Dr Sarah Taylor

If you’ve got lungs, if you can get lung cancer. So therefore, think about lung cancer in smokers and in non-smokers.

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’re both really passionate about diagnosing cancer early, and we want to use this podcast as a way of sharing some of our clinical experiences with you so you can make a 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’re fully anonymised with no identifiable patient data. GatewayC is funded by the NHS and is [00:01:00] part of The Christie NHS Foundation Trust.

Today we are in the podcast studio at Media City, but this podcast is very much wanting to replicate a 10:30 coffee break that we have in primary care, which I certainly have, and Sarah, do you also have that time?

Dr Sarah Taylor

Yeah, we do. We, we, we all try to get together mid-morning just to have a quick catch up, share any difficult patients, just review what’s gone on through the morning. Don’t always make it obviously, but yeah, we do the same thing.

Dr Rebecca Leon

Fantastic. And we’ve also got Ellen joining us today who is a junior doctor working with the team with us at GatewayC. Often at this 10:30 coffee we have multiple members of the primary care team, whether it’s junior staff, medical students, or other allied health professionals.

So, they’ll be joining us, um, throughout the podcast. So, Ellen, welcome. [00:02:00]

Dr Ellen Macpherson

Hi. I’m excited.

Dr Rebecca Leon

Okay, so, so coffee is on. Throughout the podcasts, we’re going to be talking about different cancer types, and often first presentation into primary care. So today we’ll be talking about lung cancer. Before we talk about the patients and the cases, I wanted to throw in some statistics.

All our statistics are from the Cancer Research UK website, and regarding lung cancer, this is actually the third most common cancer. The instance is, over the last decade, has remained pretty stable, but interestingly, the rates in female patients are actually on the rise and in male patients, they are starting to decrease.

Why that’s happening, we’re not sure, but I think that’s an interesting fact when you’re thinking about the typical patient that you think may have lung cancer, the older man, the smoker, mainly from the more deprived areas. Actually, with [00:03:00] more female patients being diagnosed with lung cancer, it’s something to consider.

Sarah, what experience have you got regarding this and, and have you seen any patients recently who have presented with symptoms that have gone on to have lung cancer?

Dr Sarah Taylor

Yeah, I was just thinking as, as I was driving here when we, because I knew we were going to be talking about lung cancer, about a patient I saw recently who was a guy in his early sixties, retired businessman, ex-smoker given up about 10 years ago, came in to see me with a worsening cough, shortness of breath. He hadn’t actually had any haemoptysis, sent him for a chest x-ray and just got the results back yesterday, and he has got lung cancer.

Dr Rebecca Leon

Right. And so, he was an ex-smoker, you’re saying. Did he have any other features that were concerning you?

Dr Sarah Taylor

I think it was just, it was the persistence of his symptoms. He’d been in two or three times; he’d had a couple of courses of antibiotics, and he just wasn’t getting any [00:04:00] better. And you know, as one of the lung cancer specialists that we work with quite closely, Dr Matt Everson says, you know, if you’ve got somebody who’s got a cough more than three weeks unexplained, you should send them for a chest x-ray.

So basically, I did, I was a little bit surprised that he had a lung cancer, but not massively so, and then I started, as you do, flicking back through his notes. And actually, when he had his health review recently, he had some blood tests taken, and his platelets were actually a little bit up as well, which we hadn’t really clocked at the time, but they were raised.

And I think at that time actually, if we’d thought about them in conjunction, we should have thought a little bit harder and realised that he might, he was at quite a high risk of having a lung cancer.

Dr Rebecca Leon

Yeah, because high platelets are actually now something that we have to take note of. Particularly, it might be an incidental finding on a, on a chronic health review.

Ellen, are, are you aware of this? Is this something that’s, that kind of is being [00:05:00] talked about in, in hospitals?

Dr Ellen Macpherson

I certainly don’t remember being, kind of highlighted specifically that, high platelets were a cancer risk. I remember thinking about it in the context of say, sepsis or, some kind of inflammatory process or, when people are acutely unwell, but not in kind of someone who’s just grumbling along, who’s, otherwise, well, who’s maybe got risk factors for cancer, to start thinking cancer. I hadn’t heard about it in, actually until the, the research paper that you, you shared, but it’s, it’s definitely very interesting and yeah, maybe a lot of people are being missed, I think from that.

Dr Sarah Taylor

The stats are actually quite significant. There’s a one-year cancer incidence for men is 11% if they’ve got high platelets, and for women it’s 6.2%.

Dr Ellen Macpherson

That’s actually very high.

