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GPs TALK CANCER

Prostate Cancer

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Published on: 26th September 2023

Prostate Cancer

In this episode, our GP hosts cover prostate 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
• Symptoms
• Pitfalls of PSA testing
• Investigations
• Risk factors
• Family history
• Safety netting
• NICE Guidelines

If you loved it, you know what to do – leave us a review, a rating (hopefully 5 stars) and share.

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

[00:00:00] I’ve got very little hands and it always worries me that I actually probably couldn’t feel the prostate properly, although the consultant urologist I spoke to did say that he felt that actually the prostate wasn’t high enough.

Dr Rebecca Leon

Now, just hand wise with me, Sarah, I think we’re probably very, very, very similar.

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 [00:01:00] with no identifiable patient data.

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

So official bit done and dusted. The kettles on, it’s now time to sit back and join us for today’s podcast and we’ll be talking about prostate cancer. I want to make sure everybody is well hydrated and they’ve got their coffees and teas. Sarah?

Dr Sarah Taylor

Yep. Coffee here.

Dr Rebecca Leon

And also with us today is Ellen Macpherson. She’s a doctor working with us at GatewayC, and she’s joining us remotely from Scotland. How are you today, Ellen? I hope less…

Dr Sarah Taylor

Dryer.

Dr Ellen Macpherson

I’m proud to say that I’m drinking water today.

Dr Rebecca Leon

And the weather Ellen?

Dr Ellen Macpherson

Very sunny. Beautiful.

Dr Rebecca Leon

Good. Great. Okay. It’s a bit cloudy here.

Dr Sarah Taylor

It’s okay though. It’s dry. We’re in [00:02:00] Manchester and it’s dry. That’s about as much as we can hope for.

Dr Rebecca Leon

Okay. And how are you today?

Dr Sarah Taylor

I’m good, thank you. Yes. Yeah. Yeah.

Dr Rebecca Leon

And what’s the weekend plans?

Dr Sarah Taylor

Haven’t quite thought that far ahead. We’ve got a couple of busier weekends coming up because we’ve got my daughter’s 21st in a couple of weeks’ time with…

Dr Rebecca Leon

You are not old enough to have a daughter of 21.

Dr Sarah Taylor

Oh, I’ve got a son of 25, so there you go. But yeah.

Dr Rebecca Leon

She’s looking good. Okay, so you’ve got 21 plans. That’s good.

Dr Sarah Taylor

Well, yeah. But yes, scary.

Dr Rebecca Leon

I’ll be doing my usual thing of standing on sides of football pitches and tennis courts this weekend.

Dr Sarah Taylor

I’ve, I’ve done my time on the side of netball courts and running tracks. Yeah.

Dr Rebecca Leon

Good. Okay, so let’s talk about some stats regarding prostate cancer. In males in the UK, prostate cancer is the most common cancer with over 50,000 cases diagnosed each year. But looking at the projections for the next 20 years, they kind of say between 2038 and [00:03:00] 2040, the suggestion is that the number of cases will be around 85,000.

So prostate cancer is on the rise. And I think probably a lot of this is because men are living longer. So, Sarah, let’s, talk about a couple of cases that we’ve seen in practice and, this is one that Sarah and I, it comes as, as a bit more of a challenge for us just because I certainly don’t see as many potential prostate cancers in primary care as some of my male colleagues. And I think that’s almost just the way it is at the moment. But I think it’s important, and I say this again to my female primary care colleagues, that they mustn’t get de-skilled. And so, I think it is important that we still see our male patients with their male problems.

And actually, these two cases we’re going to talk today, we’ve seen ourselves and, do you want to, start off.

Dr Sarah Taylor

Yeah, yeah, we’re just starting off by, a patient who we, who I spoke to a few weeks ago [00:04:00] who was in his mid-fifties with some, some fairly vague, he, he was a telephone consultation.

Fairly vague urinary symptoms. Actually, initial telephone consultation, arranged an MSU, came back as negative and then spoke to him subsequently because his symptoms hadn’t settled. Now actually we’ve got quite good coding on our notes, and it was fairly easily apparent that he was a black patient and therefore at an increased risk.

So, when he came back with the, the symptoms not settled in a normal MSU, it felt appropriate at that stage to talk to him about maybe doing a PSA, which we did, which came back as raised and then referred him on. I think, you know, it, it’s one of those, again, it’s, it’s really difficult because, we need to make sure that we’ve got, you know, that we do an MSU in these patients.

And actually, he was 55, so it’s probably an initial reasonable thing to do. [00:05:00] Did actually bring him in, examine him as well. And his prostate did feel normal. But it’s always one of the, although I’ve been reassured by the consultant, it’s one of the things that always worries me. I’ve got very little hands and it always worries me that I actually probably couldn’t feel the prostate properly, although the consultant urologist I spoke to did say that he felt that actually the prostate wasn’t high enough.

Dr Rebecca Leon

Now, just hand wise with me, Sarah, I think we’ve probably very, very, very similar. Yeah, very similar. And that has always been a thing whether can I actually feel the prostate?

Dr Sarah Taylor

Yeah.

Dr Rebecca Leon

And we’ve been told we can, we can.

Dr Sarah Taylor

Yeah. So, we shouldn’t put, let that put us off, doing the prostate examinations.

Dr Rebecca Leon

But I think the learning points, and I, and we work in very different practices, very different patient cohorts, which we don’t, you know, we, we see a range of patients, but really the coding is very good in your practice, and it is good in mine, just in case any of my coders are listening to it.

But something about looking at ethnicity and looking about other things because [00:06:00] from a telephone consultation, we might know who is actually on the other end of the telephone. And so, because your coding is good, that’s something for us to look into that actually, rightly so. After the initial, investigations, like the MSU, you brought them in, examine and examine, examine.

Dr Sarah Taylor

Absolutely.

Dr Rebecca Leon

As we keep saying.

Dr Sarah Taylor

Yeah.

Dr Rebecca Leon

And then, and then did the PSA.

You mentioned, can you just talk to us a little bit about the risks of ethnicity with prostate cancer?

Dr Sarah Taylor

Well, there’s a lot of research now is showing that black men have a much higher rate of prostate cancer. So, one in four black men will get prostate cancer in their lifetime.

They tend to present a little bit younger, and they often have more aggressive disease. So, it’s really important that in our black men, we think about prostate cancer at a younger age. It’s also significant that men with a positive family history are at a much more increased risk of prostate cancer.

[00:07:00] And that’s again, we keep talking about family history, family history, family history, as well as examine. You know, these are going to be the things for everybody, aren’t they? That actually, we should be thinking about it in men with a family history, as well at a younger age.

Dr Rebecca Leon

Okay. And also, if anybody listened to our previous breast cancer podcast, also ask about other family members of different cancers as well.

