Inhaler technique is more important now than ever, but when good technique cannot be confirmed. Could more use of spacers improve outcomes?

Controlling chronic respiratory diseases has never been more important.

The COVID-19 pandemic and the winter cold and flu season is here. Therefore, it is even more vital that people with respiratory diseases such as asthma and chronic obstructive pulmonary disease (COPD) control their conditions effectively. That means persistence in using inhaler-delivered medicines as often as prescribed and using the correct inhaler technique.

Sticking to the right routines and techniques can be challenging at the best of times – figures show that eight out of 10 people’s inhaler techniques are incorrect.¹ The best way to learn the right techniques is face-to-face, from a healthcare practitioner skilled in their use. Digital services, such as video appointments or website self-assessments, have provided utility in helping enhance asthma care with guides and resources, but they do not replace face-to-face services. Due to the pandemic, many regular face-to-face consultations are not taking place, which means basic levels of asthma care are not provided and will result in declining asthma care. Lives could be at risk.

“A July 2020 survey of 8,268 asthma patients by Asthma UK² showed that one in three asthma patients had delayed or avoided visiting their GP or hospital when unwell. This was because they didn’t feel safe or didn’t want to overburden the health service – even if it meant that their condition worsened. Around four out of 10 people with respiratory conditions had had an asthma attack or worsening of their lung disease since the start of the pandemic, but most did not seek help” says GP Dr Michael D Smith.

The importance of inhaler technique

“Inhaler technique is 50% of the prescription, alongside the right drugs,” says Dr Omar Usmani, consultant chest physician and Chair of the UK Inhaler Group. “But systematic reviews have shown that health care practitioners themselves are poor at understanding the devices and often relay poor techniques to patients.”

Many practitioners have turned to online or telephone consultations during the pandemic, but it is almost impossible to check inhaler technique over the phone. Even video consultations have limits, says respiratory nurse consultant Carol Stonham.

“Video consultations risk increasing health inequalities,” she says. “What if you cannot afford the necessary technology, cannot operate it or have a poor internet connection? Inability to access your GP face-to-face means missed opportunities to pick up problems with inhaler techniques.”

Due to the pandemic, many regular face-to-face consultations are not taking place, which means basic levels of asthma care are not provided and will result in declining asthma care

What could help with better inhaler use?

Better education in inhaler use for practitioners and patients is essential. But if an effective inhalation technique cannot be confirmed, the prescription of a spacer should be considered as a risk mitigation approach.

Spacers – valved holding chambers that attach to inhalers – have been typically prescribed for use by children, or adults who find it hard to co-ordinate their actions consistently. However, they could be used to help many more people.

Dr Richard Iles, a consultant in respiratory paediatrics, says: “To stand the best chance of using an inhaler with the kind of co-ordination that ensures the majority of the drug gets into your airway, you need to be fit and healthy (i.e. not having an acute exacerbation) and ideally aged 14 to 35 (without any co-morbidities). If you are not in that group, a spacer will help. It holds the gaseous drug so you can breathe it into your lower airways and removes the need for masterful coordination between actuation and inhalation.”

Recommended in guidelines for general use

GINA Report, Global Strategy for Asthma Management and Prevention (2020) and the UK BTS/SIGN Asthma Guidelines recommend the use of valved holding chambers to improve drug delivery.

Despite this, prescriptions for spacers have dropped dramatically during the pandemic, even though the guidelines recommend spacers. Doctors also say spacers should be used more widely as they can only help in monitoring disease control and avoiding exacerbations.

Smith says: “In the present circumstances in particular I am reconsidering which patients I prescribe a spacer device to and will have a low threshold for doing so, especially if it means reducing the risk of poor inhaler technique. To those asthma patients with a pMDI/puffer inhaler reading this, who think that a spacer may help them; please talk to a qualified HCP for appropriate advice.”

For more information visit www.trudellmedical.co.uk/pmdi-and-spacer-inhaler-technique or contact info@trudellmedical.co.uk

UK AC 054 1120 | Date of preparation: November 2020
This article is sponsored by Trudell Medical UK Limited (TM-UK).  All interviewees are members of TM-UK’s ActOnAsthma advisory board.
Members of the ActOnAsthma advisory board will receive an appropriate honorarium for their time dedicated to the project.

