Dr Sarah Taylor

You are not referring thinking that this patient has an 80% chance of having a cancer. We’re referring thinking that this patient has maybe a 5%, or even slightly less chance of having a cancer.

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 identifiable patient data. GatewayC is funded by [00:01:00] the NHS and is part of The Christie NHS Foundation Trust.

So, official bit done and dusted, kettles on, it’s now time to sit back and join us for today’s podcast. With us today we have Ellen back, who’s a junior doctor working alongside us at GatewayC. She is working remotely in Scotland. And you’re doing okay?

Dr Ellen Macpherson

I’m doing very well. Yeah. The rain has stopped and yes, sun has come out.

Dr Rebecca Leon

Excellent. Okay. And Sarah, how are things with you?

Dr Sarah Taylor

Well, I’m still tracking my bag, but, I’m hoping that it’ll be at home soon.

Dr Rebecca Leon

Great. Okay. So, lots of washing to do later. So, kettle’s on, I’ve just made a pot of tea. Hope that’s okay for everybody.

Dr Sarah Taylor

Yep.

Dr Rebecca Leon

And we are going to start our next podcast, which is quite an exciting one because it’s a fairly new discussed topic on vague symptoms.

Dr Sarah Taylor

Mm. Or more [00:02:00] specifically non-specific symptoms because, there was a lot of debate when this all started as to what the, this pathway should be called, and the suggestion was that patients didn’t like vague because it sounded like we didn’t know what we were talking about. Which there may be a little bit of that, but actually it is because it’s non-site specific.

Dr Rebecca Leon

I think you’re right about the vague thing. I think vague also makes us that we are not really taking them seriously as well.

Dr Sarah Taylor

Yeah.

Dr Rebecca Leon

So non-specific. So, as you know if you’ve listened to some of the other podcasts, I do like to throw in a few statistics, I’m a little bit nerdy like that. There’s not a huge amount to say about this particular group, but one of the routes we use in primary care to refer the patients in quicker and for a more efficient diagnosis is through the RDC route which is a rapid diagnostic centre. And the hope is, by 2024, the whole of the UK will have coverage and there will be RDC’s for primary care to tap into and refer patients into.

So, the couple of cases we’re going to be talking this morning, Sarah, I want you to lead on these cases, because these are actually two cases that you have seen.

Dr Sarah Taylor

Yeah.

Dr Rebecca Leon

Recently.

Dr Sarah Taylor

Yeah.

Dr Rebecca Leon

So just tell us the first one. It was about a 68 year old, you said?

Dr Sarah Taylor

Yeah, so it was a lady who came in to see me who had had a knee replacement and she came in to get some painkillers. This was quite some time ago now as well, before Covid. And we’ve used her, to design our clinics and Greater Manchester because we’ve sort of think we’ve used her as our flagship patient.

So, she came in, she had wanted some painkillers. She, as she left, she said, I’ve just lost a little bit [00:03:00] of weight, but I think it’s because I’m not moving very much because I’ve had the knee replacement and I thought, well, that’s a little bit odd, isn’t it? Because if she’s not moving very much, I would’ve expected her to put on some weight.

And she, and we, did a systems inquiry, checked whether she had any other symptoms. She didn’t have any other symptoms at all, apart from the weight loss. She was a smoker. She’s a 68 year old lady. Actually, on the day she was with me, I had a medical student sitting in with me and we would, we talked about, I said, you know. She’d lost quite a significant amount of weight. She’d gone from, remember now she’d gone from 52 to 47 kilos. So, she was a little lady to start off with, and she’d lost quite a significant amount of weight. And we talked and I said, you know, she could have, I think she could have a lung, she could have a upper or lower GI cancer, she could have ovarian cancer, she could have a haematological cancer, she could have a pancreatic cancer. And I always, every time I [00:04:00] list this, even though I know what she had, I would say renal as the last one because she had, and she, and actually she turned out to have a renal cancer. But I refer her on a lower GI pathway because at the time that was all that was on offer.

