Cancer conversations

As the pandemic eases and cancer referrals catch up, pharmacy teams have a fresh opportunity to raise awareness of gynaecological cancers

Some 45 per cent of women born after 1960 in the UK will face a cancer diagnosis at some point in their lives, the latest figures from Cancer Research UK (CRUK) reveal.

Early diagnosis and treatment give the best chance of survival, but the pandemic has had a serious impact on the level of support that’s available. Data from Public Health England (PHE) shows that the number of people diagnosed with early-stage cancer fell by 33 per cent in the first wave of the Covid-19 pandemic in 2020. And CRUK estimates that around 430,000 fewer people than usual in the UK had an urgent suspected cancer referral between March 2020 and February 2021 compared with the previous year.

Worse for women?

This interruption of care will almost certainly have detrimental effects on people’s chances of survival, with women seeming to be at a particular disadvantage.

Baroness Delyth Morgan, chief executive of Breast Cancer Now, says the charity estimates that almost 11,000 people in the UK could be living with undiagnosed breast cancer – the most common cancer affecting women in the UK – due to “the scale of disruption to cancer services”.

While breast cancer is arguably the most talked-about cancer affecting women across the home nations, there are 21,493 new cases of the five gynaecological cancers – womb, ovarian, cervical, vulval and vaginal – diagnosed every year. However, awareness of these remains very low. Put into context, gynaecological cancer charity The Eve Appeal says: “This means 58 people receive this life-changing news each and every day. Sadly, 21 of these women die a day from their gynaecological cancer.”

Better customer conversations 

As a source of trusted help and advice for women, community pharmacy teams are often the first to hear about their cancer concerns. Nonetheless, it can be hard to know what to say to customers because it may seem a difficult or frightening topic to address.

“Cancer is complicated, and no one will expect you to have all of the answers, so talk about it anyway and if you don’t know something, refer to your pharmacist, another healthcare professional, or other support service,” says Katie Edmunds, senior health community engagement manager at Cancer Research UK’s ‘Talk Cancer’ training programme, which helps healthcare professionals feel confident talking to people about cancer. 

It’s also important to ask questions, such as: ‘How long have you had your symptoms?’, ‘what does your doctor say?’ and ‘what support do you have?’. Katie adds that “this will make them feel listened to, and may even help someone realise they should seek further support”. 

If someone comes across something that isn’t normal for them and their body, they should make an appointment to see their GP because putting it off will not make the problem go away. “The earlier cancer is diagnosed, the better the outcome is likely to be,” says Katie. “For example, the survival rate in women who are diagnosed with the earliest stage of breast cancer is 98 per cent and this falls to 26 per cent when diagnosed at the latest stage.”

Recognising red flags

Pharmacy staff also play a key role in the early detection of cancer by identifying red flags during patient interactions and consultations. “This support has become even more important during the pandemic,” says Reshma Malde, superintendent at John Bell & Croyden pharmacy in central London.

There are plenty of red flags to look out for. “When giving out thrush treatment, for example, mention that if the itching persists or worsens, they should go back to their GP as persistent vaginal or vulval itching could in fact be a sign (although unlikely) of cancer,” advises The Eve Appeal’s cancer information officer Karen Hobbs. 

Karen adds that anyone who has gone through the menopause but is buying period products because they are bleeding should be referred on. “Any bleeding after the menopause is considered abnormal and needs to be investigated by a doctor,” she says.

Another red flag is late-onset IBS, and Karen warns that as “IBS doesn’t suddenly develop in our 50s, people suddenly having toilet and tummy problems should know these are also signs of ovarian cancer”.

Wider support

Whether it’s for a customer themselves or someone who is affected by a loved one’s cancer diagnosis, there is plenty of wider support and signposting that pharmacy staff can offer women dealing with cancer.

