BMJ Research News: Persistent sore throat may be a warning sign for laryngeal cancer, study suggests

Mayor, S. | 2019| Persistent sore throat may be a warning sign for laryngeal cancer, study suggests|BMJ364 | doi:

Persistent sore throat, particularly when combined with other apparently low risk symptoms, is a previously overlooked clinical risk factor for cancer of the larynx, a UK case control study in UK general practice has found.

Study author Willie Hamilton of the University of Exeter Medical School said:

“This research matters. When the National Institute for Health and Care Excellence (NICE) guidance for cancer investigation was published there was no evidence from GP practices to guide this—nor to inform GPs.”

“These results expand current NICE guidance by identifying new symptom combinations that are associated with laryngeal cancer. They may help GPs to select more appropriate patients for referral,” suggested the research group.

Diagnostic delay is one of the main predictors of poor prognosis in laryngeal cancer. An earlier UK study of 28 cancers showed it had the fifth longest delay in primary care referral.

Current NICE guidelines suggest urgent referral for patients with persistent unexplained hoarseness or lump or neck lump but these were based on consensus rather than primary care evidence.

The new study, funded by the National Institute for Health Research, compared 806 patients diagnosed with laryngeal cancer between 2000 and 2009 with 3559 controls matched for age, sex, and practice.

The study’s findings showed that 10 symptoms were significantly associated with being diagnosed with laryngeal cancer.  74%  (595 of 806) of the patients had at least one of these symptoms recorded at a primary consultant in the year before their diagnosis.

Similar to findings from secondary care, hoarseness was the commonest of the 10 features, with a positive predictive value of 2.7%.

But several symptom combinations not currently mentioned in the NICE guidance gave positive predictive values greater than 3%, which is the threshold for urgent referral.

Recurrent sore throat with hoarseness gave a positive predictive value of 12%, while positive predictive values for sore throat plus recurrent dyspnoea or dysphagia were both 4.1%. Sore throat plus otalgia was also high risk, with a positive predictive value of 3% (Source: BMJ).

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In the news:

BBC News Persistent sore throat ‘can be cancer sign’

A solution to less toxicity in chemotherapy treatment?

Oh, H. J., Aboian, et al |2019| 3D Printed Absorber for Capturing Chemotherapy Drugs before They Spread through the Body|  ACS Central Science| 

A study that describes  the development of 3D printed porous absorbers for capturing excess chemotherapy drugs that are not taken up by the targeted tumor to prevent toxic side effects is published in the journal ACS Central Science.  So far the research has not been conducted in human subjects but the early work could potentially offer a way to make chemotherapy less harmful to the body. 


Despite efforts to develop increasingly targeted and personalized cancer therapeutics, dosing of drugs in cancer chemotherapy is limited by systemic toxic side effects. We have designed, built, and deployed porous absorbers for capturing chemotherapy drugs from the bloodstream after these drugs have had their effect on a tumor, but before they are released into the body where they can cause hazardous side effects. The support structure of the absorbers was built using 3D printing technology. This structure was coated with a nanostructured block copolymer with outer blocks that anchor the polymer chains to the 3D printed support structure and a middle block that has an affinity for the drug. The middle block is polystyrenesulfonate which binds to doxorubicin, a widely used and effective chemotherapy drug with significant toxic side effects. The absorbers are designed for deployment during chemotherapy using minimally invasive image-guided endovascular surgical procedures. We show that the introduction of the absorbers into the blood of swine models enables the capture of 64 ± 6% of the administered drug (doxorubicin) without any immediate adverse effects. Problems related to blood clots, vein wall dissection, and other biocompatibility issues were not observed. This development represents a significant step forward in minimizing toxic side effects of chemotherapy.

The full article is available to download from ACS Central Science

In the news:

BBC News ‘Less toxic’ chemotherapy hope

Introducing group consultations for cancer care reviews

NHS England | January 2019 | Introducing group consultations for cancer care reviews

A new case study has been published on NHS England’s Shared Atlas of Learning; it underlines the impact of a general practice nurse (GPN) at Lancaster Medical Practice idea to address unwarranted variation relating to cancer care reviews by introducing a group consultation model at the surgery. 

