [00:07:00] aware of their symptoms and some level of concern and overly reassuring. And I think we do have this natural desire to make people feel better, that’s probably why we’re GPs, because we want people to feel better.

But actually, if you over reassure, some people will just hear the reassurance and you need to be quite clear.

Dr Rebecca Leon

Absolutely, and I, and I like to be quite open and honest with my patients and almost say, if I am concerned there’s something, I want to actually say, I do have concerns. I want to almost rule out this, because I don’t want them leaving the consultation room saying, I think Dr Leon’s actually not telling me something and actually cause anxiety in a different way. Because I’m, I’m almost saying, yeah, you’ll be fine. So, I try and be honest and say I’m talking to you how I’m, I’m being honest with you. And there is a chance this could be something more serious.

Can you, because, from a previous podcast I called you Mrs. NICE. And what I mean by that, I mean, [00:08:00] she’s a very nice person, but also from the NICE guideline point of view. And you know, you’ve done a lot of work with your cancer research hat on, looking at this kind of 3%. Are you able just to talk a little bit more about that?

Dr Sarah Taylor

Yeah, I mean I think that, you know, the, I think in some ways the NICE guidance for lower GI cancer is quite complicated. And I think the introduction of FIT has made things quite a lot easier. So, in the past I almost felt that you, on any given day, you could refer almost everybody or nobody with lower GI symptoms.

You know, there’s a, obviously the key things you’re looking out for are rectal bleeding, change in bowel habit, abdominal pain. You’re concerned if somebody’s got iron deficiency anaemia. There’s the link with high platelets, weight loss, all of these things can be signs of, of bowel cancer. The guidelines have actually, The British Society of Gastroenterologists did a whole review of colorectal referrals and the use of FIT [00:09:00] and the guidelines have now changed. And what we’re encouraged to do now is to refer patients to do a FIT in any of those patients with rectal bleeding, change in bowel habit, abdominal pain, and only refer if the FIT is positive or if they’ve got anal rectal mass, anal ulceration, or if they’ve got an abdominal mass, which is obviously a slightly different scenario.

So, in some ways, I think from a primary care point of view, things are quite a lot easier because now you’ve got a patient with symptoms. And you can do a FIT test. Now, obviously like every test, it’s not a hundred percent reliable, but it’s pretty reliable. And you can still go ahead and refer patients if they have a negative FIT, either on an urgent pathway or a routine pathway, and they will still get investigated.

And one of the things that I think was quite useful when we were talking, we did the last face-to-face event training. Roger Prudham, who’s the consultant who was there, who was [00:10:00] talking to us, was saying that the doubling time for colorectal cancer is quite a long time. So actually, you’ve got time, if the FIT is negative and you, the symptoms can, persist still to refer and for the patient to be investigated and not worry about it.

So, I think the, the old NICE guidance was incredibly complicated. You know, if they were over 60 and they had this and they were under 60 and they had that, you just, whereas now do the FIT, safety net the result, or if they’ve got the other symptoms, just refer straight away.

Dr Rebecca Leon

So, um, I want to talk to you about the FIT test.

Dr Sarah Taylor

Everybody does.

Dr Rebecca Leon

Yeah. This is, this is your, specialist interest.

Dr Sarah Taylor

Oh, it’s a mastermind today. I’ve got master, mastermind today.

Dr Rebecca Leon

Sarah, you’ll be Dr FIT. Just tell us a bit about FIT testing because it really has, as you say, made the whole two week colorectal investigations and, and who to send and what, and if you’ve got a 58 year old, can you, can’t you, it makes it a lot clearer. Just talk to us a little bit about [00:11:00] FIT testing and the difference between screening and again, and diagnostic, and then we’ll bring in the next case. Cause that’s part of, that’s something slightly different.

Dr Sarah Taylor

So, the FIT was brought in. So, the initial NICE guidance, used FOB tests, and the initial screening program used FOB.

Dr Rebecca Leon

What, what does FOB stand for?

