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Colorectal Cancer in Young People

Simon Curtis - 15 Feb, 2018

I am totally absorbed in a brilliant book at the moment, Late Fragments by Kate Gross. I think it must be one of the most inspiring books about life I have ever read. And yet it was written by a young woman who died of colorectal cancer aged just 36. Reading it brings to my mind two unexpected cases of colorectal cancer in young adults in my practice in recent years, one of who tragically died in his mid 20s.

A paper in the BJGP last year highlighted the rising incidence of colorectal cancer in younger adults. We think of it as an older person’s cancer but there are 2,500 cases annually in adults aged under 50 in the UK, a 45% increase since 2004. They are more likely than older patients to have a late, emergency presentation and have a worse 5 year survival. Research from the US shows a similar story, especially a sharp rise in anal cancers. The reasons for this increase are not clear. Changes in diet and lifestyle have been postulated but my patients were slim and healthy and I can’t help feeling there must be something else going on. There is also an increasing incidence of inflammatory bowel disease.

What does this mean for us as GPs? After all, we see a lot of haemorrhoids and IBS in young adults. Lessons from case control studies of missed diagnoses tell us that young people presenting with symptoms were frequently told that they were ‘too young’ to get cancer. This research needs to alert us to the importance of physical examination and routine blood tests. For example, always doing a PR even in young adults with rectal bleeding and considering a FBC if it is unexplained, and routine bloods before making a diagnosis of IBS. What about the role of faecal markers in diagnosis? NICE have updated their suspected cancer guidance NG12 for lower GI cancers and now advise testing for faecal blood using the FIT test in adults of any age without bleeding but unexplained symptoms that do not meet standard referral criteria. Primary care research has also found that faecal calprotectin can be a useful test in primary care to rule out colorectal cancer, and a very useful new risk assessment tool has been developed based on research from the University of Exeter which recommends wider use of a FBC and faecal calprotectin to help referral decisions.

There is an international Never Too Young movement raising awareness of this trend, so we will see more worried young people coming to see us with bowel symptoms. We need to protect them from over diagnosis and iatrogenesis, but at the same time we need to be aware that, whilst it remains rare, young people do get colorectal cancer and make sure we examine and investigate appropriately. This new guidance will help us to navigate this path.

It is tragically too late for Kate Gross, but if you read her inspiring book she will have left you a great gift.

Defensive Medicine

Ahmed Rashid - 8 Feb, 2018

What does defensive medicine mean to GPs?

This was the research question of a study that caught my eye recently. I’ve often heard colleagues describe decisions as ‘defensive’ but have sometimes wondered whether it’s meant as a compliment or an insult. Are defensive doctors conscientious and thorough? Or are they, in fact, neurotic and wasteful? In a healthcare system struggling financially, and in era of enlightenment about the harms of overtreatment, it certainly doesn’t seem like something that should be encouraged.

The study was from Denmark and was published in the BMJ Open in December 2017. The study sample included experienced GPs, who understood defensive medicine to mean actions performed without medical indication to ‘cover one’s back’ and to secure oneself against patient complaints. Interestingly, however, when the phenomenon was explored in more depth, many of these GPs found that this interpretation underestimated the plethora of daily defensive actions that can take place in general practice.

Most GPs in the study identified ‘the system’ (politicians and health authorities) to be important contributors to their defensive practices and explained that complying with policies against their own clinical judgement was a source of enormous frustration for them. National clinical guidelines were highlighted as an important driver to act defensively, as were government policy initiatives related to quality.

Other factors that the GPs identified as important were patient pressures (including the indirect effect of the media), self pressure (including the desire to minimise fear and uncertainty), and peer pressure (including fear of gossip by hospital colleagues).

The Danish authors conclude that their study “may lead to discussions within the medical establishment about the potential impact of externally imposed policy interventions on GPs’ professional autonomy and sustainability of their work”. These conversations are also desperately needed in the UK and it seems pretty clear that a substantial cultural change will only come about following policy changes at the highest level.

The case of Dr Bawa-Garba has prompted much distress and soul-searching from across the medical profession and made us think about defensive medicine in a new light. I don’t think any GP goes to work wanting to practice ‘defensively’. The reasons why we sometimes do are complex and unfortunately can’t be fixed with a magic wand. So I think the main message from this study is that we shouldn’t be too hard on ourselves. Defensive medicine is just one of a series of challenges that healthcare systems around the world are facing and although we’re grappling with it at the GP coalface, the root causes (and therefore solutions), ultimately lie elsewhere in the system.

Should we start hypertension treatment with combinations?

Simon Curtis - 22 Feb, 2018

Tomorrow you see Clive. He is 72, doesn’t smoke and weighs 100kg. He has had several high blood pressure readings noted over the previous year. You check his ambulatory blood pressure and his day time mean is 154/88. He has no co-morbidities but he is at high cardiovascular risk and his 10 year QRISK3 score is 28%. You have given lots of lifestyle advice and now you offer antihypertensive drug treatment (we’ll park the statin debate for now!). Should you start with a single agent or a combination?

The brand new American Hypertension Guidelines have generated a huge amount of debate (see current BMJ editorial) because of the lowering of diagnostic thresholds (they define Stage 1 Hypertension now as a mean systolic of 130 to 139, and Stage 2 as >140) and targets (< 130/80!!!) largely based on the ‘seminal’ SPRINT trial. The debate about this will rage on, but I think one of the most eye catching recommendations in the guideline is to start treatment with dual combinations of drugs rather than monotherapy in people whose initial mean BP is >150/90.

We have known for a long time from research and clinical experience that most patients eventually need combinations to reach targets, and also that lower dose combinations can be better tolerated than full dose single agents Hypertension 2017. Patients often have a sense of disappointment when further drugs have to be added, so starting with combinations can be an attractive idea and a dual approach makes physiological sense…and yet, we also want to reduce polypharmacy and why take two drugs if one will work for you?

The crucial question is whether initial combination therapy compared to initial monotherapy and sequentially adding drugs as needed actually improves patient outcomes, like strokes and heart attacks. Cochrane examined this in a systematic review last year Cochrane 2017. The bottom line? We don’t know, there is insufficient evidence to tell us. The recent PATHWAY 1 Trial shows that combinations give better initial control (no surprise, they are on more treatment) than initial monotherapy but at a year the BP levels are the same when second line drugs are added in to reach targets. The authors postulate that this will translate into improved CV outcomes because people are exposed to higher BP levels for longer, and although this is not proven observational research suggests it may indeed be the case.

So, what about Clive? As with so many things we have more questions than answers and ultimately it will be down to Clive’s preference and your clinical judgement. My feeling is that he is at high risk of a major cardiovascular event, we want to get rapid control of his blood pressure and he is highly likely to end up on combinations anyway so starting a low dose combination in line with this guidance is a good option. As for what target we should reach, we’ll park that debate for now (!) but as the BMJ editorial points out, debate about targets and thresholds shouldn’t distract from ensuring that high risk patients are treated.