Dr Sarah Taylor

[00:00:00] Just because you’ve been a type two diabetic for 20 years doesn’t mean that you can’t get pancreatic cancer. So, I think diabetic control going off and weight loss, again, should be a warning.

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

So, that’s the serious bit done. The kettle is on. And now it’s time to start the podcast. Today we’re going to be talking about pancreatic cancer. So, joining me today, I have Sarah Taylor, and also Dr Ellen MacPherson. She’s a junior doctor working alongside us at GatewayC. She’s joining us remotely from Scotland. Ellen, hi. How are things?

Dr Ellen MacPherson

Good. Thank you.

Dr Rebecca Leon

Sunny, sunny Scotland. I hope.

Dr Ellen MacPherson

Very sunny, very beautiful, lovely views. I really love it here. So yeah.

Dr Rebecca Leon

Good. Lovely to see you on a screen. Look forward to seeing you in place. So just checking, everyone’s got drinks.

Dr Sarah Taylor

Yep. Ready to go.

Dr Rebecca Leon

Ready to go. Okay, so let’s talk pancreatic stats.

And these today are pretty stark with [00:02:00] only 5% of patients diagnosed will survive 10 years or more. And unfortunately, it hasn’t shown much improvement in survival in the last 50 years. According to Cancer Research UK. 20% of patients are diagnosed at stage one or two, with 80% of patients diagnosed with more advanced disease at stage three or four.

Another thing that did make me sit up and think is one in two patients who were diagnosed with pancreatic cancer are diagnosed via the emergency route. So, there’s still a lot of work to be done in this particular disease group. For people who’ve not been or joining us before: A, shame on you. But B, there’s plenty of time to catch up and, we’ll be talking cases first of all.

So, Sarah, are you happy to?

Dr Sarah Taylor

Yeah, so I was going to just talk about a patient I saw who was, a man in his late seventies who came in because [00:03:00] his wife had noticed that he’d gone a bit yellow, which, you know, to be fair is one of those things that makes you sit up and get quite alarmed. So, it, it was from that point of view, it was a fairly easy decision that he needed to be rapidly assessed and referred in. And actually, we do locally have a jaundice pathway, so I was able to refer him in on that. But actually, once you started to talk to them both, you could go, you’re going back, he’d actually had symptoms for probably about six to eight weeks before coming in to see to see me. He’d just had some rumbling abdominal pain.

He’d had some back pain and he’d actually also lost a bit of weight. And unfortunately, he was diagnosed with pancreatic cancer, and he’s going to have, they’re just assessing him at the moment to see whether he is suitable for surgery. But I think it, you know, it’s a, it’s one of these things that we talk about fairly frequently, isn’t it? That it’s actually a new onset painless jaundice is a red [00:04:00] flag symptom and I think that everybody will act on that. And I, just based on local pathways, I don’t know what your, do you have access to a jaundice pathway?

Dr Rebecca Leon

Yes, we do. In, in our area as well. And I think you mentioned that jaundice is a fairly easy diagnostic or symptom that we actually refer on. But was there anything else, because pancreatic could be fairly vague, was there anything else that you were concerned about with him?

Dr Sarah Taylor

Well, I think with him it was, it was so obvious, it was only when we, I was just sort of talking to them and trying to work out how, and he’d become jaundiced over, basically over a couple of days.

But going back and talking to them, he had had these symptoms for, as I say, six to eight weeks. He had, they did mention that he had quite dark urine and they also mentioned that he had, over the preceding week or two had noticed some steatorrhea, so difficulty, you know, pale stools had been difficult to flush.

[00:05:00] So in retrospect, he had quite a lot of symptoms that were of concern, but they were quite short lived. And I think like a lot of patients with pancreatic cancer, they’re so short-lived that they don’t really recognise it. They just think it’s, you know, it’s a bit of a stomach upset, it’s going to settle or, so I think it is, it’s quite a difficult one, isn’t it?

Dr Rebecca Leon

Absolutely. And, and I think Ellen, you wanted to mention about a case that we discussed off fair. Are you happy just to talk about?