Dr Sarah Taylor

Faecal Occult Blood. And FIT is Faecal Immunochemical Test. So, the old test was FOB. It looked for any type of haemoglobin and it wasn’t particularly accurate. And it was also less acceptable to patients because it required three tests. You had to do a test on three consecutive days.

Dr Rebecca Leon

So, compliance.

Dr Sarah Taylor

So, compliance was poor. About, probably about five or six years ago, FIT was introduced into the screening program. Resulted in an increased uptake because it’s now only one test and it’s more reliable, and then it’s been gradually introduced into diagnostic pathways over the last few years as well.

So [00:12:00] quite a lot of pilots initially just doing a FIT alongside the referral. And now the guidance is that the FIT is done before the referral. One of the key things to remember is that the FIT for symptomatic patients and screening patients is at a very different level. So, for symptomatic patients, you’re looking for a FIT greater than 10. For screening patients in England, at the moment. The levels are slightly different in Wales and Scotland. And England, you’re looking at a level of greater than 120. So, your screening patient might have a level of 115 and it will come back as negative for screening, but they would obviously be well into the positive symptomatic.

So, it’s something, it’s like all screening. It’s a screening procedure and it shouldn’t be used if you’ve got a symptomatic patient.

Dr Rebecca Leon

So that’s really interesting. So actually, if I bring in case two, because this is, one of mine, a 66 year old gentleman who’d actually came [00:13:00] in with new onset, rectal bleeding. But came in, don’t worry, doc. I’ve had a, a bowel screening, kind of 10 weeks ago and, and it all came back clear, so I’m not worried about that it’s anything serious, but I’ve, but I’ve got rectal bleeding. I’ve never suffered from haemorrhoids. So, and, and then actually because of the learning, the teaching that I’ve had, regarding the, the different FIT levels, from screening and diagnostic, I realised that actually he could still have something. And so, repeated the FIT test, from a non-screening point of view, and he came back positive and it went on to have a colonoscopy and, and has bowel cancer. So, this is a really interesting thing that actually just because somebody’s had bowel screening, don’t think, well, they can’t have, and then they present with symptoms. You need to potentially repeat the FITs.

Dr Sarah Taylor

Absolutely. Yeah. To a different level.

And I think the, you know, there’s been a lot of concern as to whether you can do a FIT in somebody [00:14:00] who’s got rectal bleeding.

Dr Rebecca Leon

Oh yes.

Dr Sarah Taylor

And all the research seems to suggest that you can because rectal bleeding is often intermittent, so suggest that they do it on a day when they’re not bleeding. Or you suggest they take it from a part of the stool sample where there is no blood. And that’s, and the other thing that I think is really important that we remember that, the FIT is part of the referral guidance, but actually anal rectal mass and anal ulceration and abdominal mass are also part of it. And also, a patient with iron deficiency anaemia, you might have increased concerns of.

So, I think, you know, I think it’s really important that we examine our patients because if you don’t examine the patient, you don’t know if they’ve got a rectal mass. And if you don’t do the blood tests, you don’t know if they’re iron deficient. So, I think the whole assessment of these patients with rectal bleeding, with new onset abdominal and changing bowel habit, and that can be either, not just looser bowel [00:15:00] habit but becoming more constipated. I think it’s really important that these patients are examined and we do some blood tests. And I think, you know, so you’d obviously do the full blood count and some iron studies to check whether they’ve got an iron deficiency anaemia.

The other thing, just to help the referral pathway, if you’re doing further, if you are going to be referring on, is to do renal function. They don’t necessarily need it for CT now, but they do need it if they’re going to go ahead and do a colonoscopy. So just on a practical basis, you might as well do it all at once.