¹ GINA Report, Global Strategy for Asthma Management and Prevention (2020)
²Asthma UK: Five Headlines from our summer COVID-19 survey. August 2020 https://www.asthma.org.uk/support-us/campaigns/campaigns-blog/five-survey-headlines/ Accessed Nov. 2020
³ Suggett J et al Am J Respir Crit Care Med 2020;201:A5689
⁴ Burudpakdee C et al.  Pulmonary Therapy 2017; 3(2):283–296.

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Lockdown gave us all a glimpse of what it is like to breathe clean air and for many, including people with COPD, the experience was temporarily life-enhancing.

During the first national lockdown we were all given a glimpse of what a future with clean air could look and feel like.

As widespread travel restrictions came into effect, vehicle emissions, the highest contributors to air pollution in our towns and cities, were quickly reduced. This resulted in lower concentrations of nitrogen dioxide and fine particulate matter, known as PM2.5, in the atmosphere.

Air pollution contributes to 36,000¹ premature deaths each year and is the biggest environment threat to human health . It places a great burden on the NHS. PM2.5 is the most dangerous form and is linked to many long-term illnesses, such as lung cancer and cardiovascular disease.

There are 12 million people in the UK already living with lung diseases, such as chronic obstructive pulmonary disease (COPD), plus the new cohort of people with ongoing breathing problems as a result of COVID-19. The exposure to high levels of air pollution can have immediate devastating consequences on these groups and impact their quality of life.

One in six people with lung disease², representing two million people, said their symptoms had improved during the first lockdown due to lower air pollution.

Widening health inequalities

Lung disease disproportionately impacts those living in the most deprived communities in the UK³ and people from the poorest areas are two-and-a-half times more likely to have COPD. Research shows that these communities are often exposed to the highest levels of toxic air.

COVID-19 is exposing the harsh realities of these health inequalities. Communities living with multiple deprivation are not only suffering the worst health effects of air pollution but are also most impacted by the pandemic. 

Air pollution is increasing

Whilst COVID-19 restrictions remain, figures show that traffic levels⁴ are close to pre-pandemic levels and rising as many people shift from public transport to private cars.

The increased use of older, dirtier vehicles is likely to cause air pollution levels to soar and the problem could become even more widespread as people stay away from towns and cities.

Air pollution contributes to 36,0001 premature deaths each year and is the biggest environment threat to human health.

As part of the COVID-19 response, the government has granted local authorities extra funds to improve cycling and walking and to aid social distancing measures, which is a huge step forward.

At the same time, measures designed to reduce vehicles emissions in major towns and cities across the UK, where some of the most deprived communities live and work, are being delayed or scrapped.

Birmingham, which has high levels of lung disease and has also been heavily impacted by COVID-19, had its Clean Air Zone delayed a further six months.

The UK’s air quality laws are also inadequate and current legal limits for PM2.5 are double those recommended by the World Health Organization (WHO).

Air pollution is part of pandemic response and recovery

Tackling air pollution needs to go hand in hand with the COVID-19 response to prevent excess hospital admissions, reduce new lung conditions and improve the lung resilience of the UK population.

Widespread clean air planning to reduce toxic air is crucial to ensuring a green economic recovery and the government must use the Environment Bill, which is now back in parliament, to set tougher air quality laws, including legally binding targets on PM2.5  in line with WHO guidelines.

References:

¹ Public Health England air pollution evidence review, March 2019 | ² Asthma UK and British Lung Foundation survey of 14,000 people with lung conditions, June 2020 | ³ British Lung Foundation’s Battle for Breath Report, 2016 | Asthma UK. Car use returned to 100% of pre-lockdown levels, August 2020 ⁴

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Chronic obstructive pulmonary disease (COPD) is a lung condition where the airways have become narrow, making it hard to get air in and out of the lungs.

People with COPD are at particular risk of undernutrition (malnutrition). This can develop over several years or might occur following a flare up of symptoms.

Factors impacting dietary intake for those with COPD

Breathlessness and fatigue can affect the ability to eat, drink and consume a normal sized meal. Individuals with COPD can be left feeling they are ‘gasping for air’ when chewing and swallowing.