Samantha Dixon, chief executive of Jo’s Cervical Cancer Trust says: “It’s okay not to know everything, but knowing where to signpost for additional support is key. Be prepared to listen, and not to jump in with solutions immediately – sometimes someone just wants to be heard.”

• The Eve Appeal has a nurse-led email information service called ‘Ask Eve’ for people who have questions about the gynaecological cancers at: nurse@eveappeal.org.uk
• Breast Cancer Now has information about support groups for people with breast cancer
• Jo’s Cervical Cancer Trust provides support and signposting to anyone who is affected by cervical cancer via a free helpline, an online forum and one-to-one support sessions.

Keeping track of changes

Breast awareness campaigns have been shown to encourage women to become more aware of their breast health and check themselves for lumps and other changes. Breast Cancer Now clinical nurse specialist Addie Mitchell says pharmacy teams have a key role to play in supporting women to get changes checked out.

“Most lumps, bumps and changes to the breasts are not going to be breast cancer, but it’s still important to get it checked out,” says Addie. “You can also urge women between the ages of 50 and 70 to attend their three-yearly breast screening appointment when invited. We know lots of women were scared about going during Covid, but you can reassure them that they are safe and Covid-secure now.”

And it’s not just regular breast exams that women should keep on top of. “Do talk about taking part in the cervical and bowel screening programmes as well,” says Katie Edmunds, senior health community engagement manager at Cancer Research UK’s ‘Talk Cancer’ training programme. “If they are regular customers, you will know whether they are in the protocol ages to be invited, so have they had an invitation? Have they got an appointment? How did it go? If they chose not to go, what made them decide that?”

There are also opportunities to talk about reducing the risk of cancer. For example, Katie says it’s important to make sure customers know that cervical screening can actually prevent cancer. “It is looking for pre-cancerous conditions which can then be treated and prevent cancer from developing,” she explains. 

Customers can also reduce their risk of cancer by not smoking, being a healthy weight and drinking less alcohol, Katie adds.

Fact file: women’s cancers

• Breast cancer 

Breast cancer is the most common cancer affecting women in the UK, with around one in eight diagnosed during their lifetime.

Symptoms include a lump or an area of thickened tissue in the breast; changes in the nipple; bloody discharge from the nipple; dimpled skin on the breast; skin irritation or texture change, redness and heat. As the likelihood of getting breast cancer increases with age, all women over 50 who are registered with a GP are automatically invited for breast cancer screening every three years until their 71st birthday. 

Treatment options include surgery to remove the tumour or the breast, radiotherapy and chemotherapy. As with all cancers, the earlier breast cancer is detected, the more likely treatment will be successful. 

• Womb cancer

Also known as uterine cancer, womb cancer is the fourth most common cancer in women in the UK after breast, bowel and lung cancers. More than 9,300 people are diagnosed every year, according to cancer charity The Eve Appeal. It is more common post-menopause, although one in four cases occur pre-menopause. 

Most womb cancers have no obvious cause, but an excess of oestrogen – often caused by a high body mass index (BMI) – increases the risk tenfold. Oestrogen is stored in the body’s fat cells, so maintaining a healthy weight can reduce the risk.

Abnormal vaginal bleeding is the most common sign of womb cancer, which is why it’s vital that women with this symptom see a GP for a physical examination and possible referral for an ultrasound and biopsy. 

The most common treatment is hysterectomy. If caught early enough, this can remove the need for chemotherapy.

• Ovarian cancer 

The sixth most common cancer in women in the UK is ovarian cancer (the fifth is melanoma), with nearly 7,500 people diagnosed every year.

It is most common post-menopause, although it can affect women at any age. Certain factors can increase the risk of it developing, such as a family history of the disease.

The main ovarian cancer symptoms are increased abdominal size and persistent bloating, persistent pelvic and abdominal pain, an unexplained change in bowel habits, difficulty eating, feeling full quickly or feeling nauseous and needing to urinate more regularly.

