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Recognising cancers: Lung and prostate cancer

Smoking accounts for 85% of lung cancer cases, yet there are also other factors that can play a role

This module helps pharmacists identify and understand some common cancers seen in the community

Update Module1800
From this module you will learn:
  • The patients who are most likely to be affected by lung and prostate cancer
  • The potential causes of these cancers
  • Symptoms that warrant referral
  • Techniques for referring patients that help prevent panic

Download this module - this includes the 5 minute test - here.

Half of the UK population will be diagnosed with cancer at some point in their life. However, survival rates have doubled in the past 40 years and now half of those who are diagnosed will not die as a result of their condition. These positive outcomes are a result of a series of factors, one of which is earlier diagnosis.

The frequent contact pharmacists have with patients means they are in an ideal position to observe symptoms that may be indicative of cancer. By suitably referring these individuals, you can help ensure their timely diagnosis and treatment.

This module will focus on the various aspects of recognising both lung and prostate cancer. A separate module will examine breast and ovarian cancer.

Lung cancer

Lung cancer is the third most common cancer in the UK, below breast and prostate cancer. In 2013, more than 45,000 people were diagnosed with the condition. The risk of lung cancer increases with age, but it is most common in those aged 70 years and over, with few occurrences in those under 40.

There are two main types of lung cancer: non-small cell lung cancer (NSCLC) and the rapidly spreading small cell lung cancer (SCLC). They account for about 87% and 12% of cases respectively, with the remaining 1% consisting of unidentified types of cancer.

The prognosis of surviving lung cancer for 10 or more years is less than 5%, regardless of the success of treatment.

A recent government-led healthcare campaign entitled ‘Be Clear on Cancer’ focused on raising awareness of lung cancer. One of its main messages is that patients suffering from a cough for longer than three weeks should seek out advice from their pharmacist or GP, as this may indicate lung cancer. As a result of the NHS campaign, pharmacists should expect to be approached by patients who may have symptoms indicative of the condition.

Correctly identifying these symptoms may go some way to improving the tragically low survival rates.

Causes and symptoms

One of the most astonishing things about lung cancer is that the predominant cause is something patients have an influence over – smoking. This habit accounts for 85% of cases, with other factors playing a lesser role, such as:

  • family history of lung cancer
  • previous lung diseases
  • environmental air pollution
  • exposure to ionising radiation (eg X-rays)
  • passive smoking (this increases the risk of lung cancer, but to a far lesser extent than actively smoking)
  • past cancer treatment.

Pharmacists are ideally placed to identify patients who may be suffering from the common and uncommon symptoms of lung cancer (see table 1: Symptoms of lung cancer). Although these symptoms can be indicative of lung cancer, they do not always appear until the cancer has progressed.

Table 1: Symptoms of lung cancer

Common

Uncommon

  • A cough that lasts for longer than
    three weeks
  • A long standing cough that has changed or got worse
  • Occasional shortness of breath
  • Coughing up phlegm with dark red blood
  • An ache or pain in the chest or shoulder that worsens on coughing or is present when breathing
  • Appetite loss
  • Ongoing, unexplained weight loss
  • Persistent and unexplained tiredness
  • A hoarse voice
     
  • Difficulty or discomfort in swallowing (dysphagia)
     
  • Finger clubbing – noticeable changes of shape in the fingers and fingernails (more prominent in NSCLC)
     
  • Face swelling – due to blockage of blood vessels
     
  • Neck swelling – due to enlargement of lymph nodes
     
  • Persistent shortness of breath – caused by a build-up of fluid around the lungs

Having one or more of the symptoms of lung cancer can warrant referral. However, it is important to recommend this referral in a way that does not cause patient alarm or concern. This has to be balanced against ensuring the patient understands that the referral is a necessary precaution. There are several ways this can be done (see box 1 below).

Box 1: Referral tips

If you suspect a patient has symptoms indicative of cancer, you have an obligation to refer them to their GP or hospital. However, a delicate approach is needed – using words associated with cancer can cause justifiable concern. Getting the balance right is therefore essential, to ensure the patient takes the message seriously enough to follow through with the referral.