Dr Rebecca Leon

And we all work in different areas, but my, my lower GI two week wait actually will say, have you examined the patient, yes or no? If not, why? Have you done a PR? Have you done, an abdominal examination, the findings of that? So just to bring Ellen in, were you aware that there were different, I suppose, ranges when it came to FIT testing with screening and diagnostic? [00:16:00]

Dr Ellen Macpherson

I was aware from having worked with GatewayC, but I would imagine a lot of my colleagues wouldn’t necessarily be aware of that. And I think what I was thinking when you were talking about it is I, I do wonder if there would be patients for whom they might not know themselves. They might have symptoms, do the screening and it comes back negative and they’d never tell a GP they’ve got symptoms because they, they themselves also think, oh, well that’s fine, we’ve ruled that out. So yeah, it’s, it’s worth something that I think patients should know as well, that even if they’ve got a negative FIT, if they have symptoms, they need to see their GP about that as well.

Dr Sarah Taylor

I think that’s quite, that is part of the bowel screening stuff is it that that information is shared with patients.

Dr Rebecca Leon

I think also, when we organise a FIT test, actually the lab sends it directly to the patient. That’s how it works in, in our area.

Dr Sarah Taylor

Not in ours.

Dr Rebecca Leon

So, so what that means is that we’re, we’re actually not giving the pot, they, we put the form [00:17:00] into the lab box that gets picked up every day. It goes lab and then they send it directly to the patient and then they send it back to the lab.

I think the worry that we have, because it’s actually our responsibility as clinicians, if we organise the test, if it’s not done. So there also might need to be, particularly if you are concerned about compliance, that maybe a bit of a diary entry or something to actually almost check-up this patient has actually done the test.

If you do, if they don’t do it and there’s something further down the line, you could potentially be blamed, couldn’t you?

Dr Sarah Taylor

Yeah. I think we know, I think practices have had over the last few years have got really good systems in place now to track two-week waits and make sure the patient go on two week waits.

And actually, you’re right, the FIT is now replacing that two week wait. So actually, you need to treat it in the same way and make sure the patient has A returned the test and B, somebody’s acted on the result. We use a [00:18:00] safety netting template and one of our admin staff then does a weekly search and will notify the doctor if the sample has not been returned.

One of the issues, and I don’t know whether this is a countrywide issue, but it’s something worth checking for everybody, is that if you request via an automated system, I know in Greater Manchester people use ICE and tQuest, the request isn’t coded, so you can’t search for the request, you can only search on the result.

There’s no, so if you want to actually search for it, you have to put a separate code in to say that you’ve requested the FIT test, which I think is a sort of logistical thing. I told you I spend too much time of my life thinking about FIT. But actually, it’s a really important thing that you can’t just go in and search how many FITs you’ve done.

You have to have that diary entry of FIT requested, and then you can search, and then you can act on the results.

Dr Rebecca Leon

That’s very interesting. I think that’s something I’m going to look at in implementing into [00:19:00] my own practice. Just want to go away from FIT. You okay Sarah?

Dr Sarah Taylor

Yeah. Okay. I can cope, yeah.

Dr Rebecca Leon

Okay. So, we’re now going to be, one of the things you mentioned was about iron deficiency anaemia, which is something when, when we’re actually investigating a patient for potential lower GI cancers, iron deficiency is something that we very much want to look at, or raised platelets is the other thing as well.

There’s a cool acronym, isn’t there? Can you tell us about that?

Dr Sarah Taylor

Oh, I can, yes. So the, so this is just for the platelets.

Dr Rebecca Leon

Oh, okay.

Dr Sarah Taylor

Yeah. So, it’s not for the iron deficiency.

Dr Rebecca Leon

Apologies. It’s, yeah. Okay.

Dr Sarah Taylor

So, the raised platelets, I think we, we discussed this on the lung cancer module, raised platelets are an indicator of cancer, new onset raised platelets obviously. If somebody’s had it for years, you would be far less concerned. And actually, the main cancers that you’re concerned about are lung and colorectal. The significance is more in men than in women. But LEGO-C is the acronym for what cancers you would be concerned about, and [00:20:00] it’s lung.

Dr Rebecca Leon

So L is lung.

Dr Sarah Taylor

E is endometrial, G and O, gastroesophageal, and C is colorectal.

