Primary Care Update

Macmillan’s GP Advisers, with the support of GPs and the wider Macmillan team, produce a quarterly e-newsletter to inform GPs, primary care cancer leads and the wider primary care community.

It includes the latest developments, learning and case studies relating to cancer across primary care.

Clinical: Pancreatic cancer Q&A

In the quest to improve the rate of earlier diagnosis in pancreatic cancer, GPs need to be provided with appropriate support and information. Here, Macmillan GP Advisers answer some of the questions that may arise among GPs.

What are the signs and symptoms I should look out for to ensure I don’t miss undiagnosed pancreatic cancer – and how do I differentiate these from more common disorders?

Diagnosing pancreatic cancer can be a challenge. During the early stages of the disease, symptoms may be vague or intermittent and can vary from person to person. However, if you have a patient experiencing persistent symptoms that are unusual for them, this may lead you to suspect pancreatic cancer and refer for specialist tests.

Common symptoms include abdominal and/or back pain, unexplained weight loss, and indigestion.

Other symptoms can include:

  • loss of appetite
  • changes to bowel habits – including steatorrhea, diarrhoea or constipation
  • nausea and vomiting
  • heartburn
  • a new diagnosis of diabetes.

Pancreatic cancer symptoms are similar to those experienced in conditions such as gastro-oesophageal reflux disease, gastritis, pancreatitis, gallstones, irritable bowel syndrome or hepatitis. If a patient – of any age – presents repeatedly with unresolved gastrointestinal symptoms, consider further investigation.

If a patient has jaundice, refer them urgently.

Are there any specific patient profiles that should cause me to take particular notice of emerging signs and symptoms of pancreatic cancer?

Risk factors for pancreatic cancer are unclear. However, there is evidence that more than a third of pancreatic cancers in the UK are linked to lifestyle factors including smoking and being overweight. A family history of pancreatic cancer and a person’s age may also increase the risk of pancreatic cancer; 47% of people diagnosed are over 75 years old.

Pancreatic cancer should be considered in new onset diabetes, especially in those aged over 60 years, or unstable diabetes in previously stable type II diabetic patients.

Consider pancreatic cancer in patients with new onset mechanical back pain in association with new gastrointestinal symptoms.

Where concerning signs and symptoms exist, but suspicion of pancreatic cancer is not sufficient for immediate referral, how can I best monitor my patient?

Encourage your patient to keep a record of how often they have symptoms and for how long they are occurring.

To aid this process, a symptoms diary can be a useful tool. Ask them if they have been experiencing anything else unusual, even if it doesn’t seem to be related to the primary symptoms.

Safety netting is of utmost importance in monitoring patients with vague but concerning symptoms so give your patient a definite timescale, such as four weeks, to return if their symptoms persist. Read Macmillan's 10 tops tips on safety netting for more information.

How useful are scans in helping to confirm or exclude pancreatic cancer?

In terms of diagnosing pancreatic cancer, the pancreas is not always well visualised on an ultrasound scan and is not seen on a gastroscopy, so these tests can be falsely reassuring if normal.

Pancreatic cancer is usually diagnosed on a CT scan so if your patient’s symptoms continue or deteriorate consider an urgent suspected cancer referral or direct access CT scan, if available locally.


Case study: GP perspective on SEA

Macmillan GP Chrissie Hunt (pictured) reflects on a patient who presented with metastatic breast cancer at A+E, outlining how completing an Significant Event Analysis (SEA) allowed her practice to learn from this experience.

MM, an 84 year old woman, first presented with breast cancer in our local Accident and Emergency department. She was taken there by her son, an allied health professional, when she started to haemorrhage blood from a lesion on her right breast. 

The lesion was dressed and MM was then referred to the breast care unit where she was seen four days later and diagnosed with metastatic breast cancer. The bleeding was from a fungating tumour on her left breast. She has since died following surgery and radiotherapy.