Following these tips can help ensure patients leave your pharmacy with the best advice:

  • Do not use the terms “alarm symptoms”, “emergency” or “sinister” – these will more than likely alarm the patient.
  • Instead, use phrases such as: “Best practice would be to refer you to the GP”; “When someone presents with these symptoms, it’s recommended they speak to their GP rather than getting treated in the pharmacy”; or “These are not common symptoms seen in the pharmacy, I think you should speak to your doctor for a second opinion.”
  • Offer to ring the patient’s surgery for them, to help ensure they are seen with the right urgency.
  • If you are initially approached by the patient’s friend, relative of carer, then it may be appropriate to first speak to the patient over the phone to emphasise the need to see their doctor or ensure they are actually suffering from the symptoms described.

This list is not exhaustive and is easily adaptable. You should take time to consider previous referrals you have conducted, reflect on what went well, and what could have gone better.

The link with smoking

As already mentioned, cigarette smoking is the main culprit for lung cancer. Although heavy smokers are more likely to get lung cancer, the length of time a person has been a smoker is also a significant factor. The evidence is clear that starting smoking when young is worse than starting as an adult. To get the best chance at reducing the risk of developing lung cancer, patients should quit smoking at the earliest possible point.

Although cigarette smoking is the main cause of lung cancer, it is important to understand that those smoking pipes or cigars are also more likely to develop lung cancer than non-smokers. You should stress that no matter how long a patient has been smoking for, it is worth quitting, as benefits can still be gained.

Screening for lung cancer

Unlike other common cancers, there is no nationwide screening programme for lung cancer. This is due to several reasons:

  • there would be a high cost involved
  • current tests are not sensitive enough and do not pick up every form of lung cancer
  • these tests have associated risks (eg the use of X-rays, which introduce radiation).

Aspirin misconception

Over the past year, there has been widespread media coverage about aspirin’s properties as a preventative measure against cancer. However, a number of studies have found no link. You should not recommend that patients concerned about lung cancer should take aspirin, due to its unknown efficacy for this condition and known side effects. You should encourage any patient who insists on trying this treatment to speak to their GP.

Prostate cancer

Prostate cancer is the most common cancer found in men. More than 47,300 new cases are diagnosed each year (according to 2013 figures), with one in eight men contracting this condition at some point in their life. However, unlike some other cancers, the 10-year survival rate is relatively high at 84% (according to 2010-11 figures).

As the name indicates, this condition is a cancer of the prostate. This organ is positioned under the bladder and surrounds the urethra. Its normal role is to produce a secretion that is released during ejaculation.

As with most cancers, the cells in prostate cancer grow in an uncontrolled manner, but this normally occurs at a slow rate and may never actually cause any symptoms. However, all prostate cancer patients should be under observation to ensure it does not spread.

What are the causes?

There is no one cause, but a number of factors are thought to play a role:

  • Age – most cases are diagnosed in men over 50 years old, with the risk of having prostate cancer increasing as individuals get older
  • Ethnicity – research has shown that black men are more likely to develop prostate cancer than other groups. It is not understood why, but figures from Prostate Cancer UK indicate that this group has a one-in-four chance of being diagnosed with the condition at some point
  • Genetics – if a patient has a first-degree relative who has previously been diagnosed with prostate cancer, their risk is four times higher than that of the general population. Typically, a diagnosis at a younger age is indicative of the condition being inherited.

None of the factors above can be influenced. However, there are also certain factors – that can be influenced – that are believed to affect the likelihood of developing prostate cancer, such as obesity, exercise and diet.

Symptoms

Due to the slow onset and progression of prostate cancer, there are often few or no symptoms until the prostate has grown large enough to exert pressure on the urethra. This leads to symptoms related to urination, such as:

  • frequent urination – often at night
  • the sensation of urinary urgency
  • a hesitancy or delay when starting to urinate
  • a slow or weakened flow of urine
  • a feeling of incomplete bladder emptying
  • occasional dribbling of urine.

Less common symptoms, which can occur alongside those mentioned above, include:

  • pain on urination or ejaculation
  • blood in the urine or semen
  • problems maintaining an erection.