Dr Ellen MacPherson

Yeah. So, I had a great aunt, who passed away from pancreatic cancer just at the end of 2019, and she had a bit of a delay in her diagnosis. So, she had presented with rapid, quite severe weight loss.

I mean, I got frighten when I saw her. And she was diagnosed with new onset diabetes and they kind of put the weight loss down to the diabetes, [00:06:00] which I didn’t really understand what had happened at the time. No one had really explained to me, you know, I mean, she just called and said, well, turns out I’ve got diabetes.

And it wasn’t till later that I realised kind of what happened, but it took a couple months from then. Where she continued to lose weight, that she went for a scan and was diagnosed with pancreatic cancer and she passed away eight months later. But yeah, it was, in, in retrospect, it was kind of obvious to me she was in her late seventies, previously completely fit and well, quite an active person and yeah, it, I mean she was in Canada, so I don’t know if what the differences there were, but certainly sudden that amount of weight loss, new onset diabetes and someone who is, you know, in their late seventies for me, would be a two week wait.

Dr Sarah Taylor

I think this new onset diabetes is, is quite difficult, isn’t it? Because obviously [00:07:00] we’ll see a lot of people in their fifties, sixties, seventies who have diabetes, who have new onset diabetes. But, they’re not normally, like you are describing Ellen, they’re not normally losing weight. They’re normally people who, if anything, are a bit overweight and have other risk factors for diabetes.

I don’t know whether you have any, do you have any sort of rule of thumb, Rebecca, as to what you, when you would be concerned?

Dr Rebecca Leon

So, you’re absolutely right. We, we are picking up fifties, sixties, new diagnosis and with type two diabetes, on the whole come with other things as well. And they may have other cardiovascular issues.

They may be overweight. It’s almost the kind of the type two diabetic bond or patient. So that would also ring bells, particularly with the, with your great-aunt, a lady who was fit and well. And I mean, we know that type two diabetes doesn’t really cause weight loss. So that would be something I would consider.

And I, [00:08:00] I mean, I was doing some reading off air, and it was talking about that the prevalence of diabetes and impaired glucose tolerance in pancreatic cancer is as high as 80%. So actually, and I, and I know one of the GPs that I work with was telling me almost exactly the same case. And it’s on the, it’s now on the NICE guidelines, isn’t it?

Dr Sarah Taylor

It’s on the NICE guidelines. Yeah. And I think the other thing is, those patients who’ve always had quite well controlled diabetes who, who diabetic controls suddenly goes off and they start losing weight as well. And because obviously just because you’ve been a type two diabetic for 20 years doesn’t mean that you can’t get pancreatic cancer.

So, I think diabetic control going off and weight loss again should be a warning, a ring warning bells.

Dr Rebecca Leon

So, Sarah, you, you see a patient, they’re mid-sixties, their bloods have gone haywire, erratic, or it’s a new diagnosis, what would you do then next?

Dr Sarah Taylor

Well, you know, you can do blood tests, but they’re not likely, [00:09:00] they, normal blood tests aren’t reassuring, so you could have normal liver function.

Your patient, you know, may have normal full blood count, so that’s not very helpful. NICE guidelines suggests that you could do an ultrasound, but I know that all the radiologists I speak to say actually, ultrasound isn’t particularly reliable, so really, if you’ve got somebody who’s got these symptoms, they do fit the NICE guidance for a suspected cancer referral.

So, you either need to access a CT abdomen, which some people around the country can do, but not everybody. Or you need to think about a referral. I think these patients fit in really well to refer to the non-site, the non-specific symptom service that we talked about a couple of weeks ago. So, I think you can refer them there. Or particularly if you’ve got a real much more, you know, if you’ve got somebody who’s got steatorrhea, dark urine, abdominal pain, weight loss, then they would fit guidance for a pancreatic cancer pathway, particularly with new onset diabetes. And that varies again, across the country as to [00:10:00] whether it’s separate hepato-pancreato-biliary, that’s really testing me, pathway, or whether they’re actually referred on either the upper or lower GI pathway.

