THE PUBLIC HEALTH RISKS OF PERSISTENT HEARTBURN

Oesophageal cancer is the 7th most common cause of cancer death in the UK.

Around 70% of oesophageal cancer cases are adenocarcinoma, where there is a strong association with persistent heartburn and dysplastic Barrett’s Oesophagus. This is where a past history of apparently resolved  persistent heartburn can be relevant.

Action Against Heartburn is a campaign by 18 charities with an interest in promoting the earlier diagnosis of oesophageal cancer. One main target is the regular customers of over-the-counter heartburn remedies such as Gaviscon.

C the Signs – Double award winners

We are delighted to tell you that C the Signs has won two awards in the last month!

We are extremely proud to have won the Mayor of London’s MedTech Business award in recognition of our collaborative working with the NHS. This award highlights how C the Signs brings together clinicians, charities and patients.

It was also an honour to have been recognised by Amazon for the secure state of the art infrastructure behind the C the Signs Tool.

Cases corner – 52 YEARS OLD WITH WEIGHT LOSS

Mr L, a 52 year old man, presents to you ”not feeling well”. He can’t articulate what he means but describes mild nausea. He denies any other symptoms including abdominal pain, change in bowel habit, rectal bleeding or difficulty swallowing. He says that he weighed himself this morning as his clothes were much looser and he has lost about 10kg over the last 3 months or so. His examination is unremarkable.

What should you do next?

  1. Do not refer the patient, but offer safety-netting
  2. Perform a non-urgent upper GI endoscopy
  3. Perform a CT of the abdomen within 2 weeks
  4. Perform a FIT test
  5. Refer the patient via a 2-week-wait pathway

INTRODUCING THE FAECAL IMMUNOCHEMICAL TEST (FIT)

When diagnosed at stage 1, 90% of people with bowel cancer will survive for at least five years. This is compared to a survival rate of less than 10% when diagnosed at stage 4. Bowel cancer screening reduces bowel cancer mortality by detecting the disease in early (often pre-symptomatic) stages. A guaiac-based faecal occult blood test (gFOBT) has always been the type of bowel cancer screening used in the UK. However, the gFOBT is now being replaced by a Faecal Immunochemical Test (FIT).

HOW THREE SMALL WORDS CHANGED MY LIFE FOREVER

“You have cancer.” Friday 13th May 2011 at 11am my life fell apart. Three words that changed my life forever. A treatment plan was currently being discussed with me, but I couldn’t stop thinking “I am going to die”. Every piece of information I was given during this appointment went over my head and my mind had gone blank with shock.

Cases corner – 30 year old with change in bowel habit

Jane, a 30 year old women, presents with an 8 month history of change in bowel habit and abdominal pain. She describes the abdominal pain as a constant, dull ache with no localising features. Her bowels go from regular, to constipated to loose. She denies any rectal bleeding, weight loss, nausea or vomiting. She reports no dietary changes and has kept a food diary for you to review. Her periods are regular. She has no past medical history to note, is a non-smoker and has no relevant family history. You conduct an abdominal examination and a pelvic examination which is unremarkable. She is up to date with her smear tests.

What should you do next?

  1. Organise an abdominal and pelvic ultrasound
  2. Organise a coeliac screen, inflammatory markers and a full blood count
  3. Order a Ca125
  4. Order a Faecal Immunochemistry Test (FIT)
  5. Diagnose her with Irritable bowel Syndrome

SHINING A LIGHT ON – ROY CASTLE LUNG CANCER FOUNDATION

Every year, over 46,000 people will be told they have lung cancer. Just over a third will then get to live for a year or more.

Late diagnosis plays a significant part in this; around three quarters are diagnosed in the late stages when curative-intent treatment is no longer possible.

So, we need to diagnose earlier. Simple. If only it was that easy.

DOCTOR, HOW DO I…?

Have you ever had a patient ask, ‘How do I get to all of my appointments whilst living with the side effects of cancer treatment?’ or ‘Can I still drive with my brain tumour?’

