Cancer, COVID-19 and General Practice

David  0:15 

Hello, I’m Dr. David Stokes and today on the Dr. Family podcast I’m exploring cancer care in the UK, comparing it to the rest of the world and hearing about how continental plumbing could be saving lives. Unlike Coronavirus, we want this podcast to spread so please share widely with anyone you think may enjoy it. And don’t forget to subscribe and rate us in your podcast software as this really helps spread the word. In the UK between 2015 and 2017. There were 367,000 cases of cancer and 164,000 deaths from cancer. But 50% of people survived for 10 years after their diagnosis. So a significant number of us are touched by cancer during our lives either personally or within our families. And the incredible news is that 38 percent of cancer cases are potentially preventable. We discussed today prevention, screening, diagnosis and aftercare of patients with cancer. Focusing particularly on the role of your family doctor, we go on to discuss the effect that the COVID-19 outbreak has had on cancer diagnosis and treatment. And today I’m joined by the clinical champion for cancer at the Royal College of general practitioners, senior clinical advisor at Cancer Research UK, as well as practising GP, Dr. Richard Roope.

David  1:34 

Something that we often hear in the media is that the UK seems to be lagging behind the rest of the developed world in terms of its cancer diagnosis or survival. Is that something that you think is a true reflection of the state of play in the UK at the moment? Or is it simply a fact that our records are better and we therefore have certain biases that make the data that worse than they actually are?

Richard  1:56 

I think it very much depends on how you benchmark yourself. So as a nation, I think we aspire to be the best. So if we benchmark ourselves against the best, then we’re not quite there, things have been improving hugely, but we still lag behind some of the best in Europe, and Australia, New Zealand. So there’s a great organisation called the International cancer benchmarking Partnership, which compares similar countries with similar health systems. And when we compare ourselves with the members of that, then we are a little bit adrift. And there are many, many factors that contribute to that, some quite humorous, but some are just simple issues of capacity doctors per thousand patients length of consultations, perhaps so a whole lot of factors.

David  2:46 

So you alluded to some of the slightly more amusing reasons for these variations. Perhaps we could explore those a little bit.

Richard  2:53 

So one of the observations is actually down to the design of the toilet bowl for those who have travelled to the low countries, Belgium, the Netherlands, the loos actually have a little platform that you’re poop lands on.

David  3:06 

Oh, yes,

Richard  3:06 

The expectation is that you look, whereas in the UK, we certainly don’t do things like that and the less we see the better.

David  3:12 

No indeed

Richard  3:13 

So there is I think the Continentals are slightly more body aware, and perhaps more forward in getting to see a friendly doctor when they notice symptoms.

David  3:22 

Are there any others that you’ve come across in your travels through cancer diagnosis,

Richard  3:27 

and the other one is that there’s quite good research that shows that the Brits are worried about wasting GPs time. And of course, for those of us on the front line, we see the ones who we sometimes feel are wasting our time. And the ones who we don’t see are probably the ones who should be there. So you get this sort of almost inverse care law that we see a lot of the worried well, and we’re not seeing those with significant symptoms early enough.

David  3:53 

Yes, I want to come to that a little bit later talking about the effects of the latest changes as a result of the Coronavirus pandemic. Which is the significant changes in patient and doctor behaviour. So what other factors are there that we really need to be aware of the leading to these different outcomes? We’ve talked a little bit about the humorous ones. But in terms of other issues such as screening or other areas where cancer diagnosis could be improved,

Richard  4:17 

If you go back to very first principles as a nation, we spend a smaller proportion of our GDP on health care. And within that slice of the cake that goes towards health care, we spend less on cancer care, right from prevention right through to end of life. So it’s under resourced. There are some really quite stark statistics but if you look at numbers of CT scanners and MRI scanners per hundred thousand population, we’re pretty much at the bottom of the European league table are propping up the bottom with Moldova. But what is amazing is what we then deliver with what we’ve got. So we are not equal with Moldova in terms of what we then deliver and how much we bleed the kit we’ve got. So if you actually look at numbers of scans undertaken, we’re probably middle of the league table. But that’s done on the bottom of the league table of numbers of scanners.