Dr Sarah Taylor

It is, and it, you know, we’re looking at the nice threshold of 3%, it is quite high. And the most significant cancers are lung and [00:06:00] colorectal. It’s actually got a quite a nice, um, pneumonic, which is LEGO-C. It’s lung, endometrial, gastro, oesophageal, and colorectal. So that, so, but actually, because of the incidence of lung and colorectal being the highest, they’re the ones that you’re most, it’s most important to exclude. So actually, a patient, and particularly a man who’s got high platelets and other risk factors, you probably should be thinking quite hard about looking at, for a lung and colorectal cancer.

Dr Ellen Macpherson

So, in this chap, if I know you go back and you say, oh, he did actually have high platelets a bit earlier, would you have at that point maybe just done a chest x-ray? Just as a kind of screen, or would you have taken him in, asked if he had any symptoms or asked about smoking history, or would it have just been a, we’ll just do a chest x-ray and maybe do a colonoscopy or whatever?

Dr Sarah Taylor

I think what you’d probably do, I mean, I think one of the things is that a new onset is more concerning, rising levels are more concerning, so you might just [00:07:00] track back and see what had happened over the course of the last year or so, if he’d had other tests. And then I think probably bring him in, check whether he is got any symptoms and at the very least then organise a chest x-ray and a FIT test.

Dr Ellen Macpherson

Right. FIT. Yeah.

Dr Sarah Taylor

Because then you’ve got a good idea and it then probably, if they’re both negative, I spoke to Willie Hamilton who did a lot of the original research about this a couple of years ago, and he was saying, actually you’ve got this risk of 11% for a man. If you actually have a negative chest x-ray and a negative FIT, you bring the risk right down, so you can reassure yourself fairly significantly that that’s okay.

Dr Rebecca Leon

Yeah, so just I think just, going on from that, it’d be quite helpful to almost bring the patient back, again track back to see if there has been a, a rise in the platelet level, but then take, history including, you know, a smoking history, but also including whether, is it cigarettes? Are they actually smoking cannabis? Are [00:08:00] they smoking vapes or e-cigarettes? Which lots of people are doing these days. And also, shisha also is important to ask and also taking a good occupational history as well. And the thing that’s often missed is passive smoking. So actually, yeah, they may, have never smoked themselves, but they were brought up for the first 18 years of their life with parents that smoked very heavily. So, these are all important things to do, and almost then a full clinical picture about further investigations. I mean, this sounds like quite, I don’t like to use the word barn door, but it was, it was somebody that you saw.

What do you think about, almost like the GP nose, the GP gut instinct? What are your thoughts about that, Sarah?

Dr Sarah Taylor

Well, I mean there, there’s good research for it, isn’t there? There’s good research to back it up, that actually, you know, GPs, that GP gut instinct and the GP feeling that there’s something the matter is actually better than a lot of symptoms. And actually, for somebody like me, it’s very reassuring because actually the older you are, the [00:09:00] more gut instinct you have. And that’s probably just down to experience and having seen things. And I think it’s what we found, you know, we’ve done a lot of modules now, haven’t we, Rebecca? Where we’ve spoken to lots of patients, we’ve spoken, we’ve got lots of patient stories. And I think it’s really, it’s being clear about what questions you’re asking and specifically what a patient is saying because patients are quite, particularly men, are really keen to brush off their symptoms and be reassured by what you’re saying.

So, if you have a cough, is it bad? Well, it’s not too bad. Well, you know, is it actually stopping you doing anything? Have you, have you not gone, you know, we speak to people who will actually, when you push them, will say, well actually I did used to go out quite a lot and I used to go, but I can’t walk to the end of the road anymore.

Or, one of the guys we were talking to, Fred, who’s a patient in our lung cancer module, had started sleeping downstairs because he couldn’t make it up the stairs, but he wasn’t up for volunteering it, because he was a little bit concerned about what was going on and, he didn’t, you know, he didn’t want to admit [00:10:00] to it.

Dr Rebecca Leon

Something changed. Something had changed with him. His baseline had changed, so he now couldn’t go up the stairs. And we see it with people who used to, you know, run marathons or 10Ks and then suddenly they’re not able to do that. For them that’s a change and that’s almost, we’ve got to find out. And I think this very interesting article from the BJGP talking about a GPs gut feeling in diagnosing cancer in primary care, actually said that the odds of a cancer diagnosis were four times higher when gut feelings were recorded.