I think different areas have different things. Certainly locally we would refer on an HPB pathway. But I think that just varies and people need to be up to date with their local pathways. So, I think you’ve got good reason to refer. And you know, we were, we were talking, weren’t we just before we started to do this, about the sort of outcome stats with pancreatic cancer and all of it’s quite difficult.

Dr Rebecca Leon

Yeah, so I mean, pancreatic cancer is actually the 10th most common cancer according to CRUK. And, it’s got a very high mortality rate. And we also discussed a lot of pancreatic cancers are picked up in an A&E setting as well.

But I just wanted to, I mean we, we’ve talked about this, in other podcasts about, primary care investigations. So, you’ve got a patient, alarm bells are starting to ring. You’re absolutely right. There’s enough [00:11:00] reason to send them for a suspected cancer referral. But, an ultrasound would be a common, an ultrasound abdo would be a kind of a, a common thing that we can organise, a common investigation. That comes back normal.

We need to have the strength to say, actually, I’m still worried about this patient.

Dr Sarah Taylor

Totally.

Dr Rebecca Leon

And the other thing I want to, and refer for, we can refer for CT abdos or conversations with maybe the medical registrar or something like that if you’re not. I want to ask you about the role of the CA19-9.

You are thinking that in your particular area, you’re not sure. We can use it and I use it very much for, recurrence rates or for looking to see. So, I have a patient currently who had a Whipple’s in 2021 and he’s starting to go off a bit and we, I did a CA19-9 and it was through the roof. We showed that actually his cancer was active again.

And that’s how I used it. Do you ever use it as initial diagnosis?

Dr Sarah Taylor

No. When I, when I spoke to, when we [00:12:00] did, I think it was when we did the webinar on prostatic cancer, the specialist I spoke to…

Dr Rebecca Leon

Pancreatic.

Dr Sarah Taylor

Pancreatic, not prostate, no. Goodness me. He was, he was saying it’s not a good diagnostic test that, that unfortunately there’s no real test that’s a good diagnostic test apart from a CT abdomen. So, it’s quite difficult in primary care to make that, and I suppose we’re going to come back to what we always talk about, but also because a lot of the symptoms are vague, you might have a patient with abdominal pain, and weight loss. You would probably, if that’s all they’ve got at that stage, you would probably start with blood, probably do a FIT.

Dr Rebecca Leon

Oh yes. And, and chest x-ray, potentially.

Dr Sarah Taylor

And chest, possibly. And then actually, the whole safety netting, because these symptoms are quite vague, becomes very important again. So actually seeing the patient, you know, the patient I spoke about, if he’d come in, he had a sort of eight week history. If he’d come in four weeks in, how [00:13:00] concerned would I have been if he’d got, if he wasn’t jaundiced, he didn’t have any steatorrhea, he had dark, he didn’t have any dark urine, would I have just organised some bloods.

Dr Rebecca Leon

With a follow-up?

Dr Sarah Taylor

Probably with a follow-up. But then because it is quite a vague symptom, probably being quite specific about the follow-up and you know, saying if your symptoms don’t settle, I need to see you again. Or as you were saying before, I’m going to make you an appointment for two or three weeks’ time.

And actually if you’re better, feel free to cancel it. We’ll always fill it.

Dr Rebecca Leon

I think. Yeah, we’ll always fill it. I was also going to say this patient that you bring back after a couple of weeks, What I may do in this situation as well is weigh them at that initial consultation and then weigh them again two to three weeks later.

Dr Sarah Taylor

That’s a really good idea

Dr Rebecca Leon

Because they often don’t know. They talk about notches on belts and they talk about their, but actually, most people aren’t weighing themselves regularly. And it might [00:14:00] be a few pounds, but that could make a big difference that we see the downward trend. So that could be another way of reviewing them.

Dr Sarah Taylor

I think that’s a really good idea. It’s not something I do routinely, but I think it actually, weighing patients is a really good, it’s a good way of monitoring things.

Dr Rebecca Leon

So, I think overall pancreatic cancer is a difficult diagnosis to diagnose. We don’t have fantastic primary care investigations really, bloods are often normal in a lot of cases, and abdominal CTs are the gold standard of choice, but it may not be, it might be difficult to get. But a good history, maybe a weight, making sure that there’s no new diagnosis of diabetes or there’s no, no new erratic or changes in their HPA1C that causes concern and a low threshold to refer.