Following completion of an accredited education programme on group consultations, the practice nurse established a gynaecological cancer group consultation at the surgery as a trial. Patients with similar cancers who were living with and beyond cancer were invited to attend.


Due to the success of the initial trial, a further group consultation session was arranged to roll-out the offer of support, review progress and identify new needs as well as ensuring previous concerns had been addressed.

The new approach has led to consistency in cancer care reviews and information given to patients about cancer and the impact on their health. 25% capacity saving has been achieved and time spent consulting has had greater impact and service improvements can be seen now that all information and peer support is provided.

Challenges and lessons learnt for implementation

It can be challenging when working with a large team from different backgrounds but it is worth it.

There is reinforced learning in recognising the need to improve practice and lead on change for the benefit of patients and communities even when this change is outside of your comfort zone.

Speaking with stakeholders will support successful improvements to be implemented on a broader scale to reduce unwarranted variation.

Due to the success of the programme, the practice nurse and practice manager won the ‘Most Innovative Group Consultation’ award from Health Education England (HEE) at the North-West Group Consultation Celebration Event in October 2017, and in November 2017 won the ‘Supporting Families and Carers’ award at the NHS England Regional General Practice Nursing Conference (Source: NHS England).

Read the full,unabridged case study at NHS England  

Cancer survival in England: national estimates for patients followed up to 2017

Office for National Statistics | January 2019 | Cancer survival in England: national estimates for patients followed up to 2017

The latest release of Cancer survival in England: national estimates for patients followed up to 2017 has been published by the Office for National Statistics.

Main points

  • For the first time we have been able to produce robust 1-year and 5-year net cancer survival estimates by stage at diagnosis based on five years’ worth of cancer diagnoses (2012 to 2016), making them comparable with the adult cancer survival estimates.
  • Adults diagnosed at stage 1 with either melanoma of the skin, prostate or breast (women only) cancer have the same chance of surviving 1-year after diagnosis as an individual in the general population.
  • Melanoma of the skin had the highest net-survival estimate for 1-year survival in both men (97.4%) and women (98.6%) and for 5-year survival in both men (89.2%) and women (93.9%).
  • Pancreatic cancer had the lowest net-survival estimate for 1-year survival in men (23.7%) and women (25.3%) and for 5-year survival in both men (6.4%) and women (7.5%).
  • Predicted 10-year survival was also highest for melanoma of the skin for both men and women at 85.0% and 90.9% respectively, and lowest for lung cancer for both men and women at 7.0% and 10.6% respectively.

Sarah Caul, Head of Cancer Analysis, said:

“In general, we have seen an increase in people’s chances of survival across different types of cancer since our estimates for 2006 to 2010. Melanoma of the skin, prostate and breast cancer have continued to have the highest chances of survival across all age-standardised estimates compared to other cancer types. The higher survival figures could partly be explained by a high percentage of prostate and breast cancer patients being diagnosed at an earlier stage”

Cancer survival in England: national estimates for patients followed up to 2017

Read online at ONS

In the news:

BBC News ‘High’ survival for many cancers diagnosed at stages 1-3

[NICE Technology appraisal guidance [TA559] Axicabtagene ciloleucel for treating diffuse large B-cell lymphoma and primary mediastinal large B-cell lymphoma after 2 or more systemic therapies

NICE |  January 2019 | Axicabtagene ciloleucel for treating diffuse large B-cell lymphoma and primary mediastinal large B-cell lymphoma after 2 or more systemic therapies


Evidence-based recommendations on axicabtagene ciloleucel therapy (Yescarta) for treating diffuse large B-cell lymphoma and primary mediastinal B-cell lymphoma in adults after 2 or more systemic therapies.


Full details from NICE 

[NICE Technology Appraisal Guidance] Nivolumab for adjuvant treatment of completely resected melanoma with lymph node involvement or metastatic disease

NICE |  January 2019 | Nivolumab for adjuvant treatment of completely resected melanoma with lymph node involvement or metastatic disease


Evidence-based recommendations on nivolumab (Opdivo) for the adjuvant treatment of completely resected melanoma in adults with lymph node involvement or metastatic disease.