And as you said, as you, get older, you see more patients, you’re more experienced, we need to be using that more. It just reminds me of a, of a patient I saw actually, probably a couple of weeks ago, very different. It was a female patient, a 47 year old who again, had changed. She was going to Zumba twice a week and also a regular cyclist. And her excise tolerance was just reducing. And she came in with this [00:11:00] persistent cough, a non-smoker. She was a teacher, as I say, 47, hardly, we had no medical notes other than the births of her children. She was not a frequent attender. But she’d been in all kind of through telephone consultations and been given, a couple of courses of antibiotics and steroids.

But her exercise tolerance was, was reducing. She was also, more tired and she’d lost a bit of weight not intentionally. And it was, my nose started twitching. You call it the GP gut instinct, or you call it the GP nose. And I was concerned and actually sent her for a chest x-ray, and it unfortunately came back showing that she had a lung cancer.

I mean, do we see this in in non-smokers?

Dr Sarah Taylor

I think that’s one of the most alarming stats I heard recently really, was that the incidents of lung cancer in non-smokers is really, really significant. And it’s, you know, it’s, the stats are that 14% of [00:12:00] patients with lung cancer in the UK have never smoked, which is a fairly significant percentage when you realise how common lung cancer is.

And, if lung cancer in never smokers was considered a separate cancer from smoking lung cancer, and I think the sort of histology of it suggests that it quite possibly is, it would be the eighth most common cause of cancer related death higher than ovarian cancer, leukaemia and lymphoma, which is really, really significant.

And I think we have this tendency to assume that non-smokers don’t get lung cancer and I think that that is just wrong, and we need to be thinking about it. We spoke, I’ve spoken to quite a lot of patients from some of the charities when we were doing, updating the lung cancer module on GatewayC and they were all had very, very similar stories to your patient.

They’d all just had symptoms that were lingering on, not getting better. A couple of them were really, really blaming [00:13:00] themselves for not knowing that something was wrong but not pushing, to get a diagnosis. And then obviously we have to throw in the fact that although the chest x-ray is helpful, you know, up to 25% of lung cancers won’t show up on a chest x-ray.

So, the chest x-ray is reassuring to an extent, but if the patient still has symptoms, we still have to think again.

Dr Rebecca Leon

So, 25% of chest x-rays will come back falsely negative. So, if you still twitching and you’re still worried and you’re still thinking that this patient may potentially have lung cancer, we need to do further investigations.

Dr Sarah Taylor

Yeah, we need to refer them on if, if you have access to CT, refer them for a CT. But, if you don’t, which is what we don’t locally, refer them on and the lung teams will organise a CT for the patients.

Dr Rebecca Leon

Okay. Okay. So, I think I also just wanted to make a point that non-attenders, we see [00:14:00] patients in general practice who, who come regularly.

But it’s the non-attenders and particularly if they’re coming multiple times with similar things. I heard a phrase, three strikes and you’re in. So, it’s almost the opposite of what we normally do. So actually, we just need to take case by case seriously. But I think this, I think this, this younger patient, this non-smoking patient has definitely made me sit up and think, actually we need to be considering all patients.

Dr Sarah Taylor

I think that phrase from, it was Richard Roope who was the GP Lead for the of a cancer for the RCGP for quite a long time. He said three strikes and you’re in, and it really is. If you’ve got somebody who comes back with the same symptoms three times and you haven’t got a really clear reason for it, you need to think about referring them on to get a, a proper explanation.

You know, my daughters always used to say, mum, you’re not a proper doctor. You always say, go to bed and you’ll be better in the morning. Which is sort of what I do say quite a lot of the time. But actually, you [00:15:00] can’t say that for three nights in a row if they, you know, you have to think about things.

So, I think that, that three strikes and you’re in is really useful, and the other thing, the other sort of phrase that, one of the lung consultants uses is if you’ve got lungs, you can have lung cancer. So, I sort of think if you think three strikes and you’re in, and if you’ve got lungs, you can get l lung cancer, then everybody knows the questions to ask these patients.

I think we just don’t always, ask them and make sure that we’ve got clear, honest answers from them.

Dr Rebecca Leon

Okay, so just changing topic. Do you both know what a cough actually is? I mean, we learned this at medical school, but do we know, physiological, what is a cough?

Dr Ellen Macpherson

I would have a, a kind of idea of what I think it is in my head, how accurate that is as a… In my head, it is a, a kind of reflex action, brainstem base, that’s going to be triggered to try and expel any, you know, potential pathogen irritant, and to, to keep those lungs clear.

Certainly, [00:16:00] I did a brief stint at a CF unit and learned the kind of real value of actually being able to clear your lungs and how you kind of do it without thinking. And then when you can’t do it, it’s really dangerous. And I think a cough would play into that in terms of just an immune mechanism for one thing.

Dr Rebecca Leon

Gold star to Ellen.