As some of the symptoms are often the same as irritable bowel syndrome (IBS) or pre-menstrual syndrome (PMS), it can be difficult to recognise in the early stages. This is why most women are not diagnosed until the disease has spread, says The Eve Appeal.

Diagnosis involves a blood test, ultrasound or CT scan, and biopsy, with treatment being a combination of chemotherapy and surgery.

• Cervical cancer 

Cervical cancer can occur at any age, but is most common in those aged 30-45. 

Nearly all cervical cancers are caused by human papillomavirus (HPV) – a group of viruses spread by skin-to-skin sexual contact. Around 80 per cent of people will come into contact with HPV at some stage in their life, but it usually clears up on its own without the need for treatment. If the body is unable to clear the virus, there is a risk of abnormal cells developing, which is why the UK has an HPV vaccination programme for children before they are potentially exposed to the virus. Smoking doubles the risk of developing cervical cancer.

Key signs of cervical cancer include bleeding after sex and between periods. However, symptoms aren’t always obvious, so it’s important that women attend their cervical screening appointments to identify abnormal cells that could lead to cancer. The UK has a very successful cervical screening programme, which is estimated to save over 4,000 lives each year, according to The Eve Appeal.

If abnormal cells are found, diagnosis involves taking a biopsy. Treatment includes surgery to remove the cancerous cells, with radiotherapy if appropriate.

• Vulval cancer 

One of the rarer cancers, there are just over 1,300 cases of vulval cancer diagnosed in the UK each year. Around 80 per cent of cases are diagnosed in women over the age of 60, but The Eve Appeal says there are increasing incidences of women being diagnosed at a younger age.

Symptoms of vulval cancer include the following around the external genitals: pain, soreness or a persistent itch; thickened, raised, red, lighter or darker patches on the skin; an open sore, growth or mole that changes shape or colour; a lump or swelling. All these symptoms can be caused by other more common conditions, such as infection, so it’s important to get them checked by a GP. 

Risk factors for vulval cancer include having a potentially pre-cancerous skin condition called vulval intraepithelial neoplasia (VIN) or HPV. Smoking also increases the risk of developing VIN and vulval cancer.

Diagnosis involves referral to a gynaecologist or dermatologist, who may recommend a biopsy. Treatment is carried out by surgery, radiotherapy and chemotherapy.

• Vaginal cancer 

The rarest gynaecological cancer, around 250 women are diagnosed with vaginal cancer in the UK each year. 

It is most commonly diagnosed in women over 60 years of age, but can occur at any age. Symptoms include bleeding between periods, post-menopause or after sex; vaginal discharge that smells or is blood stained; pain during sexual intercourse; a vaginal lump, or persistent pelvic and vaginal pain. However, according to The Eve Appeal, as many as 20 per cent of women have no symptoms at all.

The cause of vaginal cancer is unknown, but risk factors include being over 60 years of age, having HPV or having previously had abnormal cells in the cervix or vagina. 

A GP can refer on to a gynaecologist for further investigation and diagnosis via biopsy, CT and MRI scans. Treatment depends on where and how advanced the cancer is, and may include radiotherapy, surgery and chemotherapy.

Further information 

• Let’s Communicate Cancer – pharmacist Jackie Lewis from Lewis Pharmacy in Exmouth, Devon, has created a series of free e-learning modules to help pharmacy teams talk to customers about cancer. The Let’s Communicate Cancer e-learning portal on the British Oncology Pharmacy Association website has bite-sized videos, animation, quizzes and slide shows to give pharmacy staff the confidence and knowledge to better help cancer patients – from early diagnosis through treatment
• Cancer Research UK runs a self-directed online course to help people talk about cancer, as well as a Talk Cancer Facebook group 
  Find out about the pharmacy-specific webinars as well as information about supporting friends and family of people who are living with cancer
• Breast Cancer Now’s ‘Touch, look, check’ leaflet is available to download as a guide for women checking their breasts for anything abnormal.