David  5:12 

Clearly, the best way to improve the country’s cancer results is to reduce the number of people developing cancer in the first place. For the most part, this is promoting a healthier lifestyle and won’t be of any news to you at all. cutting down on alcohol intake, reducing our body mass with a healthy diet and exercise. And of course, stopping people from smoking are all obvious targets. But it’s not always so obvious what the best ways are to help our patients with these issues. I asked Richard, if you had any tips?

Richard  5:38 

Yeah, so one of the opportunities that we as GPs have is that we know our patients and we engage with them. And we have that continuity of care in the main. And one of the joys of having been a GP and the same practice for nearly 30 years is that I’ve sort of grown up With my patients and beginning to grow old with my patients, and the opportunity to engage with them, there have been some really interesting research programmes which sort of undid everything that I learned at med school. Because at med school, the line was if you frighten your patients, they might act. So you tell them how they’re if they don’t change their lives, it’s all doom and gloom, and they’re going to die. And actually, the research says that has absolutely the opposite effects. And the new technique, which is called very brief advice, you can actually learn to do it and deliver it. And it takes 30 seconds to do it. And it basically involves you ask the patient, whether they’re smoking, if they say yes, you say, well, the best way of giving up is with professional advice and with some chemical support. And if you’re interested in having that support, then we’ve got a fantastic practice nurse down the corridoor who’s gonna gauge with you. That’s all you say.

David  7:03 

This could explain why you may have noticed your doctors approach to your lifestyle issues having changed recently, I will include a link in the show notes and on our website giving details of lifestyle changes that can help reduce your chance of developing cancer. We will be coming back to some of the psychological approaches you may want to try in your own approach to maintaining a healthier lifestyle in future podcasts. The recent introduction of the human papillomavirus vaccine has been a significant change in the attack on cancer. The virus that causes warts is implicated in the vast majority of cervical cancer cases. And this vaccine has the potential to slash the burden of these cancers in the future. I asked Richard about this.

Richard  7:41 

Yeah, so that’s really exciting, and it has the potential to be a complete game changer for those who are under the age of about 30. But for those he went through their teens prior to the immunisation programme, they can develop problems at any age thereafter, cervical cancer is pretty much on its own in the in terms of numbers. So if you look at the age incidence, there are sort of two peaks. There’s the sort of the mid 20s to mid 30s Peak. And then there’s a peak a lot later in life in 70s and 80s. And it’s hoped that that 25 to 35 Peak will be flattened pretty quickly with the HPV you know, coming through, and but it will obviously take a whole lot longer before it affects and reduces the peak in the later years.

David  8:40 

If we can’t prevent a cancer, then the next best thing is to catch it as early as possible in its course, to have the best chance of curing it. Screening programmes are in place to capture cancers often before people have developed symptoms. And we discussed the screening and role of general practice in this process. We started by talking about some of the latest changes to the bowel cancer screening programme.

Richard  9:00 

So we’re really hopeful that with the change of the kits from the old FOB, the guac test to the new Faeco immuno chemical test, the FIT test, we’re hopeful that that will give a lift to the numbers of patients who do return their kit. Certainly the early data suggests that the hard to reach groups, which are the male of the species will say those from a beam background that they were more reluctant to send back the old kit.

David  9:31 

So we mentioned the FIT Test, which is a more sensitive test than the old test. Is it something that people are finding more acceptable to to actually perform?

Richard  9:41 

Yeah, absolutely. So particularly for our black and mixed ethnicity groups, the idea of keeping three days worth of poo samples in the fridge was never a good one. No, and there was quite a lot of cultural challenge with that. The new test is just a single test and you basically have a little You spike into the poo, put it in the tube and send it away, so very much quicker and clearly less yuck factor.