Dr Rebecca Leon

Great. And that was the big thing that I learned when, when we were putting these podcasts together and doing our GatewayC modules, is that raised platelets, you should be, think properly, and as you say, a new onset high platelets, and if you want to repeat them, they were still high, I’d probably do a chest x-ray and a FIT test.

Dr Sarah Taylor

Yeah.

Dr Rebecca Leon

And that’s something that my colleagues in the practice are now doing. And regarding iron deficiency anaemia, ‘cause this is when it, it gets a little bit complicated in a way. Would you, would you start the patient on iron while they’re waiting for the investigations?

Dr Sarah Taylor

That’s a really good question. I think it depends on symptoms, doesn’t it? I think that if you’ve, on level of iron deficiency and on symptoms, I think the advice that we’ve had, I think we have spoken to one of the specialists about this and [00:21:00] the advice was that probably yes, because it can, they’re unlikely to have, well they’re going to have to have bowel prep anyway if they’re going to have a colonoscopy, aren’t they?

So, they’re not going to have a colonoscopy, if I say, refer a patient today, Tuesday, they’re not going to have a colonoscopy on Friday. So, there’s time for the hospital teams to stop their iron if they’re concerned about it for the colonoscopy. So, I think I’ve got a symptomatic patient probably yes. Do I routinely do it?

No, but I think it’s probably something that we should do, particularly with all the emphasis on prehab and getting patients as healthy as possible before they have cancer treatments, then probably yes.

Dr Rebecca Leon

Yeah. And also diet as well. Ellen, are you aware of any iron rich dietary modifications that people can have?

Dr Ellen Macpherson

Spinach is the one that comes to my mind.

Dr Rebecca Leon

Absolutely, spinach with everything. Kale is another good one. It’s all quite fancy.

Dr Sarah Taylor

Breakfast cereals are all reinforced with irons.

Dr Rebecca Leon

Yeah, fortified iron, like Special [00:22:00] K and stuff. Yeah. So, kind of a bit of both. Okay. So, with patients that have either got a positive, well, who have a positive FIT and then sent for a colonoscopy, bowel prep is always a bit of a headache for patients. And, I mean, what are the challenges around bowel prep and what, what do you tell your patients to do?

Dr Sarah Taylor

Oh, well, I actually, most of the bowel prep is organised from the hospital, so I do little of that. But actually, that’s quite a relief. I think that it is, I think it’s just a bit miserable.

Dr Rebecca Leon

What quantities? It’s a couple litres or something?

Dr Sarah Taylor

I don’t know how much you have but I, yeah, I’ve had a couple of friends who’ve had, who’ve used bowel prep recently and it does incapacitate you for a day or so beforehand and I think you do need to do it, but I think it is, suppose GPs will always have patients and people in primary care will always have patients coming in saying, I’m a bit worried about this, what should I do? I suppose the advice would always be just to do it as [00:23:00] well as you possibly can, because actually, a colonoscopy is a bit grim, isn’t it? And actually, having a failed colonoscopy is really not, is not what you want. So, I suppose it’s just complying with the regime, whichever, when they use, and I suspect different hospitals use different regimes of bowel prep, and probably accepting that the day before you’re not going very far from your toilet.

Dr Rebecca Leon

Absolutely. And it’s quite trendy these days for people to have colonic irrigations as well. So, they actually, people choose to have that as a bit of a, so it’s, it’s almost a way just to clear yourself up, but you’re absolutely right. A colonoscopy, patients often dread.

So, it would be a shame for them to psych themself up for that and actually have a failed one. Just going back to your, the patient we discussed earlier, which I know is, you didn’t see from, you were, you gave advice because you know the person. I mean, instance of bowel cancer in younger patients is on the rise and, it’s been highlighted because of Bowelbabe, [00:24:00] because of Deborah James and, and what she went through. And, I mean, regarding bowel cancer in younger patients, what, what kind of numbers are we talking?

Dr Sarah Taylor

I just, I don’t, I think that the, the incidence is going up, and in 20 to 29 year olds, there’s been nearly an 8% increase over the last few years, which is, is, is quite significant.