Dr Sarah Taylor

Yes.

Dr Rebecca Leon

Because of potential genetic links with prostate, breast, ovarian, and others as well. So, I think, again, family history is really important and that will definitely be on both of our PDPs next year. Can you tell us a little bit about an initiative that’s actually going on in Greater Manchester, and it may be rolled out to other parts of the UK further down the line, looking and targeting for potential prostate cancers.

Dr Sarah Taylor

So Greater Manchester piloting an NHS England project, which is to try and increase the diagnosis of prostate cancer in men at risk. So, there’ve been [00:08:00] searches. So, there’s a wonderful yellow, bright yellow van with blue writing, going around Greater Manchester called This Van Can.

And in the practices, in, in the areas it’s going round, the practices have had searches, have done searches to find their patients who are at risk and invited them to the van to have a discussion about whether or not they would like to have a PSA test done. And I think this is something that we need to get into.

I mean, I think that, you know, there are, the issue of PSA testing is a huge one in primary care. There, it, it’s not an easy one. It’s something that I struggle with a little bit. I don’t know what you feel about it, Rebecca.

Dr Rebecca Leon

Yeah, so PSA counselling, which is again, I remember doing my GP exams and one of the things was almost talking to a patient about whether they should have a PSA check.

And we get a lot of people, particularly over the age of 50, it’s around the golf course that they say, get, get your prostate, ask your GP for a PSA [00:09:00] check and they come in and they’re not sure what it is. And the word prostrate as well.

Dr Sarah Taylor

Yes. It’s always a pros.

Dr Rebecca Leon

Yes. Anyway, um, so the PSA counselling is about why they should have it, because it’s not a straightforward test.

It’s, I suppose it’s the best we have in primary care. It’s a blood test, and it’s quite easily done. And I suppose, Ellen, are you still talked to about who can and can’t have the PSA test and what they can and can’t do before? And is that still being talked about, at medical school, about a list of things that we have to tell our patients before they have their PSA test?

Dr Sarah Taylor

Myth buster?

Dr Ellen Macpherson

Yeah.

Dr Rebecca Leon

Yeah. What kind of, what kind of things?

Dr Ellen Macpherson

The, the big one is a, a urine infection, obviously, to rule that out. And then to wait, I think it’s four to six weeks before retesting?

Dr Rebecca Leon

Yeah.

Dr Ellen Macpherson

Recent catheterisation. So that’s often a problem in hospital, recent rectal exam as well, that comes up a lot.

Dr Rebecca Leon

Yeah, absolutely. We were always told, weren’t [00:10:00] we, we couldn’t do the blood test and a DRE at the same time.

Dr Sarah Taylor

But on our myth busting theme, I love a bit of myth busting.

Dr Rebecca Leon

Yeah.

Dr Sarah Taylor

When we did the recent forum, I think we were told differently.

Dr Rebecca Leon

Yeah.

Dr Ellen Macpherson

I think the other one that came up on the myth busting form was recent ejaculation, so actually Cancer Research UK has, wait 48 hours after ejaculation to test PSA, but I think the specialist said that’s, that’s not true. You can just do it, it’s fine.

Dr Rebecca Leon

And the big one also is cycling. So, you know how it’s like a new trend now for middle aged men to cycle and they decide that it’s fine to wear lycra. Or what’s known as mammals. I think I taught you that word, didn’t I, Ellen? Off air, middle-aged men in lycra. Then actually they can still have their PSA test, so they can come in their lycra to the GP examination.

Dr Sarah Taylor

No, no, no. We never said that.

Dr Rebecca Leon

No, absolutely not lycra is banned, but not for that reason. So, these are just [00:11:00] myth busters.

Dr Sarah Taylor

So, so just to clarify, we’re saying that, you can’t have a PSA if you’ve got a UTI.

Dr Rebecca Leon

Yeah.

Dr Sarah Taylor

You can’t have a PSA if you’ve had recent catheterisation or instrumentation, but you can if you’ve had a DRE, a rectal examination, if you’ve had recent ejaculation, or if you’ve been on a recent bike ride.

Dr Rebecca Leon

Wearing tight trousers, pants. I think that was the other thing as well. Anyway, those are slight myth busters that, I think it’s just important to note. But the other thing about the PSA counselling is, is say easy test done, test comes back, and we’re given certain ranges, which again will be, we can put it in the show notes, but, but I’m sure a lot of people will know that the range changes depending on age. But it was actually, I never like to do a test without discussing with the patient what we’re going to do with the results.

Dr Sarah Taylor

Totally. Yeah.

Dr Rebecca Leon

So, you could have a raised PSA, but is the patient [00:12:00] aware that we’re going to then refer them into secondary care and that they’re going to potentially have an intrusive test, have a truncal biopsy, and what that actually means.

And sometimes when I actually say a large needle will be inserted into your prostate gland, they run a mile and say, forget it. But actually, I’m being, I’m being serious now, but I think it’s really important to actually know what the next stage is.

Dr Sarah Taylor

Yeah. That has changed, hasn’t it. So, the new pathway for prostate, for investigating raised prostate looks at you are using MRI as the first investigation. Patients may then go on and have a biopsy, but MRI is a much better test for diagnosing prostate cancer and making some assessment as to the nature of it.

Because one of the other issues is that, I don’t know whether Ellen has found this YouTube video that you were talking about, Rebecca, but about the different types [00:13:00] of prostate cancer, and Rebecca’s been talking about hairs and rabbits and birds and things in relation to prostate cancer, which is an interesting thought.

Dr Rebecca Leon

Are you able to clarify what I asked you?

Dr Ellen Macpherson

I’m so sorry I was not able to find it.

Dr Rebecca Leon

Okay, so what I’ll do is I’m going to attach this, and find it personally, onto the end of this podcast so people can find it. It’s a two minute video of talking about the more slower prostate cancers and that they almost don’t metastasize and…

Dr Sarah Taylor

Sloths.

Dr Rebecca Leon

Yeah, but it wasn’t a sloth. I feel like it was another slow animal. And then…

Dr Ellen Macpherson

Turtle, wait, a turtle?

Dr Rebecca Leon

Yes. Oh yeah. So, a turtle, a bird, and a hair.

Dr Sarah Taylor

Okay.

Dr Rebecca Leon

And you got to see it to believe it. So, I’m not even talk about anymore.

Dr Sarah Taylor

But just give us the gist of it.

Dr Rebecca Leon

The, the gist of it is, actually there are three, so the, the turtle is very slow growing, hardly moves, sits there, doesn’t cause problems. A statistic that we’re [00:14:00] going to walk away with, another Sarah quote that you’ll, you’ll learn these as you go along the podcast is, 80% of 80 year olds at post-mortem, at autopsy, will have a diagnosis of prostate cancer, but that isn’t the reason that they have died.