Symptoms that suggest the prostate cancer has spread include back pain, testicular pain, loss of appetite or unexpected weight loss.

Other conditions may result in similar symptoms that also warrant referral, (see box 2 below).

Box 2: Conditions that can resemble prostate cancer

Benign prostate hyperplasia (BPH) is an enlargement of the prostate that affects older men, usually those aged over 50. The enlarged prostate puts pressure on the urethra, causing symptoms such as difficulty starting urination, a frequent need to urinate and difficulty in fully emptying the bladder.

Prostatitis is an inflammation of the prostate, which can have a bacterial or non-bacterial origin. Unlike prostate cancer and BPH, this condition occurs in men of all ages. Symptoms include pain when urinating, a frequent need to urinate and difficulties when starting to urinate.

Types of prostate cancer

Patients will present with different stages of prostate cancer, and therefore it is important to understand this, so that you can provide accurate information at each stage. Prostate cancer is split into three stages:

  • Localised – the cancer is located within the prostate itself and is usually slow-growing, with a low risk for spreading. Due to this, it may never cause symptoms and may not warrant treatment in all cases.
  • Locally advanced – the cancer has begun to spread away from the prostate. It may reach organs close to the prostate: local lymph nodes, the bladder or rectum. A specialist team will need to discuss treatment options with the patient and help co-ordinate their care.
  • Advanced – at this stage, the cancer has spread to other parts of the body through the blood and lymph systems. This may lead to the symptoms seen in the later stages of cancer including:
    • Bone pain – described as a dull ache or stabbing pain
    • Fatigue – caused by the condition itself, its side-effects or from treatment
    • Nerve pain – usually only occurs if the cancer presses on a nerve.

Screening

There is currently no UK-wide screening programme in place to detect the early signs of prostate cancer. There is, however, a test available – for prostate specific antigen (PSA) – which is used to check if a patient with relevant symptoms is likely to have prostate cancer. This test detects a protein produced by the prostate, that will have a higher level if cancer, or other conditions affecting the prostate, are present.

PSA testing is not specific enough to be rolled out at a national level, and it can be unreliable, showing false positive results – meaning a patient can undergo painful, unnecessary biopsies. Another reason routine testing is not adopted is that prostate cancer may be symptomless and cause no problems within an individual’s lifetime.

There is ongoing discussion surrounding the need to have routine screening in place, as it has been argued in some studies that it could reduce deaths caused by prostate cancer by 20%. Research has shown that screening those with a family history can help identify those who are at risk of aggressive forms of the disease.

When is treatment required?

Although treating prostate cancer in its early stages can be beneficial in some cases – for example in those individuals with aggressive cancer – the severity of side effects means that those with less aggressive forms often delay treatment until it is absolutely necessary.

As there are variations in the cancer’s aggression and onset of symptoms in individuals, treatment is dictated on an individual basis, taking into account the stage of the disease in the patient. However, “watchful waiting” or “active surveillance” – the process of actively keeping an eye on the cancer before engaging in treatment – is often undertaken.

Recognising cancers: Lung and prostate cancer CPD

Reflect What are the most common symptoms of lung cancer? What are the risk factors for prostate cancer? How can patients reduce their risks of getting these cancers?

Plan This article contains information about lung and prostate cancer, including the patient groups who are most likely to be affected, the risk factors associated with these cancers and the symptoms that warrant referral. Techniques for referring patients that help prevent panic are also discussed.

Act Read more about lung cancer on the NHS Choices website

Find out more about lung cancer campaigns from the Cancer Research UK 

Read more about prostate cancer on the Cancer Research UK 

Think about how you can improve your patients’ awareness of lung and prostate cancer symptoms. Find out about information and leaflets you could display.

Make sure your counter staff are aware of cancer symptoms, how to deal with questions sensitively and know when to refer.

Evaluate Are you now confident in your knowledge of the risk factors and symptoms of lung and prostate cancer? Could you give advice to patients and carers about these conditions?

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1 Comments

Richard Lindley, Locum pharmacist

I have passed the exam on Module 1800 but my computer has had a blip and i cant print out the certificate please advise or e mail it to me

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