Yep. Absolutely. So, it’s a reflex involving a noisy expulsion of air from the lungs. So, it’s responding something irritating your airways. It sends a message to your brain, the irritant, and then the brain tells the muscles in your chest and abdomen to push air out of your lungs to force out the irritant.

So, the irritant can be mucus, it could be tumour based. So that’s exactly when an ongoing cough needs to be investigated further. Another question to the panel. Some old wives tales for cough suppressants.

Dr Ellen Macpherson

Well, in Scotland it’s whiskey is the answer to everything.

Dr Rebecca Leon

So, okay. A hot toddy.

Dr Ellen Macpherson

Yes. Yeah.

Dr Rebecca Leon

A dram at night.

Dr Ellen Macpherson

A dram at night.

Dr Rebecca Leon

Okay. Mm-hmm. [00:17:00] Well, I’m going to say chicken soup or we, as you say, kind of Jewish penicillin, we have on a Friday night. It’s actually warm, salty fluid, which helps hydrate the patient and remove any mucus. So, I think we’ve got the whiskey and we’ve got, and we’ve got the chicken soup. Okay, something different. Anything else, Sarah, you going to add to it?

Dr Sarah Taylor

I always suggest to my patients that polos are as good as any other sweets. Not, not polos in particular, but any like a hard sweet. Yeah. It’s just as good as any, you know, anything you might buy from more expensively. Okay.

Dr Ellen Macpherson

Honey and lemon, I think would be the one that come to my mind.

Dr Rebecca Leon

Absolutely. So actually, they’re saying that honey can be as effective at reducing the frequency and severity of a cough compared to an over the counter cough medicine. So actually, honey, lemon, maybe a bit of whiskey if you’re not driving or operating heavy machinery. But all of those things, honey and lemon is very good.

And the final thing is the good old-fashioned towel over your head, steam inhalation. That’s always very good at clearing [00:18:00] passages. Okay. Yeah. So, these are just, good ways of, old wives tails for cough remedies.

Dr Sarah Taylor

So, we talked about the first patient having high platelets. Sometimes you’ll find the patients are anaemic. Sometimes you’ll find that patients have got abnormal LFTs, raised inflammatory markers, something like that. But I think one of the things that we just need to stress again, is that actually if none of those things are present, that doesn’t mean that they haven’t got a lung cancer. And I think we. I think as clinicians, we do quite like to be reassured by things.

Dr Rebecca Leon

Okay.

Dr Sarah Taylor

And I think we need to be careful about being reassured by investigations that are negative, that maybe aren’t quite giving us the answer we want.

Dr Rebecca Leon

Yeah. So, you could maybe say that, you know, with that statistic, for 11% we’re going to see another 80 odd. No, 79% of patients having normal platelet count, but there can be other things that can, you know. Yeah, absolutely. Yeah.

Dr Ellen Macpherson

So [00:19:00] as a, as a junior, I find some of this a bit, um, frightening. It’s very like they could have no smoking history. They could be young, they could have normal blood tests, a normal chest x-ray, and a really good thing is to be an older GP and to have that kind of inner. So, I’m thinking, oh, how do you not end up just. How do you screen people effectively and, and make sure you’re not over investigating people or panicking too much and get some reassurance and, I guess my concern would be if you don’t have that experience, and you haven’t seen enough people that your inner kind of alarm bells are going off, are you more likely to make mistakes? Is it, I guess it can.

Dr Sarah Taylor

I think it’s back to that thing that you’re told right as you start at medical school, that actually the majority of the information is in the history. So, I think that if you take a really careful history from the patient, you will get a lot of information from them. [00:20:00] And it’s that, I think it’s, also, there is often one of the beauties of doing general practice is that you get the opportunity to follow people up.

So actually, you know, if you see somebody, you’re not quite sure about then make sure you safety net them properly when you see them and say “You’ve got a cough, I would expect your cough to be better in two weeks’ time. If your cough isn’t better in two weeks’ time, I want to see you.” And if you’ve got somebody who think is particularly vulnerable, maybe make the appointment for them to come and see you in two weeks’ time.

So, I think it’s being really careful because you’re not going to know her every time. You probably will always have people that you can chat about and that’s the beauty of the sort of 10:30 coffee isn’t it, that you can talk to people and say, what do you think about this? What would you do? I think that’s really valuable, but I think it’s really just being really clear, listening to what the patient says, and then setting clear expectations at the end of your appointment about what you think should happen and what they should do if it doesn’t. And I think that’s a really, really important thing [00:21:00] is that sort of safety netting and saying, if you’re not better, you know, to my daughters, if they’re not, if you’ve gone to bed and you’re not better in the morning, we’ll have another think. Yeah. It’s that sort of thing.