David  10:08 

And that’s always got to be a good thing. So the stool sample changing and the screening test for bowel cancer, they’re hopefully improving things and you said that some of the early data was looking promising.

Richard  10:19 

Yeah, so it would appear that you get an uplift across the whole population, but the biggest uplift is in those who previously had the lower return rates say the uplift for men is greater. And the uplift for black, Asian and mixed ethnicity is greater. One of the things that was interesting was the original bowel screening was introduced at a time of relatively low morale in primary care. And it was decided to arrange the screening process so it didn’t have to involve GPs and as a results, GPs were pretty much disenfranchised from the whole process. And for years in our practice, we just used to file those non returning documents. But since taking on the cancer role, we started to engage and did a very interesting pilot project, which showed that the 200, who we sent letters to essentially endorsing it, saying that we would recommend doing it, we’d notice that they hadn’t been able to engage, but please do because it can save lives. We sent out about 220 in our initial screen of those who we’ve had these lessons back from the hub just over 30 would then engage and one of them was diagnosed with early bowel cancer, right so that the strap line we use was 200 stamps to save a life.

David  11:37 

It’s not a bad return,

Richard  11:39 

pretty good return. And since that time, I was involved in a research project, which we subsequently published showing the increase in uptake you get with GP endorsement.

David  11:50 

As we just heard, the GP can be a powerful advocate for screening programmes. Through their encouragement more people tend to engage with them leading to more lives being saved. I asked if there are any plans Within the NHS to encourage this engagement of general practice in the cancer screening programmes.

Richard  12:04 

Yeah, so, two exciting developments. One is the new course the improvement element to QoF. Indeed, weight has been slightly on hold because of the COVID season that we’re all in. But within that there is a screening and early detection of cancer project, which divides into two one for screening and one for early diagnosis. So within the screening, it just asks the practice and the pcn to engage in some activity that will improve screening returns. The one that has the potential for biggest sort of return for your buck of investment of time, toil and sweat is bowel screening.

David  12:47 

At the present time in the UK, there are three cancer screening programmes covering breast cervical and bowel cancer. As we’ve just heard. Designing a screening programme is a complex business and can’t be rolled out for every cancer. We might like to be able to, There needs to be a number of parameters in place to allow a screening programme to be developed successfully. These include a well understood disease progression, a good and reliable test for the disease, and an intervention that can be put in after the test has come back positive that would improve outcomes for patients. I asked Richard about the PSA blood test for prostate cancer that is requested so often in general practice after some high profile advocates have been seen in the media.

Richard  13:25 

So there are two very distinct groups which I think it’s very important to distinguish between there are the symptomatic patients who are presenting with urinary problems, where the PSA is definitely part of the workup and the assessment of the patient. But for those who don’t have symptoms, having a PSA test is much more controversial. And that is because and it’s all a bit black and white, and sort of unemotional. If you look at mortality rates, it appears to make no difference at all. And if you screen 1000 non symptomatic gentlemen, you will, on average find 20 additional prostate cancers, and they will undergo quite radical, potentially life changing treatments, actually for no change in mortality rates at all. And we’ve had a lot of publicity with the sort of the Bill Turnbull(s), Stephen Fry(s), who have been diagnosed with prostate cancer following a PSA test and the challenge with anyone so not homing in on them as specific individuals. But for a given individual, if they have treatments, which leaves them with problems subsequently, which may be for life, they will be eternally thankful to the medical world for help helping them out. But actually, they might have live with their cancer without knowing and not had any of the long term problems that can result from treatment. Yeah, there is some really interesting and helpful literature which I give to a lot of patients, which Cancer Research UK have developed which gives a very clear diagrammatic way of showing what screening results are seen, and the fact that it doesn’t actually improve mortality outcomes at all, and may cause problems with leaky bladders and sexual function that may not otherwise have been impacted upon. One of the challenges we have within the prostate cancer subject matter is that it is probably not one disease. And there are probably subtypes of prostate cancer, where some are very aggressive and very unpleasant and definitely need treatment and others which are completely innocuous. And in the medical world, we talk about the fact that you live with it and die with it rather than dying from it.