I think it probably, I mean, there’s a variety of things that you, that makes you think about then, I don’t know how much of that is dietary related? It might be, don’t know how much of it is genetic? And we’ve talked previously about the importance of asking about a family history and I think, you know, there are quite a lot of links between in familial family history, links with bowel cancer. So, I think probably for us to start asking more routinely in anybody with new onset bowel symptoms, whatever age, whether they do have any family history, that’s really probably quite important. And I think it is quite a difficult one, isn’t it?

Dr Rebecca Leon

It’s really difficult and I, and I [00:25:00] think it’s just opening your mind to potential diagnosis when, when you see a patient that something isn’t quite right. And, and I think we talked about this off mic earlier, with, with Ellen and Sarah about, that the screening age is actually coming down. Ellen, I mean, regarding the screening age, what is it currently?

Dr Ellen Macpherson

So currently 60 to 74 years. And that’s, every two years they’ll get a kit. But the program is expanding to include people 50 to 59 years old. But this is apparently happening gradually. The expansion is happening gradually over the four years and started in April 2021. So, I think it’ll be a bit of time before nationwide, all 50 year olds and up are included. But yeah, in some areas, yeah.

Dr Rebecca Leon

So, 50 and above. And that’s, that was very much what, Deborah James, never too young campaign.

Dr Sarah Taylor

Although, [00:26:00] you know, Deborah, um, the patient we’re talking about, under 50. Well under 50 and would not have been screened. But actually, they were all. Deborah was before FIT was being widely used. The patient that we spoke to at Bowel Cancer UK was similarly before FIT was widely used. Actually, if you’ve got somebody back to what, Richard Roope had said to us, if you’ve got a sort of three strikes and you’re in policy, so if the same patient comes back to you three times with symptoms that you can’t explain and you haven’t got a really good explanation for, and I think that, haemorrhoids, you know, that aren’t really obvious, or IBS and possibly not a good symptom for somebody coming back three times. You should think about doing a FIT test and you, because it is so much easier, isn’t like, you’ve got to think, am I going send a two week wait referral? Have I got to put that patient through that anxiety?

You know, what will they think? You know, I, I’ve gone past worrying about what people think about my referrals. I [00:27:00] sort of, if I think I need to refer somebody, I refer them. But, you know, all that sort of thing. It’s not such a big thing just to say, do this FIT test.

Dr Rebecca Leon

Absolutely. It’s, it’s, it’s a good and easy test. And that’s when investigations are, I suppose, are at their best because, they’re easy to, to be organised, they’re easy to be done by the patient and now that they just need one sample rather than three like the FOB. So compliance is better. And I understand, the reason why they want a FIT test alongside a potential two-week wait is because then they can triage, which ones need to be done sooner, is that correct as well?

Dr Sarah Taylor

Yeah. Yeah, yeah.

Dr Rebecca Leon

Yeah. So, the, the higher the, the FIT test results. Just wanted to just mention just one other thing was about family history and, and something that we are both, wanting to improve in our consultation skills. There is a genetic link with certain kind of genetic syndromes. Lynch is the one, that is the one that I think about.

Dr Sarah Taylor

Yeah. Familial Adenomatous Polyposis is the [00:28:00] one that we all remember.

Dr Rebecca Leon

Yeah, HNPCC, yeah.

Dr Sarah Taylor

Yeah. From medical school, remember.

Dr Rebecca Leon

Yeah.

Dr Sarah Taylor

But I don’t ever remember hearing about Lynch at medical school. I don’t know, that they probably didn’t, haven’t found it when I was at medical school.

Dr Rebecca Leon

No. So Lynch is, there’s a connection. And again, Ellen, there’s a connection I think with it’s endometrial cancer.

Dr Ellen Macpherson

Got it. Here. Yeah. It is Lynch syndrome increases the risk of developing colon cancer, endometrial cancer, ovarian cancer, as well as brain tumours. And is something to consider any, in anyone presenting under the age of 50, or with family history of multiple cancers at young age.