MM was seen at least twice yearly in practice for reviews of her diabetes and hypertension. She had had a routine appointment with our practice nurse two weeks before her presentation in A/E. At no time did she mention breast symptoms to our nursing staff or her family. Our initial thoughts were – this type of presentation is clearly out of our control. But is it?

So what did we learn about this case in our SEA meeting attended by a team of doctors, practice nurses and administrators? 

We tried to work out why MM had not disclosed her symptoms. Did we ask the right questions in her review? Our nurses are very approachable and had a good relationship with MM. But it is possible they did not offer her the opportunity to discuss any concerns outside her diagnoses of hypertension and diabetes.

So our first learning point was to try and open up consultations a little to discover if patients have any other concerns as a routine rather than in an ad hoc way. However, MM's son feels that even if she had been asked, she probably would not have disclosed anything.

When we looked at the case study in more detail we began to think of changes in practice that might encourage patients to discuss embarrassing or private issues. The BCOC (Be clear on Cancer) campaigns had run a feature on breast cancer in women over 70 that year. We decided that we should make sure these campaigns are advertised on our practice website and information boards. This may have prompted MM to come forward with her symptoms. 

The SEA meeting was also a learning opportunity to make sure all our clinical staff were aware that although breast screening stops at 70, women can still opt into screening every three years thereafter by calling the breast screening unit in the local hospital.

We also looked at the knowledge base of our receptionists, admin staff and healthcare assistants in terms of early diagnosis and have made provision for them to attend locality led courses on early diagnosis, screening and lifestyle factors contributing to cancer.

So in summary our actions were:

  • Support BCOC campaigns in practice – making them accessible to our patients.
  • Ask that extra question – ‘Is there anything else worrying you today?’– in routine medical reviews.
  • Support education for administrative staff as well as clinical staff around early diagnosis and screening.


Case study: a patient’s perspective – from diagnosis to living with consequences

When you are told you have cancer you only want to hear one thing – that you will live. After that, you just want to get through it and get on with life again.

My treatment lasted 18 months and involved chemotherapy (twice), radiotherapy, the surgical removal of my rectum, and a temporary ileostomy. Throughout this I had a timetable, and the constant attention of doctors and nurses. My GP didn't get a look in.

Six months after treatment ended – after my ileostomy was reversed – I had finished being the centre of attention of the medical world, and my life was miserable. I was stuck in the house with an unreliable bowel, racked by pain, and a million miles from the return to normal life I had imagined.

For nearly two years I could not sit down comfortably or sleep properly. I avoided many social situations and pushed myself away from my family. It occurred to me that I might never again be the confident person I was before. Who was I going to be now, and what new things were going to define me?

I was one of the lucky few who discovered the GIaNTs (GI and Nutrition Team Service) clinic set up at the Royal Marsden to treat and research bowel problems after treatment for cancers in the pelvic area. After a few simple tests – from the 27 published in the “Marsden Algorithm” – I was given dietary advice and medicine which started to turn my life around. I was also put in touch with other people who had similar problems, through the Pelvic Radiation Disease Association.

I discovered I was not alone. There are many out there with symptoms worse than mine. For them it is a major undertaking, and a considerable risk of public embarrassment, to leave the house and the safety of their own toilet.

Unfortunately, too many have not had their problems properly recognised and are unaware that improvements can be made.

Visit the Pelvic Radiation Disease Association website for more information.


A spotlight on Macmillan's resources: ask the expert

Macmillan’s Online Community has many aspects to it, including patient discussion forums and peer support networks.

One area particularly worth highlighting to patients is Ask an Expert, in which anyone can pose a question online to the experts on the forum. There are many different experts who give their time to answer questions, including specialist nurses, a gastroenterologist, a specialist dietician and many others.

The forum is monitored by Macmillan’s online team who keep it running smoothly and ensure the right support is available for both patients and clinicians. 

Available 24 hours a day, the forum allows people to ask questions they may be too embarrassed to ask healthcare professionals face to face and also gives them access to professionals they may not otherwise have easy access to. We aim to answer most questions within two days.