We work collaboratively with numerous cancer charities to empower GPs to answer these questions quickly and confidently. There is no need to reinvent the wheel, as they say. Rather than us spending time creating our own support resources for patients, we collaborate with existing charities to raise awareness of the fantastic support already available. In the same vane, our tool prevents GPs from spending valuable consultation time searching for answers or appropriate patient support, by quickly directing them to relevant resources.

Cases corner – 7 year old with unsteadiness

A 7 year old boy named James presents with his mum after falling at school. You ask him what happened, and he reports that he felt unsteady and think he tripped. He did not experience any other symptoms. He is currently asymptomatic and feels well in himself. There was no loss of consciousness or head injury. James has had an unremarkable birth history, with no past medical history of note.

You conduct a cardiovascular examination which is unremarkable. A neurological examination, demonstrates an ataxic and unsteady, which his mum confirms is new. There are no other deficits or dysfunction.

What should you do next?

  1. Organise a routine referral to the paediatric team for further evaluation
  2. Reassure Mum and advise her to bring him back for review in 2 weeks with adequate safety netting
  3. Organise an urgent referral to the paediatric team (within 48 hours)
  4. Refer the child to accident and emergency

TACKLING THE DISPROPORTIONATE EFFECT OF CANCER ON WOMEN THIS INTERNATIONAL WOMEN’S DAY

Despite more men that women dying from cancer in the UK in 2016, it is predicted cancer prevalence among women will increase six times faster than in men over the next 20 years.

Public campaigns have raised awareness of the lifestyle choices which can impact cancer risk, yet it is less clear from these campaigns that these choices are affecting women significantly more so than men. This articles hopes to highlight this disparity in honour of International Women’s Day.

Shining a light on – Target Ovarian Cancer

1 in 5 women in England are too ill to be treated by the time they receive their ovarian cancer diagnosis.

Delays, which include women not knowing the symptoms, gaps in GP knowledge and delays in getting the right diagnostic tests all contribute to these women being too ill by the time they are diagnosed to withstand the invasive surgery and chemotherapy needed to treat ovarian cancer.

At the moment these delays risk leaving many women facing no option other than palliative or end of life care.

Cases corner – 56 year old with vaginal discharge

Mrs P, a 56 year old woman, presents to you with a 1 month history of vaginal discharge. She reports no evidence of blood, pruritus, dysuria or dyspareunia She is up to date with her smear tests. She denies any other symptoms. Her last menstrual period was 4 years ago. She has a BMI of 30. You conduct an examination which is unremarkable. She has never experience vaginal discharge before.

What should you do next?

  1. Reassure and ask her to come back if she develops any new symptoms
  2. Advise over the counter clotrimazole and to come back if there is no improvement in 2 weeks
  3. Send swabs to rule out an infection
  4. Refer patient for a trans-vaginal ultrasound Scan

C the Signs – An NHS England case study

It is an honour to be featured as a Case Study of good practice for the early diagnosis of cancer and patient survival by NHS England. Since our pilot in Sutton CCG, we are now working with 130 GP practices across 4 CCGs and have over 500 primary care health professionals using the decision support tool.

SHINING A LIGHT ON – SIMPAL

Unfortunately, in the UK the instances of people being impacted by ‘cancer poverty’ are rapidly rising. As we are all aware, a mobile phone is no longer a luxury, but a necessity – particularly when you are dealing with a cancer diagnosis. SimPal, a young and innovative charity, is providing mobile phones and pre-paid sim-cards for people affected by cancer. Currently there is no other service like this in the world.

How do we get to 3 in 4 people being diagnosed early with cancer?

Last week, the C the Signs Team were proud to present a poster about our progress at Cancer Research UK’s Fifth Biennial Early Diagnosis Conference. The conference took place over three days and celebrated the research from the last decade, alongside the implementation of evidence into policy and practice.

Cases corner – 34 YEARS OLD WITH A BREAST LUMP

Jane, a 34 year old women, presents with a 2 week history of a right sided breast lump she found incidentally in the shower. The lump is non-tender and mobile. She reports regular menses and is due her next period in 4 days. There is no relevant past medical history or family history of breast cancer. She reports she commonly experiences bilateral mastalgia before her period. On examination you confirm the presence of a 2x2cm mobile lump on the right upper quadrant of her right breast. There is no associated lymphadenopathy.