Dr Sarah Taylor

I think it just highlights, doesn’t it, the importance of asking, because I think that, if we’ve got patients who were diagnosed, who had family members who were diagnosed with bowel cancer 20, 30 years ago, the samples won’t have been tested for Lynch. They probably don’t know about it. They won’t know that there’s a possibility of Lynch or any other, any other syndromes or genetic [00:29:00] problems within the family.

So, the likelihood is that, if you don’t ask, they won’t volunteer it because they won’t have thought about it. So, whereas actually if you’ve got, if you speak to somebody and they’ve got bowel and they just say, well, yeah, my, you know, my uncle did die when he was 42, of bowel cancer. Then you start to think, oh yeah.

Dr Rebecca Leon

So it’s that extra question of asking. Okay. So, I think what we’ve learned from these particular cases is, FIT testing is a new investigation in primary care that we can use and it’s effective. And the difference between somebody presenting with symptoms versus screening and the ranges, that’s something we’ve got to take into account.

The other thing I also wanted to mention was the importance of family history and that the instance of bowel cancer, unfortunately, is rising in younger patients. Always safety net. If you’re concerned, get them back, re-examine and, refer if necessary.

Dr Sarah Taylor

I think the other thing is we just need to share all [00:30:00] of the ways in which FIT tests can be rejected, which there are…

Dr Rebecca Leon

Fun facts

Dr Sarah Taylor

There are plenty.

Some of them are our fault. So sometimes GPs are, but patients are given the wrong bottle, they are quite specific bottles. They’ll be different in different areas, but they are quite specific. They’re not the same as the ones that are sent for, culture, in patients with diarrhoea. So, you need to get the right one.

We need, I label all my patient samples for them because I’m a bit of a control freak, and they just feel better having actually labelled it myself. And then I know the sticker is put on in the right way. But there are, and I give quite specific information and details about how to collect the sample.

Dr Rebecca Leon

Tell me how you collect the sample.

Dr Sarah Taylor

Well, we’ve had a discussion as to whether or not meat containers or mushroom containers are best, but any sort of container like that, you put some toilet paper in poo into the, the receptacle and then use the stick within the sample to [00:31:00] collect it. Now there are lots of rejected samples. I think the result number of rejected samples is up to about 10%.

Dr Rebecca Leon

Wow.

Dr Sarah Taylor

Which is quite high. And reasons for this are partly because patients overfill the sample. One of the consultants recently was saying that patients use the wrong end of the sample, which it actually

Dr Rebecca Leon

Wrong end of the sample stick.

Dr Sarah Taylor

Stick. Yeah. There’s, it’s a little stick. it’s, it’s sort of very difficult to understand quite how that can happen, but it does. So, I think it’s really important, you know, there’s, there’s quite a lot of, certainly Bowel Cancer UK, Cancer Research UK have produced quite a lot of leaflets to help patients do that.

There are texts that you can send with leaflets attached to encourage patients to do it. The texts have been produced, you know, we, we are working with Greater Manchester. There’s, they’ve been produced in loads of different languages to try and encourage people from different, backgrounds to do the test and support them in doing it. There will still be people who won’t do it and who will get it wrong, and I think that, actually, if you get to that stage and you’ve [00:32:00] asked a patient, a symptomatic patient two or three times and you’ve given them the support to do it, I think it is acceptable to refer the patient without the test and just explain that you’ve tried.

And it might be that a call from the hospital will actually mean that the patient will try a little bit harder again, because it, it really needs to be done. But some of the, yeah, the, the wrong end of the sample is, stick, is just still something I can’t quite get my mind around.

Dr Rebecca Leon

I think one of the other, things we heard was somebody actually put it on the outside of the bag, and I know that a sample arrived in a, in a Tesco bag, not in a…

Dr Sarah Taylor

Sample bag.

Dr Rebecca Leon

Not in a sample bag, in a Tesco bag.

Dr Sarah Taylor

Oh, dear.