Macmillan’s Online Community is a safe website where people can share their experiences of cancer – somewhere your patients and their loved ones can find emotional and practical support from others in a similar situation.

  • If you think the Online Community could help your patients, they can find it at community.macmillan.org.uk.
  • You can order free leaflets about the Community on Be.Mac.


Topical highlights

New talking therapy could help cancer survivors cope

Queen Mary University of London, Barts Health NHS Trust and King's College London are leading a project assessing a novel talking-based therapy for cancer survivors.

Even though people with cancer may be in good physical health or in long-term remission, the impact of the condition and its treatment can be very difficult. About a third of the two million cancer survivors in the UK report poor quality of life, citing problems such as fatigue, fear of cancer recurrence, and concerns about returning to work as major contributing factors.

The award-winning project, known as SURECAN (SUrvivors' Rehabilitation Evaluation after CANcer) is assessing a variation of a talking therapy known as Acceptance and Commitment Therapy (ACT), which puts patients’ views about what they value most in their lives at the heart of the therapy.

ACT helps patients to accept what they cannot change (e.g. the cancer might recur) and commit themselves to goals they are able to and want to achieve, based on their own values.

Previous research suggests that cognitive behavioural therapy (CBT) and exercise have some effect on improving the quality of life of cancer survivors. If the SURECAN therapy proves successful and cost effective, it could be implemented across the NHS to help those cancer survivors who are struggling to cope after the completion of their treatment.

Cancer patients may suffer PTSD

Around one fifth of people with cancer may experience post-traumatic stress disorder (PTSD) several months after diagnosis, and many of these patients continued to live with PTSD years later. This was a conclusion of a study published in the journal Cancer.

According to the authors, the findings highlight the need for early identification, careful monitoring, and treatment of PTSD in cancer survivors.

The research, carried out among 469 adults with various cancer types, revealed a PTSD incidence of 21.7% at 6 months follow-up, with rates dropping to 6.1% at 4 years follow-up.

But although overall rates of PTSD decreased with time, roughly one-third of patients initially diagnosed with PTSD were found to have persistent or worsening symptoms four years later.

Diabetes and weight trigger major cancer rise

A study led by researchers at Imperial College, London has found that around 6% of new cancer cases worldwide may be caused by the combined effects of diabetes and high BMI.

As individual risk factors, being overweight was responsible for twice as many cancers as diabetes.

Worldwide, the two factors accounted for a quarter of liver cancers and more than a third of all endometrial cancers. However, in high-income western countries, the leading cancer due to diabetes and high BMI was breast cancer, accounting for 23.8 per cent of all cancers attributable to these risks.

Reporting in The Lancet Diabetes and Endocrinology, the authors say that if global rates of diabetes and overweight continue to rise, the share of cancers attributable to the combined factors will increase by over 30% in women and by 20% in men by 2035.

Study highlights factors affecting life quality in older cancer patients

A new US study has provided insights on the factors that affect health-related quality of life in older adults with cancer. Published in Cancer, the findings support the importance of addressing persistent symptoms, managing comorbidities, promoting leisure-time physical activity, and addressing financial challenges.

Based on a survey of 1457 adults aged 65 years or older who were one year or more past their cancer diagnosis, the study explored factors in physical, psychological, social, and spiritual domains that could impact quality of life.

The most important contributors associated with worse physical quality of life included severe symptoms of pain, fatigue and disturbed sleep in the week leading up to the survey.

Also important were social domain factors, such as needing help when fatigued. Being physically active appeared to be an important contributor to better physical quality of life. 

The most important contributors linked with worse mental quality of life were again the severity of symptoms such as fatigue and disturbed sleep. Other contributors included the need for emotional support and having financial hardship events.

The study’s results have implications for the care of older cancer survivors, say the authors. As well as appropriate management of symptoms and comorbid conditions and the promotion of healthy lifestyles, their care should recognize the importance of patients’ social contexts and their support needs, including those related to financial challenges, they point out.

Thanks to Mike Livesey, editorial adviser, for his support in producing these articles.