What should you do next?

  1. Safety net the patient and ask her to come back in two weeks
  2. Reassure the patient and advise her that the if the lump remains after her period to come back for review
  3. Refer the patient for a non-urgent breast referral
  4. Referral the patient along an urgent 2-week-wait breast referral

SHINING A LIGHT ON – TREKSTOCK

Every day in the UK 34 young adults are told the life shattering words ‘you have cancer’, stopping them in their tracks. Trekstock is working hard to be here for each and every one of them.

The state of screening in the UK

Last week the BBC published an article exploring the deteriorating state of screening in the UK. The programmes can save lives by detecting cancer at an early stage, prior to symptoms developing. The UK has three main screening programmes for bowel, breast and cervical cancer. Here we explore some of the complex issues involved.

Cases corner – 21 YEAR OLD WITH ABDOMINAL PAIN AND BLOATING

A 21 year old women presents with new onset symptoms of crampy lower abdominal pain, bloating and increased flatulence. She reports experiencing these symptoms on average 3-4 x a week. Her diet is mainly fast food and can bee erratic since she started university 6 months ago. The symptoms are not related to any particular foods and she is opening her bowels normally with no rectal bleeding. Her weight is normal. No symptoms of fatigue or clinical signs on examination.

What would you do next?

  1. Reassure her that her symptoms are suggestive of IBS with safety netting advice
  2. Order baseline bloods, FBC, U+E, LFT and reassure if normal
  3. Order a CA125 to evaluate her risk of ovarian cancer and a FIT test for low risk colorectal cancer
  4. Organise an abdominal ultrasound scan and Ca125
  5. Offer dietary advice, gut health and recommend a food diary

Dry January is not really about January

Dry January, the campaign set up by Alcohol Change, challenges participants to give up alcohol for a month. The initiative has now been running for six years, with increasing numbers of people participating each year. This January 1.1 million more people than last year vowed to give up alcohol. Rather than a campaign about giving up alcohol forever, Dry January asks the social drinker to reflect on their drinking habits and to give their body a break from their normal drinking routine (especially after the festive period)!

This article explores the potential long-term benefits of Dry January and why the message behind the campaign ought to be considered throughout the year.

A 21-year low on Cervical Cancer Screening in England

Cervical cancer affects women of all ages. There are currently over 49,000 women living with or beyond the diagnosis in the UK, with a further 3,000 diagnosed every year.

We know that one day we can eliminate this cancer. This is through the HPV vaccination and cervical screening programmes that we are fortunate to have – with screening providing the best protection against the disease. Worryingly though, attendance for screening is falling year on year and is at a 21-year low in England alone. This means our vision of making cervical cancer a disease of the past is getting further away.

Cases corner – 62 years old with back pain

Mr K, a 62 year old man, attends with persistent upper back pain for the last 3 months. He denies any other symptoms and denies radiation of the pain. On examination, the pain is elicited on firm pressure over the vertebral body.

What would you do next?

  1. Reassure him and offer safety-netting advice if he deteriorates
  2. Request a full blood count, serum calcium and erythrocyte sedimentation rate (ESR)
  3. Request protein electrophoresis
  4. Request serum immunoglobulins
  5. Refer the patient along a 2-week-wait pathway to haematology

C THE SIGNS VISITS NO. 10 AND THE NHS LONG TERM PLAN

In December, C the Signs visited 10 Downing Street to discuss the impact C the Signs has been having and how it can improve the early diagnosis of cancer. This week we welcome the publication of NHS England’s much awaited Long Term Plan to tackle the challenges the NHS is going to face in the coming years. Here we take a look at the cancer priorities and what it means for primary care.

BE THE MOTIVATION YOUR PATIENTS NEED TO QUIT SMOKING THIS NEW YEAR

As 2019 begins I am sure many of us will be setting ‘New Year’s resolutions’, as will be the case for many of your patients. Quitting smoking is one of the most popular health-related resolutions, but also one of the least successful, with the Royal Society for Public Health reporting quitting smoking to be the most difficult resolution to keep (and by some margin). In the New Year of 2016, of those who resolved to quit smoking, 3 in 5 were smoking again by the end of January 2016 and just 13% had stuck to their resolution by the end of the year.