Dr Sarah Taylor

Yeah, and I think specific asking [00:15:00] about dark urine and steatorrhea, because patients may not always volunteer it. They might not even really think about it.

I think Louise was saying that that was one of her favourite facts about GatewayC at the moment or on the pancreatic stuff was the difficult to flush poo, but people might A, not recognise it or B, just be embarrassed to mention it. So, I think it’s something that’s worth just checking.

Dr Rebecca Leon

You have to actually ask that question.

Dr Sarah Taylor

Specifically. Yeah.

Dr Rebecca Leon

Yeah. Okay. I don’t really have any fun facts today, Sarah.

Dr Sarah Taylor

No, I, I’m not, no.

Dr Rebecca Leon

Just a couple of risk factors. I think it’s just important to say because it’s always good to ask. Males more than females we’re seeing are getting pancreatic cancer. Not a huge difference in sexes, but it’s just something to be aware of.

Smoking, can also increase chances. The new onset diabetes, chronic pancreatitis is another one as well. And almost what’s caused the chronic pancreatitis. So, there’s some links to, to alcohol [00:16:00] and…

Dr Sarah Taylor

I think there’s probably some link with family history as well. Cause I’m aware that there’s some very early work happening on, targeted case finding in patients at risk and patients with family history.

So again, I think we, we talk every week, don’t we, about the importance of asking about family history. But when I know more about that, I’ll pass it on as well.

Dr Rebecca Leon

Excellent. Series two.

Dr Sarah Taylor

Series two.

Dr Rebecca Leon

Okay. A few key clinical points we’d like to end it with. It’s the 10th most common cancer, but it counts to 6% of all cancer deaths, so it has a very high mortality rate and a high pickup in emergency care.

Dr Sarah Taylor

Yeah, I think the new onset diabetes in patients that you wouldn’t expect it is really significant and poorly diagnosed, poorly controlled diabetes is also a risk factor and should be ringing alarm bells.

Dr Rebecca Leon

Abdominal CT scan is the investigation of choice. [00:17:00] And finally, a really good history as Sarah said.

And ask those more difficult questions and sometimes that will start raising alarm bells and we can do further tests. Ellen, was there anything else that you wanted to add?

Dr Ellen MacPherson

No, I think you’ve, you’ve covered everything. The only thing that I did think of is I remember at medical school remembering the CA99, because a nine kinda looks like a pancreas.

Dr Rebecca Leon

Oh, the, the CA19-9.

Dr Ellen MacPherson

Yeah.

Dr Rebecca Leon

Okay.

Dr Ellen MacPherson

That’s how I just remembered that’s the tumour marker for pancreatic.

Dr Rebecca Leon

It’s funny, it’s funny how you remember things for exams.

Dr Ellen MacPherson

Anyone can remember that.

Dr Rebecca Leon

Yeah, no, it’s funny how you remember, certain, like equations in your head. Mine are always a bit rude.

Okay. Okay.

Dr Sarah Taylor

I won’t put that on the WhatsApp group either, Rebecca.

Dr Rebecca Leon

Honestly, my physics ones were really rude. I’ll have to remember them. I never liked physics. Thank you for that, Ellen. So, I’ll never, I’ll always [00:18:00] think of that, CA19-9 looks like a pancreas, the nine. There we go. So, thank you for listening today.

We’ve got a free pancreatic cancer module, which you can find on the GatewayC website, and we’ve put all references to the studies and guidelines that we mentioned into our show notes. So, we’ve got a few thank yous as well to my two co-hosts, Sarah and Ellen, thank you again. To our producers, Louise from GatewayC and Jo from ReThink Audio. Thank you for keeping us on the straight and narrow.

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 [00:19:00] 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 this podcast direct to your feed and we’d love it if you share this podcast with your friends or colleagues. It really does help spread the word. And a thank you again for listening to our first series. We hope you have enjoyed it. Bye-bye.