The condition can lead to a reduction in the body’s ability to maintain muscle, resulting in gradual muscle loss. This reduces the ability to breathe well and keep active.

The effort of laboured breathing increases the amount of energy the body requires.

Oxygen, nebulisers and inhalers, often used in COPD treatment, can cause dry mouth and taste changes which may affect appetite.

Depression, social isolation and living conditions can also interfere with the ability to shop, purchase, and prepare food.

All these factors can result in less nutrients being consumed than required with subsequent unplanned weight loss, muscle loss, increased susceptibility to infections and the need for hospital care.

How do I know if I am undernourished?

A self-screening website is available for people who are concerned about their diet and weight, it helps calculate the risk of malnutrition and advises on next steps.

What can I do to keep well nourished?

The Malnutrition Pathway has developed free leaflets for people with COPD; containing advice on diet and the importance of protein rich foods combined with physical activity to increase the strength of the lungs and body, along with tips for coping with common symptoms.

Similar eating and drinking difficulties can occur with COVID-19 infection and advice is also available: www.malnutritionpathway.co.uk/covid19

The Malnutrition Pathway is supported by an unrestricted educational grant from Nutricia

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In a world where tiredness comes as standard, weight loss is welcomed and a cough is COVID-19, how do we diagnose lung cancer earlier?

With a disease as serious as lung cancer, you would expect symptoms to match the severity. You would expect a clear or obvious warning light – gasping for breath, a violent and unshakable cough, intense chest pains. How could something so acute not send out an adequate alert?

However, the reality is when it comes to lung cancer, it’s less about the tyre blow out at 70mph down the M6 and more about the slow puncture.

Recognising the signs

Lung cancer symptoms can be subtle and easily dismissed as something else. A bit of breathlessness is because you’re a bit out of shape. Lack of energy can be down to anything from poor diet to low mood. A persistent cough? Well, we all know how our perceptions of hearing someone cough have changed.

For Keshu, one of the patients featured in our ‘Still Here’ awareness campaign, the first symptom was weight loss. Instead of seeing this as a warning, Keshu was happy to have lost a few kilos. Even when the cough started, alarm bells still didn’t ring.

It was only when the third set of antibiotics failed to work that questions were finally asked. But by then it was too late. The tire had blown. It was lung cancer and it had spread.

The reality is when it comes to lung cancer, it’s less about the tyre blow out at 70mph down the M6 and more about the slow puncture.

Acting on instinct

Ruthra’s story starts in similar fashion. She put her symptoms – recurrent chest infections – down to her child bringing bugs home from nursery.

However, Ruthra soon noticed that she was getting these infections far more regularly than her husband and was even succumbing to them in the summer months. As a fit and healthy 37-year-old, Ruthra recognised something wasn’t right. Even though lung cancer was not even a passing thought, she asked to see a respiratory specialist.

It was a decision that may have saved her life because, as unlikely as it was, Ruthra was diagnosed with early-stage lung cancer.

Finding lung cancer early, like Ruthra, is key. To do that, we have to take notice of the little differences in our health and be our own advocate. They might be small. They are probably something far less serious. Why take that risk? Get the slow puncture checked. Avoid the tire blow out. Prevent the crash.

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Professor John Hurst

Professor of Respiratory Medicine, University College London and Consultant Physician, Royal Free Hospital

New Patient Charter outlines action needed to tackle COPD, the Cinderella disease that claims 30,000 lives a year.¹

COPD is the fifth leading cause of death in the UK, causing 30,000 deaths every year.¹ More needs to be done to increase awareness.

Why is reform needed?

“In the 20 years since I became interested in chronic obstructive pulmonary disease (COPD), it remains a Cinderella disease. The main, but by no means only, cause is smoking, leading to a stigma associated with COPD,” says Dr Kevin Gruffydd-Jones, a GP who co-authored the Patient Charter.

COPD affects 1.2 million people in the UK,² is the second largest cause of emergency admission,¹ and costs the NHS £1.9 billion a year.³ One in eight emergency hospital admissions is for COPD and ~30% patients are readmitted within 90 days.¹

With early diagnosis and proactive treatment, the burden can potentially be reduced.