David  15:45 

It is clear that with a test for prostate cancer currently available and are as yet incomplete understanding of the disease the screening programme is not yet advisable more research is ongoing to look at improving our understanding of the disease which will hopefully allow us to detect more dangerous prostate cancers. With a screening test in the future. I will include a link to the literature mentioned by Richard in the show notes and on our website thedoctorfamily.com since the beginning of the lockdown for the corona virus pandemic. Within our practice, we’ve noted a significant reduction in the number of people coming forward with the symptoms that would normally prompt a referral for the exclusion of a diagnosis of cancer. I asked Richard, what have been seen nationally,

Richard  16:25 

So from the National picture from the cliff edge from the second half of March, if you look across the whole of England, prior to COVID, there were about 40,002 week referrals made each week. Yeah, the line we use, it’s a referral pathway to exclude the possibility of cancer. The vast majority of those actually current up until COVID 93% of those patients who were referred along that route did not have cancer. 7% were very grateful they had been referred because they indeed were found to have cancer. So pretty much overnight from 40,000 per week referrals, it went down to 10,000 per week. And the latest data suggests that that has improved to about 20,000 per week. So we’re still 50% down from the pre COVID levels.

David  17:22 

I suppose it’ll be interesting to see whether as a result of this, the number of those referrals are positive, whether it will improve the specificity of the referrals or if sadly, as I suspect, we are missing some of them

Richard  17:33 

So you get both say we have got some early data coming through. So in one of the units, they are seeing a 45% conversion rate, which as either means that the GPs are being totally amazing and referring just the patients who need to be referred, but I think more likely, is that we’re only seeing the patients with an On symptoms. So the message really to get out to the public is that we are open for business not quite as usual. Because the way your first encounter with a GP is most likely to be either by internet or by telephone. But we are very much open for business and want to hear about your symptoms. If you’ve got symptoms that are different to normal and you’re concerned about them.

David  18:25 

I’ll also put a link in the show notes and on the website to the CRUK web page giving details of the symptoms that should prompt a visit or in the current times at least a call or an online contact with your GP.

Richard  18:36 

Yeah, in very simple terms, if you’re going to go for for symptoms, so that the for our blood pain and lumps that come stay, don’t go away and there’s no good explanation for them, and weight loss that you can’t explain.

David  18:52 

Thanks. I’ll commit those for to memory. So if we look further down the cancer journey once a cancer has been diagnosed, those patients may well The treatments in terms of surgery or chemotherapy, how is the COVID pandemic been affecting these treatments?