So, it shows that with age, a vast majority of older men will have prostate cancer, but they will be asymptomatic or there’ll be other symptoms. And we’re going, we’re going a bit backwards and forwards here, but I think the PSA test can be raised for non-malignant reasons, can’t it? Which is part of the aging process.

And we say that actually, 75% or three out of four men with a raised PSA will actually not have cancer. And actually, the PSA test can actually miss 15% of cancers. So, it’s not a great test.

Dr Sarah Taylor

No, it’s [00:15:00] not, is it? And I, and so if you, if you’re saying that you’ve got a high false positive rate.

Dr Rebecca Leon

Yeah.

Dr Sarah Taylor

So, you’re going to have lots of raised PSA that isn’t cancer.

Dr Rebecca Leon

And then they’re going to be referred in.

Dr Sarah Taylor

Yeah. And then of those, you have a lot who might have a very, almost an, an incidental finding that actually isn’t going to cause them any problems.

Dr Rebecca Leon

My turtles.

Dr Sarah Taylor

Yeah. You’ve then you’ve got some that you’re going to miss.

Dr Rebecca Leon

Yeah.

Dr Sarah Taylor

Because the, you’re trying to identify those patients who need more intensive investigation from our point of view is really, really difficult, isn’t it? From primary care. It’s really difficult to work out who out of the, because we can’t tell out of those 20 patients that we might see and referring over the course of a few years, how many of them have got, are more, are not turtles? Because the turtles, we don’t need to worry about.

Dr Rebecca Leon

Turtles we don’t have to worry about.

So, the turtles the ones that almost, it’s just there [00:16:00] and it’s not going to become bothersome. I think the other thing that’s making me feel slightly better, because MRI is now available, when we used to send these turtles in to primary care and they might have a diagnosis, something like BPH, which again is a common, that’s Benign Prosthetic Hypertrophy, not hyperplasia, sorry. BPH. Benign Prostatic Hypertrophy, which is a normal part of the aging process when the prostate gland enlarges and can cause certain symptoms. I felt that they were going for almost unnecessary, intrusive tests, which could then have problems of their own. The MRI is non-intrusive, so there is a slight, with the improvement of the secondary care test, I am feeling a little bit better about PSAs.

Dr Sarah Taylor

I suppose, you know, if we’re pragmatic in primary care, if, I think if somebody comes in and asks for a PSA and a prostate test, then we have those discussions with them and if they want the [00:17:00] test, I think, on the whole, I would probably go ahead and do it.

I would explain to try and explain to them what’s going on, and then if it’s raised, follow guidelines and refer them in and let somebody else have those discussions about what investigations should happen next and what they should go onto. Because things do change, and I think they’re, you know, the, the MRI is really important, as a much less invasive next investigation.

Dr Rebecca Leon

And more, and probably more detailed.

Dr Sarah Taylor

And more accurate. Yeah. So, I think that, you know, our role is to have those conversations say, yeah, the test isn’t perfect. It might indicate something that isn’t concerning, but then we do that with a lot of other cancers, don’t we? And to refer them, and to refer them in and let somebody else have a discussion about what happens next. Because that’s quite difficult.

Dr Rebecca Leon

Absolutely. It it’s just being honest with the patient. Yes, Ellen?

Dr Ellen Macpherson

Just kind of on that point, for your patient that you described who came in and you did the test, if it hadn’t been raised, how would that have [00:18:00] changed your management there? Would you have not referred or, or would you have still made the referral anyway?

Dr Sarah Taylor

I think if I, if I’m being totally honest, if he had a low normal PSA and normal feeling prostate, which I’m assured that I can feel, I would probably not have referred at that point, but I might have done, or I might not have referred on a two week wait, but I might have referred if he’d got persistent symptoms.

I think that it, again, it’s this, it’s the constant thing of sort of safety netting and actually, yeah if, if things, symptoms don’t settle referring then, don’t know what, what do you think, Rebecca?

Dr Rebecca Leon

Yeah. Okay. I’m, I’m trying to think. Probably the same again, the safety netting is so important. Maybe making a telephone in a month’s time and booking the appointment to phone.

And I think if it’s still persevering with his risk factors, with his potential family history, I think I would, refer him because it would be something that’s [00:19:00] not right. The other thing about is, I suppose if you had a positive MSU had been treated and still had symptoms, again, that’s something again to, but again, don’t be over reassuring in some ways.

So, actually say, please do come back.

Dr Sarah Taylor

Yeah.

Dr Rebecca Leon

Because I don’t want them to think, well, the doctor doesn’t think it is anything, so I’m not going to bother them again.

Dr Sarah Taylor

I think that’s really to go back to, you know, you know how I love my quotes with, so your three strikes and you’re in. If this, if he comes back, two or three, if he comes back three times with the same symptom and you haven’t got a good explanation for it, then you probably do need to be referring at that stage, don’t you?

Dr Rebecca Leon

Absolutely. I mean this, you talk about if you’ve got lungs, you can get lung cancer. Is that the same with a prostate?

Dr Sarah Taylor

Well, it must be, mustn’t it?

Dr Rebecca Leon

Yeah, that’ll be the new one. I, I’m going to also put you on the spot here, Ellen and Sarah, just about when we feel the prostate, what is a normal feeling prostate versus an abnormal feeling prostate? [00:20:00]

Dr Sarah Taylor

Ooh.

Dr Rebecca Leon

Go on Ellen. You’ve done training sooner than earlier than us, not earlier, more recent.

Dr Ellen Macpherson

Normal is nose. That’s my, the one that I was taught.

Dr Sarah Taylor

Okay, good. That’s a nice one.

Dr Ellen Macpherson

Or there’s, there’s thenar eminence. People have used that as well.

Dr Rebecca Leon

Oh, you mean how it feels?

Dr Ellen Macpherson

Yeah.

Dr Rebecca Leon

Oh, nice. Okay. I didn’t know that.

Dr Sarah Taylor

Nor me.

Dr Rebecca Leon

And I know it’s a size of a walnut. Yeah, and the word craggy.

Dr Sarah Taylor

Craggy is not good.

Dr Rebecca Leon

Craggy is not good. You want it smooth, and about the central sulcus. Yeah. There we go. So, feels like the thenar eminence. I like that.

Dr Sarah Taylor

Or a nose you said?

Dr Rebecca Leon

Or a nose. I know. But noses can have cartilage

Dr Ellen Macpherson

And kind of consistency of bounciness. And if it’s harder than that, like your forehead, that’s concerning. If it’s a regular craggy, yeah. Or you’ve lost that sulcus in the middle, then those are concerning features.

Dr Rebecca Leon

Dang. I knew you should know more than us.