But actually, if I’d put her details into the QCancer, her highest chance of having a cancer was of a lung cancer because she was a smoker. So, actually what the non-site specific pathways are doing now is giving us a one stop place to refer this patient. So, what we did was we, we spoke, I spoke to her, I took the history, arranged some blood tests. Everything I think came back normal. And then she was sent on with the results of the blood tests. Now the blood test would definitely include a FIT, not the blood test. It’s not blood test is it? But the, the test would include a FIT. In some areas, it might include a chest x-ray. In other areas, it won’t. And then the patients are filtered into a clinic where there is no assumption that [00:05:00] they are likely to have any specific cancer.

And it’s just a sort of, let’s think about this really broadly and work out what’s going on. So, my patient didn’t go to a non-specific clinic, but actually it would’ve been the best place for her to go, because we’ve got some data, haven’t we? That you know, patients tend to have long, if they don’t go in on the right pathway, first off, they have a longer journey.

Dr Rebecca Leon

Yeah. And this and this patient, I could probably name five at the top of my head where it’s just they come in an older patient with aches and pains. But actually, it’s that again, what we’ve talked to another podcast, that extra question almost asking, have you, you know, any weight changes, appetite, those kind of things. Bowels okay, urinary symptoms? It’s almost those vague questions that you ask, and it could start to think, actually, why are they asking for painkillers and why are they losing weight? So, if this patient, Jackie had come along when you had these non-specific, sorry, [00:06:00] non-specific symptom clinics.

Dr Sarah Taylor

I would’ve referred her that you referred to that I would’ve definitely, yeah.

I’d have done the bloods. I’d have referred her there.

Dr Rebecca Leon

Yeah. Okay. And she ended up with renal cancer?

Dr Sarah Taylor

She did, yeah. And I think, you know, we, we, there’s a lot of discussion about what symptoms warrant referral. And again, that does vary slightly by clinics across the country, but actually, my general feeling is that any patient where you can’t have a reasonably good first stab at what cancer you’re concerned about, you should think about referring here.

So, I think the patients with normal investigations and abdominal pain, weight loss is the classic one. You know, weight loss is you’ve got weight loss, it could be almost anything. So, I think that that’s my sort of, that’s my definition.

Dr Rebecca Leon

Yeah. And a real bug bear of mine is, is if we send a patient, you sent this lady down the two-week colorectal route, we get a colonoscopy report, say that they’ve not found a cancer, there’s never in secondary care almost, but what is it?

There is something [00:07:00] going on, let, let’s refer to another area. It’s very much back to your GP and then out again.

Dr Sarah Taylor

Yeah. And I think that’s what these clinics have been designed to avoid is to give that. No, you can never say a complete yes no to cancer, but really to give a yes no to cancer and then refer on if the patient does have a site-specific cancer to the right pathway because these patients, you know, it is just more difficult, isn’t it? If you’ve not got a clear idea to start off with, it is quite difficult to do.

Dr Rebecca Leon

Absolutely. Okay, so that was Jackie. The other patient I wanted to talk about and then we can go into more detail with some points of discussion after that was…

Dr Sarah Taylor

He was actually, again, a bit like we talked about a couple of weeks ago or we talked about previously, was he was a patient who he was actually the grandfather of one of my daughter’s friends, and he had back pain. He was in his mid-late fifties and he had back pain and he was a lorry driver and he went to his GP and the GP said, oh, it was because you’re a lorry driver. And, [00:08:00] but actually a bit like we’ve talked about quite a lot, he then, having never, ever been to see the GP really over the course of a few weeks, went to two or three different A&E departments, called the out of hours out two or three different times because he had really severe back pain. And in the end, I think they ended up seeing, somebody privately who did an MR scan who found that he’d got bone mets. And I think, I don’t think, I think he, he died so quickly that he actually his cancer wasn’t diagnosed. But I think it’s, again, it was a non-specific symptom, but it was rapidly worsening, and he was seeing people very, you know, frequently. And I think it’s one of the things that’s quite difficult for us now is that you don’t necessarily have, if he’d been to see a physio as well, which he might have done, I can’t remember. But if he’d been to see GP out of hours, two or three different A&E departments and a physio, do we necessarily, in our practice know, that [00:09:00] he’s been, that his three strikes and you are in includes lots of different settings. So, I think, although, no, I suspect that even if he’d been diagnosed six, eight weeks earlier, it wouldn’t have made a massive difference to his outcome, although his palliative care might have been better.