Richard  19:07 

So really challenging. So in the early days, and we didn’t really know how things were going to pan out, a lot of people were having treatment put on hold for a while, because it was felt that the risks of attending hospital were too great and were probably greater than not having the treatment as social distancing had its impact. And we didn’t get the peak that we feared. hospitals have been pretty quick in setting up what are called Green sites, or protected sites, or sometimes called cold sites, so they lots of different words being used, but they’re essentially either areas of the hospital or in the case of lately, a one of the local private hospitals has been effectively commandeered by the NHS, where it means that patients can receive their cancer treatments in an area where they are no COVID or essentially sick patients coming through the department or the building. So, treatments have opened up again, which is really encouraging. There is always the concern. And there are ongoing discussions as to how we can address it for the realisation that people are infectious, pre symptoms, or actually are infectious and never get symptoms. So we talked about the pre symptomatic or the asymptomatic, and there is certainly a significant elements of that going on. And there were some quite interesting things with the lack of smell being added to the list of symptoms yesterday, that it would appear that there are clinicians who lost their sense of smell and had no other problems at all. And they have probably had COVID So interestingly, one of the real concerns is protecting the patients from the doctors and nurses and other clinical stuff. Yeah, yeah, say say although the With all the fantastic support we’ve had from the public, that they’re they’re trying to protect us from becoming ill. Actually, we’re really aware that we want to protect patients becoming ill from contact with us. Absolutely. Which, which is why two or three weeks ago, general practice adopted wearing PP for all patient contacts, not just those with patients we thought might have COVID Finally, I asked about Richard’s thoughts on the future of cancer care in the UK, and in general practice in particular. Yeah, so at the moment, there are pilots and lung checks going on. One of the areas where the UK is really less good than a lot of other comparable countries, is our lung cancer survival rates, which are pretty poor. And there is good evidence that screening does look as though it works if it’s targeted. So for the purists, screening is activity that is for whole populations. We’re seeing increasingly when you’re looking again for value for investments, actually having targeted screening can be really effective. And there are currently or currently 10 pilots going on in the country, rolling out a programme of what are called lung health checks, where those who have a history of smoking within a certain age group are having a low dose CT scan, and in addition getting support to adjust their lifestyle to reduce the risk of lung cancer. Is that being focused very much in areas where there is a higher smoking rates than others? Absolutely. So they’ve targeted the 10 areas are those with high smoking rates and therefore, very understandably, high lung cancer rates. So in terms of the South Southampton is the one area that’s undergoing the pilots progress All the others are either London or the sort of through the strip across the sort of the what was referred to as the red line, but it’s now become the blue line in the last election. So it’s the sort of the Liverpool Manchester Sheffield area.

David  23:16 

And in terms of the changes in general practice, has there been anything that you think has come out of the COVID crisis, which has been positive?

Richard  23:23 

Yeah, I think the just the amazing innovation that has happened through this COVID season. I mean, everyone talks about looking for the silver lining, and certainly in our practice and our pcn there is a fairly thick silver lining in terms of bringing together a community of clinicians and health care workers and support workers and managers. So that’s been fantastic. I think some of the the it the progress that’s been made in the last two or three months would probably have taken three or four Yours we like COVID. So I think it is mpg improved our productivity. I think the patients have been amazing adopting it. I’m always amazed with some of our more senior patients who’ve engaged with it wholeheartedly. And that’s just fantastic. In the cancer world, there are two elements coming through. I think the lung health checks look as though they are here to stay. We’re hoping for more helpful blood markers. So we were talking earlier about the rather poor PSA test, there is the hope that we’ll get better markers coming through that we’d much more helpful for prostate cancer.

Richard  24:39 

prostate cancer. The other thing is the rise of genomics. So again, with the prostate cancer discussion, we may be able to do a biopsy of the prostate cancer, work out which subtype it is as to whether you then need treatments or not, and that will probably be rolled out. The other area very similar to actually with breast cancer, where breast cancer is probably not one condition, but Many with many subtypes, and we will then be able to personalise the care to each individual patient with their individual cancer type, so that they are getting the right treatments. And in some cases not having treatment that wouldn’t have helped, indeed.

David  25:18 

Well, Richard, I really thank you very much for taking the time to spend with us today. And I look forward to hopefully catching up with you face to face some time, rather than Oh, great. But, yeah, you take care and hopefully, as I say, catch up soon. I’d like to thank Dr. Richard Roop for sharing his insights with us today. Please do check out our show notes, and the website as I will be putting up the links to the information mentioned in this podcast. I hope you’ve enjoyed this episode. As much as I’ve enjoyed making it. We’ve been overwhelmed by the positive response we had for the first podcast, and we’d be very grateful for your reviews and ratings on your podcast players as they really helped get the message out. Please share this with anyone you think may enjoy the show. Come and interact with us on the Facebook and website for this show. Once more, I’d like to thank drew wordly for his beautiful music. See you next time.