Dr Sarah Taylor

Yeah.

Dr Rebecca Leon

So, can we talk about the second case? Well, it’s kind of my case, isn’t it?

Dr Sarah Taylor

Yeah. You have [00:21:00] the old patients at your practice, I’ve got all the students.

Dr Rebecca Leon

Yeah. So, I, so yeah, my patient cohort is, of the elegant aging.

So, this was a patient of mine, I think he was kind of about eighty three, eighty four, and we’ll call him Jimmy for this. And comes to see me twice a year and was just getting, hip pain that was different from, he’d had his knee replaced a few years earlier, and he just almost described it as a, as an ongoing dull ache.

He went to see the physio. He, he was quite a proactive patient, so had done all the things, had taken analgesia, was doing stretching from the physio, but it was ongoing. I, with an elderly person, no real other symptoms, no weight loss, had the usual getting up in the night, but had been going on for a few years, and[00:22:00] the issues were just this ongoing hip pain. So, I organised a full set of bloods. I organised a PSA cause I know the two things can be an intertwined, and also organised an x-ray. And his PSA actually came about raised. And also, there was evidence of kind of hip mets, so bony mets, likely coming from the prostate cancer.

We’ve, we, I’ve also seen pathological fractures as well, which is, can be related to primary prostate, is these case that you’ve seen before?

Dr Sarah Taylor

Yeah, I’ve seen a few people like this. Yeah, and, actually again, it’s one of these things that the treatments are actually pretty, they are quite good and patients do get quite a lot of relief from their symptoms by being treated.

So, I think it’s something that is definitely worth looking for.

Dr Rebecca Leon

So actually very different from the first case [00:23:00] that you, that you discussed very almost urinary symptoms and had the family history and the ethnicity that starts getting, thinking, actually, could this be something, but a younger man in his fifties. Mine is an older patient who had pain in his hip that we see a lot of.

Dr Sarah Taylor

Absolutely.

Dr Rebecca Leon

Because it can be wear and tear OA. It can be lots of different things. But I was concerned because I did know him quite well and I could see that he was struggling and it wasn’t his first presentation, even though it wasn’t, even though it was his first presentation to me, he had been to the pharmacist, he had been to the physio and was, and was still struggling.

So actually, think about these things.

Dr Sarah Taylor

And I think that it is, the other thing is to think about it in new onset back pains because it is one of the presenting symptoms of metastatic spinal cord compression. And so, I think, you know, in new back pains as well, I think we just need to be vigilant.

Dr Rebecca Leon

Absolutely. And make sure [00:24:00] we ask all about the red flags. I’ve been told it’s a tortoise, it’s not a turtle, by the way. Because the tortoise and the hair. It’s an Aesop Fable.

Dr Ellen Macpherson

I think it is actually a turtle. I, I have found some articles on the topic and it is a turtle.

Dr Rebecca Leon

Yes.

Dr Ellen Macpherson

A rabbit and a bird.

Dr Sarah Taylor

Okay. Not a hair.

Dr Rebecca Leon

What is it? Oh, a turtle, a rabbit, and a bird. I was right about the bird.

Dr Ellen Macpherson

Oh yeah. So, we’ve got turtles are patients with very slow growing tumours that aren’t going anywhere.

Dr Rebecca Leon

Yeah.

Dr Ellen Macpherson

They’re so slow that, in order for them to cause you any harm, you’d have to live for longer than is the human life expectancy.

Dr Rebecca Leon

Okay.

Dr Ellen Macpherson

Birds are the opposite end of the spectrum. Diagnosis comes too late, they’ve flapped about, they’ve spread the coop and they’ve gone all over the place.

Dr Rebecca Leon

So, this is my second case.

Dr Ellen Macpherson

And rabbits sit in the middle. So, a man with a rabbit cancer may still have curable cancer, so it’s fast growing, but it’s not gone anywhere yet.

Dr Rebecca Leon

So, it kind of [00:25:00] hops around, but it might not actually spread like the bird.

Dr Ellen Macpherson

That’s the analogy.

Dr Rebecca Leon

That’s so we, so we can actually use it for any cancers. But this particular one, I think it works really well for prostate cancer.

Dr Sarah Taylor

There’s a bigger number of turtles.

Dr Rebecca Leon

Yeah, because there are a lot more turtles. So, I’m glad we cleared that up.

Dr Sarah Taylor

I’m, yes.

Dr Rebecca Leon

So, I think we’re up to the key clinical points now.

Dr Sarah Taylor

Yeah.

Dr Rebecca Leon

You know, the podcast, we want to, we’re having honest chats about things that we see in in primary care, and I think we both struggle a bit with the PSA just because it’s not the ideal test, but it does have its role and I think being honest with patients about the pitfalls of the test can be really helpful.

Dr Sarah Taylor

And I, yeah, and I think your point that you, you should never have a test for reassurance because a test might not reassure you. And so, you should, so, so people shouldn’t come in and have a test because they want to be reassured about it because the results may not be reassuring and therefore, discussing the possible [00:26:00] outcomes.

Dr Rebecca Leon

Absolutely. So, some of our key, key clinical points, we talked about ethnicity, which I think is very important and it is a risk factor for prostate cancer, and I’m certainly going to take away that it’s important that we look at this in our own practices, making sure that they are, are up to date, particularly with new patients.

Dr Sarah Taylor

Yeah, so you’ve got your ethnicity recorded so you can identify the black men who might be at a, who are at a higher risk. And I think the other thing that we know, we talk about all every podcast is the importance of family history and recording family history because the family history of prostate cancer, and breast or ovarian cancer and colorectal cancer, because of the association with the BRCA gene, should also be asked about and would just be something else that would increase your suspicion and make you want to refer.

Dr Rebecca Leon

And finally, a raised PSA may suggest there is a problem with the prostate. But it doesn’t necessarily mean cancer. There are other possible diagnoses, [00:27:00] but it should be in your thinking about referring on and particularly having a discussion with the patient first.

Dr Sarah Taylor

And I think there’s just one more from your patient, your elderly patient, that persistent bone pain in older men could be related to metastases from an unknown prostate cancer.

Dr Rebecca Leon

Absolutely. So, thank you for listening today. It’s been a more challenging podcast today, but I’ve actually thoroughly enjoyed it and feel that I have some definite learning points that I’ll be taking back to practice with me. If you want to learn more about prostate cancer, we’ve got a free prostate cancer module that you can find on the GatewayC website.

We’ve put all the references and studies and guidelines that we mentioned in our show notes, including the turtle and the hair. We’ve got a few.

Dr Sarah Taylor

Rabbit.