Make Every Contact Count – Tackling Obesity

Obesity is the second biggest preventable cause of cancer in the UK, with Cancer Research UK reporting that more than 1 in 20 cancer cases are caused by excess weight. The risk increases with the more weight a person gains and the longer they are overweight for. Yet small changes that are maintained long-term can make a significant difference. Making every contact count (MECC) is an approach to behaviour change that utilises daily interactions to encourage others to make a behaviour change which would have a positive effect on health. This is an important initiative run by NHS Health Education England which can be implemented by GPs to encourage patients to lose weight.

Cases corner – 19 YEARS OLD WITH LYMPHADENOPATHY

Mr X, a 19 year old man, presents to you with a one week history of lumps in his groin. He is otherwise well, denying any fever, sore throat, appetite loss, pain, urethral discharge, urinary frequency or dysuria. On examination you note generalised lymphadenopathy (cervical, axilla and groin). There is no evidence of pharyngitis and his spleen is not palpable.

What would you do next?

  1. Reassure him and offer safety-netting advice if he deteriorates
  2. Request a very urgent full blood count
  3. Request an urgent blood film
  4. Refer the patient along a 2-week-wait pathway to haematology
  5. Refer the patient immediately to hospital

Loneliness this Christmas

In 2016, approximately 400,000 people with cancer in the UK reported feeling lonely over the festive period. MacMillan Cancer Support reported that 16% of cancer patients felt that the Christmas and New Year period was one of the loneliest times of the year, equalling that of the anniversary of the death of a loved one.

Several factors may contribute to feelings of loneliness among people living with cancer over Christmas, but there is support available for these people over the festive period.

Read about why this time of year can be particularly lonely and some examples of support to recommend to your patients.

Shining a light on – Samaritans

For more than 60 years, Samaritans volunteers have been there for anyone who is struggling. During December 2017, Samaritans responded to more than 400,000 calls for help by phone, email and text throughout the UK and Ireland. Despite the festivities, more than 11,000 of those calls for help and emotional support came in on Christmas Day, with a third dealing with loneliness and isolation.

Samaritans volunteers will be making sure there’s a listening ear day and night again this year for anyone who’s feeling overwhelmed and needs to talk, throughout the festive period.

Cases corner – 8 year old boy with a rash

An 8 year old boy presents to you with his mum, with a 2-day history of a spreading rash over his lower limbs. He is otherwise well with no other symptoms. There is no evidence of confusion, neck stiffness, photophobia or fever. He has previously been fit and well and is up to date with his immunisations. His observations are all within the normal range. You examine his lower legs and see the following rash on his feet and legs. Otherwise, the examination is unremarkable.

What would you do next?

  1. Reassure his mum and offer safety-netting advice if he deteriorates
  2. Refer the patient for an urgent full blood count (within 48 hours)
  3. Refer the patient for a full blood count (within 2 weeks)
  4. Consider urgently referring the patient to a specialist within 48 hours
  5. Refer the patient immediately to hospital

GPs need to be encouraged to become gate openers rather than asked to be gate keepers

On Tuesday 4th December, C the Signs was invited to present at the Britain Against Cancer 2018 Conference, hosted by the All Party Parliamentary Group on Cancer. C the Signs outlined the challenge GPs face in primary care with rising demand and the pressure they are under as gatekeepers, the need for better straight to test pathways and why GPs aren’t the barrier to early diagnosis.

Shining a light on – BOOBS!

CoppaFeel! is an education charity on a mission to educate young people on the signs and symptoms of breast cancer, encourage them to get to know their boobs/pecs and empower them to visit their GP if they spot something abnormal.

“I have lost count of the number of times I have heard a woman say that her GP kept telling her that she was ‘too young’ to have womb cancer”

On 23rd December 2009, I was diagnosed with womb cancer. The diagnosis came out of the blue. I was being seen by a gynaecologist for fibroids when an MRI scan picked up the cancer. I had never heard of “endometrial carcinoma” and actually had to ask where exactly the cancer was. I know now that this happens to many other women.

