Cancer – Sunshine and platelets

 Dr Richard Roope, FRCGP (RCGP and Cancer Research UK Clinical Champion for cancer)

Melanoma incidence continues to rise across the U.K. It is the second commonest cancer in the under 50s after breast cancer1. It is also has the third fastest rate of increasing incidence of all cancers, increasing by 57% in the last 9 years (only thyroid and liver cancer incidences are increasing faster – 74% and 60% respectively)2. It is felt that 86% of melanoma cases are preventable3. UK melanoma mortality rates continue to rise – increasing by 156% since the early 1970s. Primary care clinicians have an important role to play promoting skin health. The Australian Public Health “Slip, Slop, Slap” campaign of the early 1980s was one of the most successful campaigns. It has now been extended to “Slip, Slop, Slap, Seek, Slide”4 (Shirt, sun-screen, hat, shade and sunnies respectively) – information easily passed onto patients in travel chats. Where prevention has not been successful, early diagnosis is essential. The 7-point weighted check list is now the recommended assessment tool for professionals – however to equip patients the ABCDE checklist may be more user friendly. The Cancer Insight Summer 2017 publication5 is particularly helpful, and reviews the scoring schemes.  Cancer Research UK has some very useful guidance for the public6: “Ways to enjoy the sun safely”. If out in the sun, SPF 15 sunscreen is felt to be sufficient – as long as it is applied generously and frequently.  The other skin lesion to look out for is the “Ugly Duckling sign” – a mole that stands out from the rest7

A recent paper in the BJGP8 highlights the significance of a raised platelet count.  It has been recognised for some time, that a raised platelet count is noticed in patients with some cancers (lung, colorectal, renal and endometrial), and indeed it is a metric used in the NICE “Suspected cancer: recognition and referral” NG129. This new paper is the first from primary care comparing the incidence of all cancers in those with a raised platelet count with those with normal counts. It then followed the health events in both groups for 12 months. There was an increased incidence of cancer in those with raised platelet counts in this period. In males with a raised platelet count 11.6% (4.1% in those with normal platelet counts) were diagnosed with cancer in the following 12 months, and in females the numbers were 6.2% vs 2.2%. The increase in cancer incidence increased with age, and a higher platelet count.  The positive predictive value (PPV) rises to 18.1% in males and 10.1% in females if the patients had a second raised platelet count within 6 months.  These PPVs are significantly above the 3% threshold used by NICE to recommend a referral via the 2 week referral pathway. The paper interestingly compares these data with the PPV of patients aged 50-59 with breast lumps having breast cancer diagnosed (8.5%) and the PPV of those with haemoptysis being diagnosed with lung cancer (3.5%).

Lung and colorectal cancers were the most commonly diagnosed cancers in the thrombocytosis cohort.  Approximately 1/3 of those subsequently diagnosed with these two types of cancer had no symptoms suggestive of cancer. In these patients, instigating further investigations following a raised platelet count has the potential to make the cancer diagnosis at least 2 months earlier, with the potential to improve the outcomes for up to 5,500 patients every year.
 

  1. https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/conditionsanddiseases/bulletins/cancerregistrationstatisticsengland/2015
  2. http://www.cancerresearchuk.org/health-professional/cancer-statistics/incidence/common-cancers-compared#heading-Three
  3. http://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/skin-cancer
  4. http://www.cancer.org.au/preventing-cancer/sun-protection/campaigns-and-events/slip-slop-slap-seek-slide.html
  5. http://publications.cancerresearchuk.org/downloads/Product/2017%20June%20CI_GPs_FINAL.pdf
  6. http://www.cancerresearchuk.org/about-cancer/causes-of-cancer/sun-uv-and-cancer/ways-to-enjoy-the-sun-safely?_ga=2.212835600.525437655.1499371239-148649371.1393791263
  7. http://www.cancernetwork.com/melanoma/use-ugly-duckling-sign-could-improve-efficiency-melanoma-detection
  8. Br J Gen Pract 2017; DOI:https://doi.org/10.3399/bjgp17X691109
  9. https://www.nice.org.uk/guidance/ng12

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