Dr Rebecca Leon

The turtle and the rabbit. We’ve got a few thank yous as well. Thank you as ever to Sarah and for Ellen for joining us today and to our producers, Louise Harbord from GatewayC and Jo Newsholme from ReThink [00:28:00] 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 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 do press the follow button so you can get the podcast direct to 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. [00:29:00]

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Dr Sarah Taylor

[00:00:00] I’ve got very little hands and it always worries me that I actually probably couldn’t feel the prostate properly, although the consultant urologist I spoke to did say that he felt that actually the prostate wasn’t high enough.

Dr Rebecca Leon

Now, just hand wise with me, Sarah, I think we’re probably very, very, very similar.

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 [00:01:00] with no identifiable patient data.

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

So official bit done and dusted. The kettles on, it’s now time to sit back and join us for today’s podcast and we’ll be talking about prostate cancer. I want to make sure everybody is well hydrated and they’ve got their coffees and teas. Sarah?

Dr Sarah Taylor

Yep. Coffee here.

Dr Rebecca Leon

And also with us today is Ellen Macpherson. She’s a doctor working with us at GatewayC, and she’s joining us remotely from Scotland. How are you today, Ellen? I hope less…

Dr Sarah Taylor

Dryer.

Dr Ellen Macpherson

I’m proud to say that I’m drinking water today.

Dr Rebecca Leon

And the weather Ellen?

Dr Ellen Macpherson

Very sunny. Beautiful.

Dr Rebecca Leon

Good. Great. Okay. It’s a bit cloudy here.

Dr Sarah Taylor

It’s okay though. It’s dry. We’re in [00:02:00] Manchester and it’s dry. That’s about as much as we can hope for.

Dr Rebecca Leon

Okay. And how are you today?

Dr Sarah Taylor

I’m good, thank you. Yes. Yeah. Yeah.

Dr Rebecca Leon

And what’s the weekend plans?

Dr Sarah Taylor

Haven’t quite thought that far ahead. We’ve got a couple of busier weekends coming up because we’ve got my daughter’s 21st in a couple of weeks’ time with…

Dr Rebecca Leon

You are not old enough to have a daughter of 21.

Dr Sarah Taylor

Oh, I’ve got a son of 25, so there you go. But yeah.

Dr Rebecca Leon

She’s looking good. Okay, so you’ve got 21 plans. That’s good.

Dr Sarah Taylor

Well, yeah. But yes, scary.

Dr Rebecca Leon

I’ll be doing my usual thing of standing on sides of football pitches and tennis courts this weekend.

Dr Sarah Taylor

I’ve, I’ve done my time on the side of netball courts and running tracks. Yeah.

Dr Rebecca Leon

Good. Okay, so let’s talk about some stats regarding prostate cancer. In males in the UK, prostate cancer is the most common cancer with over 50,000 cases diagnosed each year. But looking at the projections for the next 20 years, they kind of say between 2038 and [00:03:00] 2040, the suggestion is that the number of cases will be around 85,000.

So prostate cancer is on the rise. And I think probably a lot of this is because men are living longer. So, Sarah, let’s, talk about a couple of cases that we’ve seen in practice and, this is one that Sarah and I, it comes as, as a bit more of a challenge for us just because I certainly don’t see as many potential prostate cancers in primary care as some of my male colleagues. And I think that’s almost just the way it is at the moment. But I think it’s important, and I say this again to my female primary care colleagues, that they mustn’t get de-skilled. And so, I think it is important that we still see our male patients with their male problems.

And actually, these two cases we’re going to talk today, we’ve seen ourselves and, do you want to, start off.

Dr Sarah Taylor

Yeah, yeah, we’re just starting off by, a patient who we, who I spoke to a few weeks ago [00:04:00] who was in his mid-fifties with some, some fairly vague, he, he was a telephone consultation.

Fairly vague urinary symptoms. Actually, initial telephone consultation, arranged an MSU, came back as negative and then spoke to him subsequently because his symptoms hadn’t settled. Now actually we’ve got quite good coding on our notes, and it was fairly easily apparent that he was a black patient and therefore at an increased risk.

So, when he came back with the, the symptoms not settled in a normal MSU, it felt appropriate at that stage to talk to him about maybe doing a PSA, which we did, which came back as raised and then referred him on. I think, you know, it, it’s one of those, again, it’s, it’s really difficult because, we need to make sure that we’ve got, you know, that we do an MSU in these patients.

And actually, he was 55, so it’s probably an initial reasonable thing to do. [00:05:00] Did actually bring him in, examine him as well. And his prostate did feel normal. But it’s always one of the, although I’ve been reassured by the consultant, it’s one of the things that always worries me. I’ve got very little hands and it always worries me that I actually probably couldn’t feel the prostate properly, although the consultant urologist I spoke to did say that he felt that actually the prostate wasn’t high enough.

Dr Rebecca Leon

Now, just hand wise with me, Sarah, I think we’ve probably very, very, very similar. Yeah, very similar. And that has always been a thing whether can I actually feel the prostate?

Dr Sarah Taylor

Yeah.

Dr Rebecca Leon

And we’ve been told we can, we can.

Dr Sarah Taylor

Yeah. So, we shouldn’t put, let that put us off, doing the prostate examinations.

Dr Rebecca Leon

But I think the learning points, and I, and we work in very different practices, very different patient cohorts, which we don’t, you know, we, we see a range of patients, but really the coding is very good in your practice, and it is good in mine, just in case any of my coders are listening to it.

But something about looking at ethnicity and looking about other things because [00:06:00] from a telephone consultation, we might know who is actually on the other end of the telephone. And so, because your coding is good, that’s something for us to look into that actually, rightly so. After the initial, investigations, like the MSU, you brought them in, examine and examine, examine.

Dr Sarah Taylor

Absolutely.

Dr Rebecca Leon

As we keep saying.

Dr Sarah Taylor

Yeah.

Dr Rebecca Leon

And then, and then did the PSA.

You mentioned, can you just talk to us a little bit about the risks of ethnicity with prostate cancer?

Dr Sarah Taylor

Well, there’s a lot of research now is showing that black men have a much higher rate of prostate cancer. So, one in four black men will get prostate cancer in their lifetime.

They tend to present a little bit younger, and they often have more aggressive disease. So, it’s really important that in our black men, we think about prostate cancer at a younger age. It’s also significant that men with a positive family history are at a much more increased risk of prostate cancer.

[00:07:00] And that’s again, we keep talking about family history, family history, family history, as well as examine. You know, these are going to be the things for everybody, aren’t they? That actually, we should be thinking about it in men with a family history, as well at a younger age.

Dr Rebecca Leon

Okay. And also, if anybody listened to our previous breast cancer podcast, also ask about other family members of different cancers as well.

Dr Sarah Taylor

Yes.