Full details from NICE

Faecal immunochemical tests versus colonoscopy for post-polypectomy surveillance: an accuracy, acceptability and economic study

Atkin, W., et al | 2019|Faecal immunochemical tests versus colonoscopy for post-polypectomy surveillance: an accuracy, acceptability and economic study| Health Technology Assessment| Vol.23| 01|


A study which recruited male and female patients (aged between 60-72) from the Bowel Screening Programme between 30 January 2012 to 30 December 2013,  finds that annual faecal immunochemical testing, with colonoscopy in positive cases, was generally acceptable to patients and would be cost-saving compared to three-yearly colonoscopy, although it has lower sensitivity, resulting in missed lesions.

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Plain English Summary 

Bowel cancer typically develops from lesions called adenomas. Although common, most adenomas do not develop into cancer. Adenomas detected during a bowel examination, called a colonoscopy, are usually removed during this procedure. However, even after adenoma removal, some patients are still at greater risk of bowel cancer.

Depending on the number and size of adenomas found, patients are invited for a colonoscopy after 1, 3 or 5 years. Most of these additional colonoscopies will not detect cancer and they are expensive, often uncomfortable and can harm the bowel.

Both bowel cancer and adenomas can cause bleeding in the bowel. This study examined whether or not a test for blood in stool, completed at home [known as the faecal immunochemical test (FIT)], could be used instead of colonoscopy to monitor patients following adenoma removal. Colonoscopy would then be offered only to those who had a positive FIT result, indicating blood in the stool.

This study invited individuals for annual FITs for 3 years who, as part of the Bowel Cancer Screening Programme, had one or two large adenomas or three or four small adenomas removed. If a FIT detected blood in the stool at any of the tests, these individuals were immediately offered a colonoscopy. If a FIT did not detect blood in the stool at any test, these individuals were offered a colonoscopy 3 years after their adenomas were removed, as were participants who did not return their second or third FIT.

The study demonstrated that an annual FIT could identify 85 of every 100 cancers and 57 of every 100 patients with adenomas if repeated over 3 years. Annual FITs were considerably cheaper than colonoscopy after 3 years. Participants reported that the FIT was easy to use and provided reassurance. However, some were concerned that the FIT would not be as effective as colonoscopy.



In the UK, patients with one or two adenomas, of which at least one is ≥ 10 mm in size, or three or four small adenomas, are deemed to be at intermediate risk of colorectal cancer (CRC) and referred for surveillance colonoscopy 3 years post polypectomy. However, colonoscopy is costly, can cause discomfort and carries a small risk of complications.


To determine whether or not annual faecal immunochemical tests (FITs) are effective, acceptable and cost saving compared with colonoscopy surveillance for detecting CRC and advanced adenomas (AAs).


Diagnostic accuracy study with health psychology assessment and economic evaluation.


Participants were recruited from 30 January 2012 to 30 December 2013 within the Bowel Cancer Screening Programme in England.


Men and women, aged 60–72 years, deemed to be at intermediate risk of CRC following adenoma removal after a positive guaiac faecal occult blood test were invited to participate. Invitees who consented and returned an analysable FIT were included.


We offered participants quantitative FITs at 1, 2 and 3 years post polypectomy. Participants testing positive with any FIT were referred for colonoscopy and not offered further FITs. Participants testing negative were offered colonoscopy at 3 years post polypectomy. Acceptibility of FIT was assessed using discussion groups, questionnaires and interviews.

Main outcome measures

The primary outcome was 3-year sensitivity of an annual FIT versus colonoscopy at 3 years for detecting advanced colorectal neoplasia (ACN) (CRC and/or AA). Secondary outcomes included participants’ surveillance preferences, and the incremental costs and cost-effectiveness of FIT versus colonoscopy surveillance.