Dr Ellen Macpherson

And you’ve highlighted in the past kind of the difference and being really specific with the language. The difference between, if it doesn’t get any better, versus it come back if it gets worse.

Dr Sarah Taylor

Yes.

Dr Ellen Macpherson

And how patients can get confused around the language around that.

Dr Sarah Taylor

I think that’s really, really important, isn’t it? You know, I think if it doesn’t get better is very, you know, patients will put up with something that is exactly the same, if you’ve said it has to get worse for them to come back. And I think that’s really important. I think it’s really important that we make, that we give really, really clear instructions and possibly back it up with, written information, with texts. You know, the text is a, it’s wonderful, isn’t it, Rebecca? This ability to text patients. So, you could even text a patient a week down the line if you’re a bit concerned about them and say, are you better? Come and see me. You know, if you’re not, I wanted to see you again. Please come.

Dr Rebecca Leon

I wanted to also just talk about continuity in general [00:22:00] practice. Yeah. Because if you go back to both of the cases, you know, the second case that I discussed with our 47 year old who, unfortunately was diagnosed with lung cancer, I, didn’t know her. She was, she’d never presented before.

The beauty and the privilege of general practice I always think is actually getting to know your patients. Getting to know them when they’re well and when they’re unwell and almost seeing a difference when they walk in through the door. I personally go and get them from the waiting room and bring them upstairs to my room and I can, I start the consultation, see them as they climb the stairs, and if they’re able to bound up the stairs six months ago, but now at the top, they’re really struggling, I know that there’s something different. So, continuity of care is the privilege that we have in general practice compared to hospital practice because they come, they get patched up and they leave. So again, it’s just almost regular reviewing, doing, I [00:23:00] think that’s a really good idea what Sarah said. Either almost texting them, phoning them to see how they are, particularly if you’re concerned or actually booking a review appointment in, so you know that they’re going to attend.

So, these are all, all things that, that we can do. You, just wanted to mention about if the platelets were normal with this particular, with that 60 year old.

Dr Sarah Taylor

I think it was just that whole point about if blood tests are normal, don’t be reassured.

Dr Rebecca Leon

Okay. So, for a first podcast, I’ve thoroughly enjoyed our chat today and I’ve, I’ve certainly learned things and shared things, but if there are a few things from both of you that are takeaways, that even if you’ve heard nothing else from the last 20 minutes, what would you say, Sarah?

Dr Sarah Taylor

I would say if you’ve got lungs, you can get lung cancer, so therefore, think about lung cancer in smokers and in non-smokers.

Dr Rebecca Leon

Okay. Thank you. And Ellen? [00:24:00]

Dr Ellen Macpherson

Yeah, I think the, the raised platelets, being linked to cancer, and the LEGO-C acronym is definitely something that will stick in my mind.

And, yeah, the lung cancer in never smokers being the eighth most common cancer. Definitely a surprising statistic and I think maybe there’s been a lot of public health messaging around smoking that’s maybe overshadowed that a bit. So that will kind of correct that and yeah, remember that.

Dr Rebecca Leon

Great. Okay.

Dr Sarah Taylor

And you, Rebecca?

Dr Rebecca Leon

So, I’ll finish off with a negative chest X-ray. 25% were missing. So, if you are still concerned that a patient may have cancer, we do further investigations. And, putting together this podcast. I also just want to say, go deep on your smoking history, taking, ask about other things, and passive smoking is also something you’ve got to ask about.

Dr Sarah Taylor

And not just your smoking history taking, as we said to Ellen, all of your history taking all of your history, to get your context for patients who…

Dr Rebecca Leon

Absolutely, absolutely. [00:25:00] It’s been a pleasure and I look forward to the next one, which will be out soon. And thank you very much to both of you.

Dr Ellen Macpherson

Yeah. Thank you very much.

Dr Rebecca Taylor

Well, thank you for listening today, and I also want to thank our producers, Louise Harbord from GatewayC and Jo Newsholme from ReThink Audio. We have a free lung module, which is on the website, and all references to the studies and guidelines we’ve discussed will be in our show notes.

Before we go, I wanted you to just clear up and discuss the positive predictive value, which is something that we touch on in a few of the episodes. The positive predictive value was used to determine the threshold, to encourage clinicians to refer on for a suspected cancer pathway, or for urgent tests, and this was agreed at 3%.

For more information, we [00:26:00] 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. Please do press the follow button so you can get the podcast, direct your feed. And we’d love it if you share this podcast with your friends or colleagues. It really helps spread the word. Thanks, and see you all again soon.