Dr Rebecca Leon

Because of potential genetic links with prostate, breast, ovarian, and others as well. So, I think, again, family history is really important and that will definitely be on both of our PDPs next year. Can you tell us a little bit about an initiative that’s actually going on in Greater Manchester, and it may be rolled out to other parts of the UK further down the line, looking and targeting for potential prostate cancers.

Dr Sarah Taylor

So Greater Manchester piloting an NHS England project, which is to try and increase the diagnosis of prostate cancer in men at risk. So, there’ve been [00:08:00] searches. So, there’s a wonderful yellow, bright yellow van with blue writing, going around Greater Manchester called This Van Can.

And in the practices, in, in the areas it’s going round, the practices have had searches, have done searches to find their patients who are at risk and invited them to the van to have a discussion about whether or not they would like to have a PSA test done. And I think this is something that we need to get into.

I mean, I think that, you know, there are, the issue of PSA testing is a huge one in primary care. There, it, it’s not an easy one. It’s something that I struggle with a little bit. I don’t know what you feel about it, Rebecca.

Dr Rebecca Leon

Yeah, so PSA counselling, which is again, I remember doing my GP exams and one of the things was almost talking to a patient about whether they should have a PSA check.

And we get a lot of people, particularly over the age of 50, it’s around the golf course that they say, get, get your prostate, ask your GP for a PSA [00:09:00] check and they come in and they’re not sure what it is. And the word prostrate as well.

Dr Sarah Taylor

Yes. It’s always a pros.

Dr Rebecca Leon

Yes. Anyway, um, so the PSA counselling is about why they should have it, because it’s not a straightforward test.

It’s, I suppose it’s the best we have in primary care. It’s a blood test, and it’s quite easily done. And I suppose, Ellen, are you still talked to about who can and can’t have the PSA test and what they can and can’t do before? And is that still being talked about, at medical school, about a list of things that we have to tell our patients before they have their PSA test?

Dr Sarah Taylor

Myth buster?

Dr Ellen Macpherson

Yeah.

Dr Rebecca Leon

Yeah. What kind of, what kind of things?

Dr Ellen Macpherson

The, the big one is a, a urine infection, obviously, to rule that out. And then to wait, I think it’s four to six weeks before retesting?

Dr Rebecca Leon

Yeah.

Dr Ellen Macpherson

Recent catheterisation. So that’s often a problem in hospital, recent rectal exam as well, that comes up a lot.

Dr Rebecca Leon

Yeah, absolutely. We were always told, weren’t [00:10:00] we, we couldn’t do the blood test and a DRE at the same time.

Dr Sarah Taylor

But on our myth busting theme, I love a bit of myth busting.

Dr Rebecca Leon

Yeah.

Dr Sarah Taylor

When we did the recent forum, I think we were told differently.

Dr Rebecca Leon

Yeah.

Dr Ellen Macpherson

I think the other one that came up on the myth busting form was recent ejaculation, so actually Cancer Research UK has, wait 48 hours after ejaculation to test PSA, but I think the specialist said that’s, that’s not true. You can just do it, it’s fine.

Dr Rebecca Leon

And the big one also is cycling. So, you know how it’s like a new trend now for middle aged men to cycle and they decide that it’s fine to wear lycra. Or what’s known as mammals. I think I taught you that word, didn’t I, Ellen? Off air, middle-aged men in lycra. Then actually they can still have their PSA test, so they can come in their lycra to the GP examination.

Dr Sarah Taylor

No, no, no. We never said that.

Dr Rebecca Leon

No, absolutely not lycra is banned, but not for that reason. So, these are just [00:11:00] myth busters.

Dr Sarah Taylor

So, so just to clarify, we’re saying that, you can’t have a PSA if you’ve got a UTI.

Dr Rebecca Leon

Yeah.

Dr Sarah Taylor

You can’t have a PSA if you’ve had recent catheterisation or instrumentation, but you can if you’ve had a DRE, a rectal examination, if you’ve had recent ejaculation, or if you’ve been on a recent bike ride.

Dr Rebecca Leon

Wearing tight trousers, pants. I think that was the other thing as well. Anyway, those are slight myth busters that, I think it’s just important to note. But the other thing about the PSA counselling is, is say easy test done, test comes back, and we’re given certain ranges, which again will be, we can put it in the show notes, but, but I’m sure a lot of people will know that the range changes depending on age. But it was actually, I never like to do a test without discussing with the patient what we’re going to do with the results.

Dr Sarah Taylor

Totally. Yeah.

Dr Rebecca Leon

So, you could have a raised PSA, but is the patient [00:12:00] aware that we’re going to then refer them into secondary care and that they’re going to potentially have an intrusive test, have a truncal biopsy, and what that actually means.

And sometimes when I actually say a large needle will be inserted into your prostate gland, they run a mile and say, forget it. But actually, I’m being, I’m being serious now, but I think it’s really important to actually know what the next stage is.

Dr Sarah Taylor

Yeah. That has changed, hasn’t it. So, the new pathway for prostate, for investigating raised prostate looks at you are using MRI as the first investigation. Patients may then go on and have a biopsy, but MRI is a much better test for diagnosing prostate cancer and making some assessment as to the nature of it.

Because one of the other issues is that, I don’t know whether Ellen has found this YouTube video that you were talking about, Rebecca, but about the different types [00:13:00] of prostate cancer, and Rebecca’s been talking about hairs and rabbits and birds and things in relation to prostate cancer, which is an interesting thought.

Dr Rebecca Leon

Are you able to clarify what I asked you?

Dr Ellen Macpherson

I’m so sorry I was not able to find it.

Dr Rebecca Leon

Okay, so what I’ll do is I’m going to attach this, and find it personally, onto the end of this podcast so people can find it. It’s a two minute video of talking about the more slower prostate cancers and that they almost don’t metastasize and…

Dr Sarah Taylor

Sloths.

Dr Rebecca Leon

Yeah, but it wasn’t a sloth. I feel like it was another slow animal. And then…

Dr Ellen Macpherson

Turtle, wait, a turtle?

Dr Rebecca Leon

Yes. Oh yeah. So, a turtle, a bird, and a hair.

Dr Sarah Taylor

Okay.

Dr Rebecca Leon

And you got to see it to believe it. So, I’m not even talk about anymore.

Dr Sarah Taylor

But just give us the gist of it.

Dr Rebecca Leon

The, the gist of it is, actually there are three, so the, the turtle is very slow growing, hardly moves, sits there, doesn’t cause problems. A statistic that we’re [00:14:00] going to walk away with, another Sarah quote that you’ll, you’ll learn these as you go along the podcast is, 80% of 80 year olds at post-mortem, at autopsy, will have a diagnosis of prostate cancer, but that isn’t the reason that they have died.