People with COPD are three times more likely to die if they are hospitalised with COVID-19.

Barriers to optimal care

The name: “People do not know what COPD stands for, let alone what it is. Many assume they have a smoker’s cough and nothing can be done.”

The stigma is a barrier to reporting and treatment. “Many patients believe their condition will be perceived as “their own fault” leading to low treatment expectations. People delay seeking a diagnosis, resulting in hospital admissions after experiencing an exacerbation (also called ‘flare ups’).”

Adherence to guidelines: “We have pretty good treatment guidelines, but lack of awareness and confusion means they are not always followed” he says. “Many practitioners treat patients’ symptoms but are less aware of the need to prevent harmful exacerbations.”

Access to therapy: “Pulmonary rehabilitation is not available everywhere, even though it is known to reduce hospital admissions.”⁴

Expertise: “Often patients are reviewed by clinicians without specialist respiratory expertise. For example patients admitted to hospital with COPD are 14% more likely to die than those not reviewed by a respiratory specialist within 24 hours.”⁵

The principles of the Patient Charter include:

1. Timely diagnosis and assessment of COPD
2. Understanding what a COPD diagnosis means
3. Access to personalised treatment
4. Review management plans to prevent exacerbations
5. Access to specialist care
6. Reducing stigma

“This is all particularly important now,” he says. “People with COPD are three times more likely to die if they are hospitalised with COVID-19.”⁶

Professor John Hurst, at the Royal Free highlights: “At a time when the NHS is experiencing increased pressure, it has never been more important to optimise the care of people living with COPD helping them to stay out of hospital and living well.”

The future of COPD care

Hurst says: “The Charter will empower people to know what good care looks like, to know what to ask for when care falls short.” Gruffydd-Jones adds: “Collaboration between patients, practitioners and policymakers will prevent needless suffering, hospitalisation and deaths. Working together, we can transform COPD care.”

The Charter was created and funded by AstraZeneca in partnership with GAAPP
This article has been developed and written by AstraZeneca
GB-25430 I November 2020

References:

¹ NICE. QS10. Health and social care directorate. Quality standards and indicators – Chronic obstructive pulmonary disease (COPD) update. May 2015. Available at: https://www.nice.org.uk/guidance/qs10/documents/briefing-paper (accessed November 2020) | ² British Lung Foundation. Chronic Obstructive Pulmonary Disease (COPD) Statistics. Available at: https://statistics.blf.org.uk/copd (accessed November 2020) | ³ British Lung Foundation. The battle for breath – Estimating the economic burden of respiratory illness in the UK. Available at: https://www.blf.org.uk/policy/economic-burden (accessed November 2020) | ⁴ Kjaergaard J et al. Chronic obstructive pulmonary disease. Adherence to early pulmonary rehabilitation after COPD exacerbation and risk of hospital readmission: a secondary analysis of the COPD-EXA-REHAB study. BMJ Open Respiratory Research. Chronic obstructive pulmonary disease 2020. Available at: http://dx.doi.org/10.1136/bmjresp-2020-000582 (accessed November 2020) | ⁵ Royal College of Physicians. National Asthma and COPD Audit Programme (NACAP): COPD Clinical Audit 2017/2018. May 2019. Available at: https://www.rcplondon.ac.uk/projects/outputs/national-asthma-and-copd-audit-programme-nacap-copd-clinical-audit-201718 (accessed November 2020) | ⁶ Venkata V and Kiernan G. Covid-19 and COPD: pooled analysis of observational studies. J Chest. October 2020. V158:4. PA2469. Available at: https://doi.org/10.1016/j.chest.2020.09.046 (accessed November 2020) |

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Focusing on reducing the environmental impact of respiratory healthcare is a priority we cannot ignore.

In 2020, the Primary Care Respiratory Society (PCRS) launched the Greener Respiratory Healthcare Initiative. Healthcare accounts for 4% of carbon emissions in England and minimising the environmental impact of healthcare in general is a key goal for the NHS¹.

Environmental pollution also contributes to the burden of lung disease. Around one in five people in the UK are living with a lung disease and a further 10,000 people are diagnosed every week². For many of these people, air pollution is both a cause and an aggravating factor, making their symptoms worse and their lives more difficult.