I think that there’s a learning from it that actually you just need to know the, absolutely the full story. And if you don’t know the full story, you’re a bit stuck.

Dr Rebecca Leon

So, in our practice, I, I lead on all kind of cancer related diagnoses and, and any late presentations, I look back at them retrospectively and this would be one that we’d look at and say, what could we have done differently?

And, and there’s actually one that’s coming to mind of a patient who was presenting, with kind of vague chest pain and ended up being a, we thought it was costochondritis and somebody else went down a oesophageal spasm route and ended up having a, a lung cancer. So, it’s, it’s fine in hindsight.

And with it, with this particular patient with [00:10:00] back pain, how many back pains do we see? Mechanical back pain. You’ve got a man in his mid-fifties who’s a lorry driver. You think about all those hours he’s driving, and it’s, it’s really, really difficult, and I think with back pain, again, it would be the red flag symptoms that would be seen straight away.

But it’s when all these different areas need to come together. Like the prescribing team needs to say, well actually, he’s asking for a lot of painkillers, but then is he going to the pharmacist to get the over the counter stuff? We’re not going to know that, we’re not going to get the out of hours notes necessarily.

And the A&E notes and all of, and the physio notes. So again, it’s just taking a very good history, doing a good examination and safety netting.

Dr Sarah Taylor

Yeah, I think, and it’s what Ellen asked right in our first podcast is, you know, what do you do if you, if the investigations aren’t reliable? Because actually, it’s perfectly possible that you could have done a full range of blood tests on a, an x-ray and not shown anything in this patient. [00:11:00] You’re not as old as I am, and I know you’re younger than I am, to have that, that sort of the same amount of gut instinct because you haven’t seen as many patients. What do you do? I think you have to ask really, really thorough histories and the bits and pieces that people, so, you know, we always ask, does anything make it worse? Does anything make it better? But that whole, how many painkillers are you taking? Where are you getting them from? Who else have you been to see? All of those things, you know, is it getting better? Is it getting worse? All of these things are really important, aren’t they? And they give you a fuller picture.

And I think that’s the whole of the vague symptoms, non-site specific symptoms things, because they are going to be much more difficult to pin down.

Dr Rebecca Leon

So, when we go back to these, this new pathway for non-specific symptoms. I sent you a text didn’t I, a week or so ago, Sarah, and said, in my area in East Cheshire, what do I do?

And you said, unfortunately they’re not available there at the moment. So, for, for people listening for this and, and for people who are, [00:12:00] are not maybe in the areas that, that are able to refer into, what, what would I have done with our lorry driver?

Dr Sarah Taylor

Wow. Your lorry driver. I, I think, having spent a long time doing this cancer referral stuff and doing pathways, I think I would now probably refer to the lung teams with that sort of patient because lung, you know, I’m assuming he had normal PSA, which is another cause of bone mets. I think just, but, but that might just be because my experience is that I have a really helpful local lung team and that they would be the best people to refer to. So, but I think just to reassure everybody that the non-specific pathways are a NHS England initiative and they, I think it’s by March next year, March 24, there should be national coverage.

So, everybody should have access to one by March of next year. And I think that, it’s something that I would be asking if you haven’t got it, I think I’d be asking, when it’s coming.