Dr Rebecca Leon

Not even in a pot. And it was landed on our reception desk. So, I mean, I suppose the fun facts today really was try and encourage your patients to, do the FIT sample properly. [00:33:00] And there are aids and videos and leaflets that can support that.

And the new thing I learned today is a mushroom box. I presume that’s the same as like a strawberry punnet.

Dr Sarah Taylor

Yeah. Any of those. You could, I think.

Dr Rebecca Leon

Okay. Yeah. Any of those. But on kind of on a serious note, we have to also think that certain patients may find it difficult to do the test for mobility issues, for understanding issues.

You know, it, it actually takes quite a lot to do the sample and then actually, do everything else that comes with it. So, as, as much support as possible.

So, we go onto our, final key clinical points. I’ve really actually enjoyed this podcast. I enjoy all the podcasts, but I, I think this has been, a podcast rich in information. So, iron deficiency, anaemia, something that we see regularly in primary care. Iron deficiency anaemia is a reason to refer and particularly to organise a FIT test. The other one, which is something from blood results [00:34:00] are raised platelets, and we’ve talked about the acronym, and this should increase the index of suspicion for colorectal cancer.

Dr Sarah Taylor

But I think it’s important to remember as well, isn’t it the flip side of that, that actually if the investigations are normal, it shouldn’t reassure you because actually normal platelets and normal haemoglobin are not, you know, they don’t, they don’t rule…

Dr Rebecca Leon

They don’t rule out

Dr Sarah Taylor

No, they don’t rule out at all normal LFTs. And you know, the FIT stuff is that we, the new guidance is now that all that FIT should be done for all colorectal referrals and patients only referred if they have a FIT greater than 10, anal or rectal ulceration or an anal mass, but obviously to know that you have to have examined your patient.

Dr Rebecca Leon

Absolutely. And an abdominal mass as well. Regarding rectal bleeding, which again, we see a lot of in general practice, it will come up and saying if they’ve got rectal bleeding, you can’t do a FIT test. You can do a FIT test. You can do it on the, the days when they aren’t bleeding, or you can do a mid-sample. [00:35:00] Which again needs to be explained to the patient.

Dr Sarah Taylor

And going back to the FIT test, I think the other thing to remember is that a negative FIT is quite reassuring for a colorectal cancer. But you know, we’ve discussed ovarian cancer previously. It doesn’t, that can also cause abdominal pain, altered bowel habit.

A negative FIT doesn’t exclude any of those cancers, and therefore you have to think about other things and you might want to refer your patient on a non-specific pathway if they’ve got a negative FIT, and ongoing symptoms.

Dr Rebecca Leon

So, any negative test, but you still are concerned. Keep digging. Keep looking for a possible reason for this.

It’s not just a reason to say you haven’t got bowel cancer. Thank you very much. Goodbye.

And finally, communication, essential. Don’t over reassure. Don’t under reassure. And take a family history because we’re seeing more and more that actually family history is key and ask the question and learn how to do a good pedigree diagram as well. [00:36:00]

So that is for today. Thank you to both Sarah and Ellen, and thank you for listening today to this podcast from GatewayC. Alongside this podcast, we have a free colorectal module, which is available on the GatewayC website, for healthcare professionals. All our references to the studies and guidelines we’ve discussed will be in our show notes and we really look forward to seeing you next time on our next podcast on non-specific symptoms.

And thank you to Ellen Macpherson for joining us today from Scotland. And our producers, Louise Harbord from GatewayC and Jo Newsome from ReThink Audio.

Before we go, I wanted to just clear up and discuss the positive predictive value, which is something that we touch on in a few of the episodes. The positive predictive value was used to determine the threshold to encourage clinicians to [00:37:00] refer on for a suspected cancer pathway or for urgent tests, and this was agreed at 3%. For more information, we have attached the link via the show notes, and this is through the NICE guidelines, and I would encourage all listeners to have a look at this and understand this in more detail.

And we’d love it if you share this podcast with your friends or colleagues. It really helps spread the word. Bye bye.

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