Cases corner – 50 years old with thrombocytosis

Mr D, a 50 year old man, attends for his annual health check. He is currently fit and well and his examination is unremarkable. A urine dipstick is negative. You perform routine bloods as part of your assessment. The results of this show an abnormal platelet count of 620 x10⁹/L. His previous blood test 6 months ago, was normal. A repeat 2 weeks later is also raised at 624 x10⁹/L.

What would you do next?

  1. Reassure, as patient is asymptomatic, and safety net if symptoms arise to comeback
  2. Re-book patient for a repeat platelet count in 3 months
  3. Refer for a chest x-ray
  4. Refer under a 2-week-wait pathway to haematology for further investigation

Shining a Light on – Pancreatic Cancer Action

Pancreatic cancer is the 5th biggest cause of cancer death in the UK. However, it is set to become the 4th biggest by 2026 as other cancers’ survival rates continue to improve. The survival statistics for pancreatic cancer have not changed significantly in nearly 50 years, with less than 7% surviving 5 years. Pancreatic Cancer Action is the only UK charity that specifically focuses on early diagnosis of the disease.

"I went to the GP that morning with non-specific symptoms and I was admitted to hospital that night with a confirmed diagnosis of Chronic Myeloid Leukaemia"

On Friday 19th January 2007 I received a phone call that would change everything. I went to the GP that morning with non-specific symptoms including lack of concentration, weight loss, fatigue and I had nearly fainted twice that week. I was sent for a blood test and was told to come back next week. I was admitted to hospital that night with a confirmed diagnosis of Chronic Myeloid Leukaemia. I was 22. To say this was a very unexpected shock is an understatement!

Cases corner – 62 year old with dysuria and urinary frequency

Mrs G, is a 62 year old female, who presents to you with a two month history of urinary frequency and polydipsia. She has also noticed that her clothes feel looser. She is otherwise well in herself with no other symptoms. You perform a random plasma glucose which is 13 mmol/L. You also weigh her and she’s 7 kg lighter than last year (last recorded weight).

What would you do next?

  1. Confirm the diagnosis of diabetes and start treatment
  2. Refer the patient to endocrinologist
  3. Refer the patient along a 2-week-wait pathway
  4. Refer the patient for a CT scan of the pancreas

“Could this patient have cancer and how best should I investigate this possibility?”

C the Signs is a clinical decision support tool that makes my life as a GP so much easier. When faced with the clinical dilemma of “Could this patient have cancer and how best should I investigate this possibility?”, C the Signs offers me a tool that I can use during the consultation to check the best options available to me.

Born out of humour – Cancer on board

James was diagnosed with stage 3 cancer of the tonsil at the age of 44. The difficulties he experienced when accessing public transport for his appointments led him to start Cancer on Board.

“We joked with each other that we should pretend we were pregnant, so that people would offer us seats on the tube”

Cases corner – 65 years old with haematuria

Mrs B, a 65 year old woman, presents to you with a 2 week history of visible haemturia. She denies any other symptoms. Examination is unremarkable, but the blood tests you requested show an iron deficiency anaemia. A urine sample confirms visible haemturia and a culture is negative for infection.

Which cancer is Mrs B at risk of? (more than one may apply)

  1. Bladder
  2. Colorectal
  3. Endometrial
  4. Lung
  5. Renal

Shining a Light – The Brain Tumour Charity

Every day, 31 people in the UK are diagnosed with a brain, spinal or other intracranial tumour. The Brain Tumour Charity provides a variety of services online, over the phone and face-to-face to support as many people as possible.

News – C the Signs announces £1,000,000 award from SBRI Healthcare, an NHS England Initiative

We are delighted and honoured to be awarded £1m in funding from SBRI Healthcare. This funding will be transformative in how we diagnose patients with cancer, using our technology. Early diagnosis of cancer has the potential to save more lives than any cancer treatment in history. Using C the Signs technology, patients can be identified at the earliest and most curable stage of the disease. The future of cancer is survival.