Dr Rebecca Leon

But you’re absolutely right though, from an educational point of view, [00:13:00] by knowing which particular cancer types spread to bones, which could therefore cause, and you’re thinking of lung and prostate, which are the obvious ones. Prostate, you know, if it was a, a woman, you think breast and if it was, you know, prostate. So actually, by doing a PSA, doing a full history on urinary symptoms, et cetera. Checking for the prostate and, and making sure that you actually write all of this down in your notes as well.

And so yeah, sending for a chest x-ray would probably be appropriate.

Dr Sarah Taylor

Yeah, I think so. And I think that those whole list of first tests are useful. They’re important, aren’t they? You need to know whether the patient’s got a raised CA125. You need to know whether the patient’s got an iron deficiency anaemia, raised platelets that we’ve talked about before.

You probably need to dipstick the urine, you need to do a PSA in a man. You definitely need to do a FIT. You need to be checking all of these things, so you’ve got a full picture, because that then [00:14:00] makes it easier once the patient’s referred on to the non-site specific clinic for them to make the assessment as to what’s going on.

And again, like we’ve talked about before, you don’t, you’re not referring thinking that this patient has an 80% chance of having a cancer. We’re referring thinking that this patient has maybe a 5% or even slightly less chance of having a cancer. So, you’re just referring to get an exclusion.

Dr Rebecca Leon

Yes, exclusion, absolutely.

Dr Sarah Taylor

But often and, and not always, but you know, do you need to be able to exclude a cancer. Most patients then when they get to the clinic will have a CT Thorax, abdo pelvis, and that will give you a much clearer idea as to what’s going on.

Dr Rebecca Leon

Okay. So just talking about as part of the referral criteria, can you just talk about just some of the symptoms which would make us think about referring to this particular clinic?

Dr Sarah Taylor

Well, I think the classic one, when we’ve looked at it, the, the classic referral symptom is weight loss.

Dr Rebecca Leon

Unintentional.

Dr Sarah Taylor

Unintentional weight loss. I think it’s nominal, I think it’s about [00:15:00] 5% over the preceding, what is it, four month? I think it’s, and I think most of these symptoms you’d expect somebody to have had them for about four weeks.

So, weight loss is the classic one. Abdominal pain, iron deficiency anaemia is included in some pathways, but not all of them. Persistent pain, a lot of them will have a box for, GP gut instinct or persistent patient or family concern. And, and actually when you look at it, the GP gut instinct box is one of the ones that’s used quite frequently and is quite reliable.

The most common cancers found are lung, pancreatic, and lymphoma. And, the pickup rate is still in line with all of the other non, of the other site specific clinics. So, we’re obviously referring the right patients, and there’s a need for this, so we are actually getting it right. And refer it is not, it’s not the, the pickup rate in these clinics is 1% [00:16:00] because it’s quite difficult to do, actually I think GPs are quite good at assimilating and other primary care professionals assimilating all the information and working out which patients they’re concerned about.

Dr Rebecca Leon

Yeah. And I think the test that we do in primary care and we’ve got a lot more now at our fingertips. What tests would you have organised before or almost alongside sending in for the NSS, the non-specific symptom clinic? What would you do?

Dr Sarah Taylor

I suppose, yeah, I think if you’ve got, I mean, you’ll do your, as you do, full blood count, for anaemia, raised platelets, do your liver and renal function. I think it’s worth, most of the time if you’ve got somebody to do with weight loss, you need to think about the other obvious things.

I don’t want to be sending a 35 year old who’s got a new onset of hypothyroidism or celiac. So, you do a thyroid functions TTG as well. I think it’s worth dip sticking the urine, and I think it’s worth doing a FIT. I think there’s a little bit of debate as to [00:17:00] whether or not you do a chest x-ray, because most of these patients, obviously the chest x-ray isn’t a hundred percent reliable, and most of these patients will have a CT thorax when they get there. So I think it, it, but I think that that opinion on that varies and I think it, yeah, I think it just depends on circumstance. You’ve got very heavy smoker than you might do if it’s…

Dr Rebecca Leon

Yeah. Yeah.

Dr Sarah Taylor

I think it just depends.