So, it shows that with age, a vast majority of older men will have prostate cancer, but they will be asymptomatic or there’ll be other symptoms. And we’re going, we’re going a bit backwards and forwards here, but I think the PSA test can be raised for non-malignant reasons, can’t it? Which is part of the aging process.

And we say that actually, 75% or three out of four men with a raised PSA will actually not have cancer. And actually, the PSA test can actually miss 15% of cancers. So, it’s not a great test.

Dr Sarah Taylor

No, it’s [00:15:00] not, is it? And I, and so if you, if you’re saying that you’ve got a high false positive rate.

Dr Rebecca Leon

Yeah.

Dr Sarah Taylor

So, you’re going to have lots of raised PSA that isn’t cancer.

Dr Rebecca Leon

And then they’re going to be referred in.

Dr Sarah Taylor

Yeah. And then of those, you have a lot who might have a very, almost an, an incidental finding that actually isn’t going to cause them any problems.

Dr Rebecca Leon

My turtles.

Dr Sarah Taylor

Yeah. You’ve then you’ve got some that you’re going to miss.

Dr Rebecca Leon

Yeah.

Dr Sarah Taylor

Because the, you’re trying to identify those patients who need more intensive investigation from our point of view is really, really difficult, isn’t it? From primary care. It’s really difficult to work out who out of the, because we can’t tell out of those 20 patients that we might see and referring over the course of a few years, how many of them have got, are more, are not turtles? Because the turtles, we don’t need to worry about.

Dr Rebecca Leon

Turtles we don’t have to worry about.

So, the turtles the ones that almost, it’s just there [00:16:00] and it’s not going to become bothersome. I think the other thing that’s making me feel slightly better, because MRI is now available, when we used to send these turtles in to primary care and they might have a diagnosis, something like BPH, which again is a common, that’s Benign Prosthetic Hypertrophy, not hyperplasia, sorry. BPH. Benign Prostatic Hypertrophy, which is a normal part of the aging process when the prostate gland enlarges and can cause certain symptoms. I felt that they were going for almost unnecessary, intrusive tests, which could then have problems of their own. The MRI is non-intrusive, so there is a slight, with the improvement of the secondary care test, I am feeling a little bit better about PSAs.

Dr Sarah Taylor

I suppose, you know, if we’re pragmatic in primary care, if, I think if somebody comes in and asks for a PSA and a prostate test, then we have those discussions with them and if they want the [00:17:00] test, I think, on the whole, I would probably go ahead and do it.

I would explain to try and explain to them what’s going on, and then if it’s raised, follow guidelines and refer them in and let somebody else have those discussions about what investigations should happen next and what they should go onto. Because things do change, and I think they’re, you know, the, the MRI is really important, as a much less invasive next investigation.

Dr Rebecca Leon

And more, and probably more detailed.

Dr Sarah Taylor

And more accurate. Yeah. So, I think that, you know, our role is to have those conversations say, yeah, the test isn’t perfect. It might indicate something that isn’t concerning, but then we do that with a lot of other cancers, don’t we? And to refer them, and to refer them in and let somebody else have a discussion about what happens next. Because that’s quite difficult.

Dr Rebecca Leon

Absolutely. It it’s just being honest with the patient. Yes, Ellen?

Dr Ellen Macpherson

Just kind of on that point, for your patient that you described who came in and you did the test, if it hadn’t been raised, how would that have [00:18:00] changed your management there? Would you have not referred or, or would you have still made the referral anyway?

Dr Sarah Taylor

I think if I, if I’m being totally honest, if he had a low normal PSA and normal feeling prostate, which I’m assured that I can feel, I would probably not have referred at that point, but I might have done, or I might not have referred on a two week wait, but I might have referred if he’d got persistent symptoms.

I think that it, again, it’s this, it’s the constant thing of sort of safety netting and actually, yeah if, if things, symptoms don’t settle referring then, don’t know what, what do you think, Rebecca?

Dr Rebecca Leon

Yeah. Okay. I’m, I’m trying to think. Probably the same again, the safety netting is so important. Maybe making a telephone in a month’s time and booking the appointment to phone.

And I think if it’s still persevering with his risk factors, with his potential family history, I think I would, refer him because it would be something that’s [00:19:00] not right. The other thing about is, I suppose if you had a positive MSU had been treated and still had symptoms, again, that’s something again to, but again, don’t be over reassuring in some ways.

So, actually say, please do come back.

Dr Sarah Taylor

Yeah.

Dr Rebecca Leon

Because I don’t want them to think, well, the doctor doesn’t think it is anything, so I’m not going to bother them again.

Dr Sarah Taylor

I think that’s really to go back to, you know, you know how I love my quotes with, so your three strikes and you’re in. If this, if he comes back, two or three, if he comes back three times with the same symptom and you haven’t got a good explanation for it, then you probably do need to be referring at that stage, don’t you?

Dr Rebecca Leon

Absolutely. I mean this, you talk about if you’ve got lungs, you can get lung cancer. Is that the same with a prostate?

Dr Sarah Taylor

Well, it must be, mustn’t it?

Dr Rebecca Leon

Yeah, that’ll be the new one. I, I’m going to also put you on the spot here, Ellen and Sarah, just about when we feel the prostate, what is a normal feeling prostate versus an abnormal feeling prostate? [00:20:00]

Dr Sarah Taylor

Ooh.

Dr Rebecca Leon

Go on Ellen. You’ve done training sooner than earlier than us, not earlier, more recent.

Dr Ellen Macpherson

Normal is nose. That’s my, the one that I was taught.

Dr Sarah Taylor

Okay, good. That’s a nice one.

Dr Ellen Macpherson

Or there’s, there’s thenar eminence. People have used that as well.

Dr Rebecca Leon

Oh, you mean how it feels?

Dr Ellen Macpherson

Yeah.

Dr Rebecca Leon

Oh, nice. Okay. I didn’t know that.

Dr Sarah Taylor

Nor me.

Dr Rebecca Leon

And I know it’s a size of a walnut. Yeah, and the word craggy.

Dr Sarah Taylor

Craggy is not good.

Dr Rebecca Leon

Craggy is not good. You want it smooth, and about the central sulcus. Yeah. There we go. So, feels like the thenar eminence. I like that.

Dr Sarah Taylor

Or a nose you said?

Dr Rebecca Leon

Or a nose. I know. But noses can have cartilage

Dr Ellen Macpherson

And kind of consistency of bounciness. And if it’s harder than that, like your forehead, that’s concerning. If it’s a regular craggy, yeah. Or you’ve lost that sulcus in the middle, then those are concerning features.

Dr Rebecca Leon

Dang. I knew you should know more than us.

Dr Sarah Taylor

Yeah.

Dr Rebecca Leon

So, can we talk about the second case? Well, it’s kind of my case, isn’t it?