Of 8008 invitees, 5946 (74.3%) consented and returned a round 1 FIT. FIT uptake in rounds 2 and 3 was 97.2% and 96.9%, respectively. With a threshold of 40 µg of haemoglobin (Hb)/g faeces (hereafter referred to as µg/g), positivity was 5.8% in round 1, declining to 4.1% in round 3. Over three rounds, 69.2% (18/26) of participants with CRC, 34.3% (152/443) with AAs and 35.6% (165/463) with ACN tested positive at 40 µg/g. Sensitivity for CRC and AAs increased, whereas specificity decreased, with lower thresholds and multiple rounds. At 40 µg/g, sensitivity and specificity of the first FIT for CRC were 30.8% and 93.9%, respectively. The programme sensitivity and specificity of three rounds at 10 µg/g were 84.6% and 70.8%, respectively. Participants’ preferred surveillance strategy was 3-yearly colonoscopy plus annual FITs (57.9%), followed by annual FITs with colonoscopy in positive cases (31.5%). FIT with colonoscopy in positive cases was cheaper than 3-yearly colonoscopy (£2,633,382), varying from £485,236 (40 µg/g) to £956,602 (10 µg/g). Over 3 years, FIT surveillance could miss 291 AAs and eight CRCs using a threshold of 40 µg/g, or 189 AAs and four CRCs using a threshold of 10 µg/g.


Annual low-threshold FIT with colonoscopy in positive cases achieved high sensitivity for CRC and would be cost saving compared with 3-yearly colonoscopy. However, at higher thresholds, this strategy could miss 15–30% of CRCs and 40–70% of AAs. Most participants preferred annual FITs plus 3-yearly colonoscopy. Further research is needed to define a clear role for FITs in surveillance.

(Source: Health Technology Assessment (HTA)


The study can be read in full from HTA

Radiotherapy benefits some men whose prostate cancer has spread to their bones

NIHR | January 2019 | Radiotherapy benefits some men whose prostate cancer has spread to their bones

An NIHR Signal highlights a trial part-funded by NIHR, published in October 2018, which compared the effects of standard care with or without radiotherapy to the prostate on overall survival for over 2000 men.  The standard treatment for men with metastatic prostate cancer is anti-androgen hormone therapy, and this is sometimes combined with chemotherapy. Radiotherapy of the prostate itself is only usually used for symptom relief.

The trial found that radiotherapy improved three-year survival rate from 73 to 81% in men with a limited number of metastases confined to the spine and pelvis. In this group, it also prevented any disease progression over three years in half of them compared to a third on standard care.


STAMPEDE was a randomised controlled trial  that took place in more than 100 hospitals in Switzerland and the UK. Over 2,000 men with newly diagnosed prostate cancer with metastases, confirmed on a bone scan, were recruited to the study.

Participants were randomised to either standard care (lifelong anti-androgen hormone therapy, with or without chemotherapy using docetaxel) or standard care plus radiotherapy to the prostate.

This study adds further evidence that radiotherapy could benefit men with newly diagnosed prostate cancer with local metastases.

The trial used CT and bone scans to define low and high metastatic burden. PET scans, which can detect smaller cancer deposits, are becoming widely available and may allocate people differently.

Treating the primary once the cancer has metastasised has conventionally thought to be futile. This has been challenged by finding that in low metastatic burden prostate cancer, radiotherapy to the primary significantly improves survival and should become standard of care.

This study raises the issue whether this would apply to other cancers and interesting biological questions as to the mechanism. Is it an effect of debulking the primary?  Is it immunological?  Is it due to reducing secondary spread of aggressive clones?

It seems we have underestimated in prostate cancer, the impact of local control in the setting of metastatic disease

Professor Robert Huddart, Reader and Honorary Consultant, Royal Marsden NHS Foundation Trust 

(Source: NIHR)

NIHR Radiotherapy benefits some men whose prostate cancer has spread to their bones


 Parker, C.  et al | 2018| Radiotherapy to the primary tumour for newly diagnosed, metastatic prostate cancer (STAMPEDE): a randomised controlled phase 3 trial|  The Lancet| 