Dr Rebecca Leon

And then probably a, maybe a PSA and a CA125 appropriate.

Dr Sarah Taylor

Yeah, totally.

Dr Rebecca Leon

Yeah. Okay. And again, we’ve discussed this another podcast, kind of, are you quite open with your patients as far as that you’re not sure what’s happening and you want to rule out something.

Dr Sarah Taylor

Totally. Yeah. I, I tend to say, my, I think you were talking last time about what you say. I tend to say, it depends on my level of concern, if I’m really concerned, I will tell them. So occasionally I’ve seen women with breast lumps and I’ve been really concerned and I’ve told them that I’m really quite concerned about it.

Often I’ll say, I, I’m not a hundred percent sure what’s causing this and I need to be quite sure, and I think you probably want me [00:18:00] to be quite sure. So, we’re going to look into things and sometimes I talk, depending on the patient, I’ll talk about, you know, the fact that we refer with 3, 5% risk and say, you know, that means that the majority of the patients that I refer won’t have a cancer.

Dr Rebecca Leon

Yeah.

Dr Sarah Taylor

But, we need to be sure.

Dr Rebecca Leon

But with some patients who you worry may not turn up, sometimes you need to almost say, I think this could be very serious.

Dr Sarah Taylor

Yeah.

Dr Rebecca Leon

So, you almost have to, again, it, it, it’s very much, it’s dependent on the patient, isn’t it?

Dr Sarah Taylor

It is. Yeah. Yeah, yeah. If you’ve got somebody you think won’t turn up, then yeah, you sometimes need to be a bit more direct.

Dr Rebecca Leon

Ellen, when it comes to kind of safety netting patients, from your hospital jobs and from the work that you’ve done with us, et cetera, do you think it’s, it’s important to be honest with the patient?

Dr Ellen Macpherson

Oh yeah, a hundred percent. I am, at least, if I were the patient, or it was my family member, that’s what I would want.

I would want to know [00:19:00] that, exactly what the thinking process was behind any decisions that were being made. And I think it’s always worse to go into a situation and to be surprised by bad news, than it would be to be kind of, a little bit prepared that that’s a possibility. And then I think as well, patients don’t take in as much as we think they take in.

And so even if you kind of think that the patient has an idea, they might have less of an idea than you think they do because they’ve not actually processed what’s been said to them before, or they’ve just kind of been in a bit of denial and just not really taking stuff in or been in a lot of stress.

And so, yeah, I think it’s best, you know, to, to reiterate as well, there is some concern if you are really concerned and then you know that you’re on the same page as a patient the whole way through their journey and they’re not suddenly hit with really bad news and kind of saying, why haven’t you? Why didn’t you warn me that this was a possibility?

And yeah.

Dr Rebecca Leon

Absolutely.

Dr Sarah Taylor

I think that’s really important with these clinics as well actually, [00:20:00] because a lot of them are run as one stop clinics. So, the patient will go and have the CT scan and the result in the same day. And so, if you haven’t got any of that, firstly they need to be warned that they could be at the hospital for quite a long time. And that they may have investigations on the same day, and they may have results on the same day. So, I think that if you haven’t given any sort of warning shot that you have a concern, that can be really difficult, can’t it? And you maybe don’t take somebody with you.

Dr Rebecca Leon

Absolutely. It’s taking or getting the lift there and not driving, and et cetera. And having somebody to support you. And again, we talk about the GP gut instinct, which is something, or the GPs nose that starts twitching. The more experienced, the more patients you see, the more understanding and, and looking back retrospectively at cases and things, I think your GP gut instinct increases.

Dr Sarah Taylor

Yeah.

Dr Rebecca Leon

Was there anything, anything else that you wanted to cover?

Dr Sarah Taylor

I mean, I think this is all, this is the place where it, a lot of the stuff that we’ve, we talk [00:21:00] about all the time is so important, isn’t it? It’s the, it’s the clear questioning. It’s the safety netting because, you know, the weight loss. If the weight loss has been gone for two weeks, well are we that concerned?