Dr Sarah Taylor

Yeah. You have [00:21:00] the old patients at your practice, I’ve got all the students.

Dr Rebecca Leon

Yeah. So, I, so yeah, my patient cohort is, of the elegant aging.

So, this was a patient of mine, I think he was kind of about eighty three, eighty four, and we’ll call him Jimmy for this. And comes to see me twice a year and was just getting, hip pain that was different from, he’d had his knee replaced a few years earlier, and he just almost described it as a, as an ongoing dull ache.

He went to see the physio. He, he was quite a proactive patient, so had done all the things, had taken analgesia, was doing stretching from the physio, but it was ongoing. I, with an elderly person, no real other symptoms, no weight loss, had the usual getting up in the night, but had been going on for a few years, and[00:22:00] the issues were just this ongoing hip pain. So, I organised a full set of bloods. I organised a PSA cause I know the two things can be an intertwined, and also organised an x-ray. And his PSA actually came about raised. And also, there was evidence of kind of hip mets, so bony mets, likely coming from the prostate cancer.

We’ve, we, I’ve also seen pathological fractures as well, which is, can be related to primary prostate, is these case that you’ve seen before?

Dr Sarah Taylor

Yeah, I’ve seen a few people like this. Yeah, and, actually again, it’s one of these things that the treatments are actually pretty, they are quite good and patients do get quite a lot of relief from their symptoms by being treated.

So, I think it’s something that is definitely worth looking for.

Dr Rebecca Leon

So actually very different from the first case [00:23:00] that you, that you discussed very almost urinary symptoms and had the family history and the ethnicity that starts getting, thinking, actually, could this be something, but a younger man in his fifties. Mine is an older patient who had pain in his hip that we see a lot of.

Dr Sarah Taylor

Absolutely.

Dr Rebecca Leon

Because it can be wear and tear OA. It can be lots of different things. But I was concerned because I did know him quite well and I could see that he was struggling and it wasn’t his first presentation, even though it wasn’t, even though it was his first presentation to me, he had been to the pharmacist, he had been to the physio and was, and was still struggling.

So actually, think about these things.

Dr Sarah Taylor

And I think that it is, the other thing is to think about it in new onset back pains because it is one of the presenting symptoms of metastatic spinal cord compression. And so, I think, you know, in new back pains as well, I think we just need to be vigilant.

Dr Rebecca Leon

Absolutely. And make sure [00:24:00] we ask all about the red flags. I’ve been told it’s a tortoise, it’s not a turtle, by the way. Because the tortoise and the hair. It’s an Aesop Fable.

Dr Ellen Macpherson

I think it is actually a turtle. I, I have found some articles on the topic and it is a turtle.

Dr Rebecca Leon

Yes.

Dr Ellen Macpherson

A rabbit and a bird.

Dr Sarah Taylor

Okay. Not a hair.

Dr Rebecca Leon

What is it? Oh, a turtle, a rabbit, and a bird. I was right about the bird.

Dr Ellen Macpherson

Oh yeah. So, we’ve got turtles are patients with very slow growing tumours that aren’t going anywhere.

Dr Rebecca Leon

Yeah.

Dr Ellen Macpherson

They’re so slow that, in order for them to cause you any harm, you’d have to live for longer than is the human life expectancy.

Dr Rebecca Leon

Okay.

Dr Ellen Macpherson

Birds are the opposite end of the spectrum. Diagnosis comes too late, they’ve flapped about, they’ve spread the coop and they’ve gone all over the place.

Dr Rebecca Leon

So, this is my second case.

Dr Ellen Macpherson

And rabbits sit in the middle. So, a man with a rabbit cancer may still have curable cancer, so it’s fast growing, but it’s not gone anywhere yet.

Dr Rebecca Leon

So, it kind of [00:25:00] hops around, but it might not actually spread like the bird.

Dr Ellen Macpherson

That’s the analogy.

Dr Rebecca Leon

That’s so we, so we can actually use it for any cancers. But this particular one, I think it works really well for prostate cancer.

Dr Sarah Taylor

There’s a bigger number of turtles.

Dr Rebecca Leon

Yeah, because there are a lot more turtles. So, I’m glad we cleared that up.

Dr Sarah Taylor

I’m, yes.

Dr Rebecca Leon

So, I think we’re up to the key clinical points now.

Dr Sarah Taylor

Yeah.

Dr Rebecca Leon

You know, the podcast, we want to, we’re having honest chats about things that we see in in primary care, and I think we both struggle a bit with the PSA just because it’s not the ideal test, but it does have its role and I think being honest with patients about the pitfalls of the test can be really helpful.

Dr Sarah Taylor

And I, yeah, and I think your point that you, you should never have a test for reassurance because a test might not reassure you. And so, you should, so, so people shouldn’t come in and have a test because they want to be reassured about it because the results may not be reassuring and therefore, discussing the possible [00:26:00] outcomes.

Dr Rebecca Leon

Absolutely. So, some of our key, key clinical points, we talked about ethnicity, which I think is very important and it is a risk factor for prostate cancer, and I’m certainly going to take away that it’s important that we look at this in our own practices, making sure that they are, are up to date, particularly with new patients.

Dr Sarah Taylor

Yeah, so you’ve got your ethnicity recorded so you can identify the black men who might be at a, who are at a higher risk. And I think the other thing that we know, we talk about all every podcast is the importance of family history and recording family history because the family history of prostate cancer, and breast or ovarian cancer and colorectal cancer, because of the association with the BRCA gene, should also be asked about and would just be something else that would increase your suspicion and make you want to refer.

Dr Rebecca Leon

And finally, a raised PSA may suggest there is a problem with the prostate. But it doesn’t necessarily mean cancer. There are other possible diagnoses, [00:27:00] but it should be in your thinking about referring on and particularly having a discussion with the patient first.

Dr Sarah Taylor

And I think there’s just one more from your patient, your elderly patient, that persistent bone pain in older men could be related to metastases from an unknown prostate cancer.

Dr Rebecca Leon

Absolutely. So, thank you for listening today. It’s been a more challenging podcast today, but I’ve actually thoroughly enjoyed it and feel that I have some definite learning points that I’ll be taking back to practice with me. If you want to learn more about prostate cancer, we’ve got a free prostate cancer module that you can find on the GatewayC website.

We’ve put all the references and studies and guidelines that we mentioned in our show notes, including the turtle and the hair. We’ve got a few.

Dr Sarah Taylor

Rabbit.

Dr Rebecca Leon

The turtle and the rabbit. We’ve got a few thank yous as well. Thank you as ever to Sarah and for Ellen for joining us today and to our producers, Louise Harbord from GatewayC and Jo Newsholme from ReThink [00:28:00] 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 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 do press the follow button so you can get the podcast direct to 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. [00:29:00]

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