Based on previous findings, we hypothesised that radiotherapy to the prostate would improve overall survival in men with metastatic prostate cancer, and that the benefit would be greatest in patients with a low metastatic burden. We aimed to compare standard of care for metastatic prostate cancer, with and without radiotherapy.
We did a randomised controlled phase 3 trial at 117 hospitals in Switzerland and the UK. Eligible patients had newly diagnosed metastatic prostate cancer. We randomly allocated patients open-label in a 1:1 ratio to standard of care (control group) or standard of care and radiotherapy (radiotherapy group). Randomisation was stratified by hospital, age at randomisation, nodal involvement, WHO performance status, planned androgen deprivation therapy, planned docetaxel use (from December, 2015), and regular aspirin or non-steroidal anti-inflammatory drug use. Standard of care was lifelong androgen deprivation therapy, with up-front docetaxel permitted from December, 2015. Men allocated radiotherapy received either a daily (55 Gy in 20 fractions over 4 weeks) or weekly (36 Gy in six fractions over 6 weeks) schedule that was nominated before randomisation. The primary outcome was overall survival, measured as the number of deaths; this analysis had 90% power with a one-sided α of 2·5% for a hazard ratio (HR) of 0·75. Secondary outcomes were failure-free survival, progression-free survival, metastatic progression-free survival, prostate cancer-specific survival, and symptomatic local event-free survival. Analyses used Cox proportional hazards and flexible parametric models, adjusted for stratification factors. The primary outcome analysis was by intention to treat. Two prespecified subgroup analyses tested the effects of prostate radiotherapy by baseline metastatic burden and radiotherapy schedule.
Between Jan 22, 2013, and Sept 2, 2016, 2061 men underwent randomisation, 1029 were allocated the control and 1032 radiotherapy. Allocated groups were balanced, with a median age of 68 years (IQR 63–73) and median amount of prostate-specific antigen of 97 ng/mL (33–315). 367 (18%) patients received early docetaxel. 1082 (52%) participants nominated the daily radiotherapy schedule before randomisation and 979 (48%) the weekly schedule. 819 (40%) men had a low metastatic burden, 1120 (54%) had a high metastatic burden, and the metastatic burden was unknown for 122 (6%). Radiotherapy improved failure-free survival but not overall survival. Radiotherapy was well tolerated, with 48 (5%) adverse events (Radiation Therapy Oncology Group grade 3–4) reported during radiotherapy and 37 (4%) after radiotherapy. The proportion reporting at least one severe adverse event (Common Terminology Criteria for Adverse Events grade 3 or worse) was similar by treatment group in the safety population (398 [38%] with control and 380 [39%] with radiotherapy).
Radiotherapy to the prostate did not improve overall survival for unselected patients with newly diagnosed metastatic prostate cancer.

New report shows more young people surviving cancer

Teenage Cancer Trust | January 2019 | New report shows more young people surviving cancer

A new report from Teenager Cancer Trust uses data collected by NCRAS  (National Cancer Registration and Analysis Service) which has been analysed to identify trends and share finding with partners to improve cancer services and awareness.  Now Teenage Cancer Trust report 13-24 years old who were diagnosed in England up to the end of 2015. The publication marks the first time a detailed analysis has been conducted of cancer rates of the 13 to 24-year age group and shows an encouraging increase in survival rates.



Some of the report’s key findings:

  • Mortality rates of all cancers combined in 13 to 24 year olds have decreased from 42.9 per million in 2001 to 32.3 per million in 2015.
  • The largest reduction in mortality by diagnostic group in England between 2001 and 2015 has been in Leukaemias. There were also reductions seen in mortality from Central Nervous System tumours, bone cancer and in lymphoma.
  • Five-year survival rates for cancer in 13 to 24 year olds have risen from 83% females / 80% males in (2001-05) to 87% in females / 84 % males (2007-11).
  • There are statistically significant variations in incidence and survival rates of cancer in 13 to 24 year olds based on geography and deprivation.
  • The incidence of cancer in 13 to 24 years olds in England has increased from a crude rate of 233.1 per million in 2001, to 299.7 per million in 2015 (Source: Teenage Cancer Trust).

News release Teenage Cancer Trust New report shows more young people surviving cancer

The report is available to read and download from Teenage Cancer Trust 

BMJ Cancer: more young people in England are surviving

In the news: BBC News Teenage cancer survival ‘on the up’ in England, report finds

Cancer registration: patient information leaflet

Public Health England | January 2019 | Cancer registration: patient information leaflet

Cancer registration: why it matters and what you need to know, is a leaflet for health professionals to distribute to cancer patients explaining what the cancer registry is and what it does.

This leaflet should be given to cancer patients to help them understand:

  • why information about cancer is recorded
  • the benefits of recording cancer data
  • how this information is used
  • how they can see their record
  • how they can have their information removed (PHE)
Image source:

Cancer registration: why it matters and what you need to know