But if it’s gone on, it goes on for another two or four weeks, then we might be. So, I think it’s, it’s that clear questioning and it’s that clear safety netting that I think is so important in this because it’s, it is by definition, more difficult than some of the site-specific stuff.

Dr Rebecca Leon

Okay, so finally we’d like to, before I go onto the, the key clinical points, I just want to talk about something that we were chatting over coffee earlier.

I’m a new dog owner of five and a half years and she’s pretty special. And, so I’m on this, you know, this thing now that dogs are great, but we know that dogs have been helping, with like barrels of rum around their necks and, all sorts of things. Yeah, and, [00:22:00] and you know, guide dogs and all these other things.

But now there’s talk about that actually dogs can potentially sniff out a cancer. And, there was an article talking about whether in GP surgeries, dogs should be there almost…

Dr Sarah Taylor

Wandering around?

Dr Rebecca Leon

Wandering around and picking out those patients that need to be seen sooner rather than others. And I don’t run that late.

And, again, it’s, there needs to be a lot of research with this and, and I know there has been better figures with, amongst breast cancer patients but…

Dr Sarah Taylor

You’d have to be quite careful, wouldn’t you? Because you know, if you’ve got, I know Joe and I have both got Labradors. If you let you Labrador go around, they’d, they’d love it, but they’d be sniffing out all the snacks, wouldn’t they?

Dr Rebecca Leon

Exactly. And we will look into this a bit more and…

Dr Sarah Taylor

Not sure we’re going to get anywhere, but we can have a look.

Dr Rebecca Leon

We’re not,

Dr Sarah Taylor

It’s interesting, it’s a nice thought.

Dr Rebecca Leon

But it’s interesting and, and I do like hearing things like that. So, that’s my kind of fun discussion rather than fun fact today.

Back to our [00:23:00] key clinical points. Rustle of paper. I’m going to get shouted at. So, you start with the first one.

Dr Sarah Taylor

Yeah. I think that there are, there’s a cohort of patients with non-site specific symptoms of whom there is a cancer pickup rate of about 8%. And the patients with these tumours tend to present later, and we need good pathways and good ways of managing them.

Dr Rebecca Leon

Okay. And hopefully East Cheshire’s the next one you’re going to look at.

Dr Sarah Taylor

Not my responsibility.

Dr Rebecca Leon

So, with, with all patients that we’re seeing, whether there’s a potential diagnosis, there needs to be a set of pre-referral tests. Sarah talked about possible blood tests, whether chest x-ray would be appropriate, FIT testing, maybe a urine dipstick.

So, these will support the referral to the NSS pathway and exclude other potential causes.

Dr Sarah Taylor

And I think the other thing is just to consider the NSS pathway in any patient who’s got unexplained non-specific symptoms. And by that, my personal criteria is, any [00:24:00] symptom where you can’t be reasonably sure what you’re concerned about at the first thing.

So typical one’s a weight loss, lethargy and GP gut instinct.

Dr Rebecca Leon

Great. Ellen, was there anything else that you wanted to add?

Dr Ellen Macpherson

Yeah, just what we spoke about, about being really clear throughout the process, why you’re referring patients, what you’re concerned about, and the possibility that they may end up with a cancer diagnosis.

Certainly informing patients that you’re referring them on a cancer pathway.

Dr Rebecca Leon

Absolutely. Good. Well, thank you very much to both of you and I will see you next time. And thank you for listening today to this podcast from GatewayC. I also want to thank our producers, Louise Harbord from GatewayC and Jo Newsholme from ReThink Audio.

Alongside this podcast, we have a free non-specific module, which is available on the GatewayC website. This is available for all healthcare professionals. All references to the studies and guidelines we’ve discussed will be in our [00:25:00] show notes, and we really look forward to seeing you next time on our next podcast on breast cancer.

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 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. Please follow and share this podcast with any friends and colleagues, as it really helps spread the word. [00:26:00]