Early and accurate diagnosis is key

We believe that a key to greener respiratory healthcare is to ensure patients receive an early and accurate diagnosis. This is critical so that patients can receive the treatment that’s right for them. Accurately diagnosed and well controlled respiratory disease is already greener as it avoids wasted medications and additional hospital visits.

We need to work collaboratively to ensure optimal respiratory health for all.

Greener medications must be fit for purpose

Many of the medications prescribed for respiratory disease come in inhalers, delivering medicines straight to the lungs. The choice of inhaler should be made based first and foremost on what best controls a patient’s condition and that the patient is able to use effectively.

As a patient you can do your part by making sure you can use your inhaler correctly every time and letting your doctor or respiratory nurse know as soon as your COPD starts to flare up.

After that, if there is more than one inhaler that might be right for you, the greener option may be the one you want to choose. In the future we hope that all inhalers will be kind to the environment. For now, we need to make sure they are used correctly, used until they are empty and are safely disposed of or recycled where possible.

Greener respiratory health care

We need to work collaboratively to ensure optimal respiratory health for all. We can do this by raising awareness, providing education, and advocating for proactive strategies to reduce the impact of respiratory healthcare on the environment. This is at the heart of the PCRS Greener Respiratory Healthcare Initiative, as we enable our members to deliver healthcare that is kinder to environment.

¹ NHS England. Delivering a ‘Net Zero’ National Health Service | ² British Lung Foundation. Lung disease In the UK – big picture statistics. Accessed November 2020.

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There are 1.2 million people living with diagnosed COPD in the UK, with many more estimated to be waiting for a diagnosis. We need to address this, now.

If you ask the average person in the street what COPD (chronic obstructive pulmonary disease) is, or how life limiting it is, they won’t have a clue. For the most part, COPD continues to be a hidden and ignored condition.

I live with COPD

My father died as a result of COPD in 1996, so when I started to show the same symptoms in 2004, I knew, deep down, that I had it, too.

COPD is life changing. I don’t think anyone really realises how frightening and isolating it is to not be able to plan ahead. Even something small like a walk to the corner shop can become an impossible task, there are days where I can’t walk more than 20 meters.

The progression of this condition is slow and insidious. You often aren’t aware of your limitations before a lot of damage has been done. But slowly – because of breathlessness – normal life becomes a process of compromise until on some days, some things just aren’t achievable.

This year, I would really like to try and change the conversations around this deadly condition, which is the fourth leading cause of death in the world.

Changing the way people talk about COPD

This year, I would really like to try and change the conversations around this deadly condition, which is the fourth leading cause of death in the world.

I want COPD to be mentioned every time serious lung conditions are spoken about. It’s so much more than wheezing or being breathless. We need the media to engage more with people like myself to highlight its symptoms and what life with COPD is like. Even when I’ve been to the hospital people have assumed that I have asthma because I’m wheezing and out of breath.

A public lack of awareness, stigma and fear surrounding this long-term condition leads to late diagnosis and life changing interventions being missed and sadly, people dying earlier than they might with the right treatments.

It could happen to anyone

There are 1.2 million people living with COPD, and this could happen to you, too. We need you to question any symptoms such as persistent coughs or wheezing. We need your loved ones to say, ‘get it checked out!’.

The Taskforce for Lung Health and the British Lung Foundation work hard to raise awareness of COPD. But we all have a part to play in changing the narrative and raising awareness of the condition, together.

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By studying the very early stages of chronic obstructive pulmonary disease (COPD), researchers across the UK are hoping to be able to identify those at risk of developing the condition, which affects three million people in the UK.

The British Lung Foundation Early COPD Cohort is a group of young adult smokers between the ages of 30 and 45. Their lung function is being tracked over time and the study will pick out those whose lung function is beginning to decline and are therefore at risk of developing COPD.

Although anyone can develop COPD, people who smoke run a particularly high risk of developing this lung disease. However, 20% of people with the condition have never smoked and not all smokers develop it.

There remains an urgent need to provide people with better treatments, but this is dependent on us gaining a better understanding of how the condition develops and progresses.

Simple tasks become challenging

Ian Jarrold, Head of Research and Innovation (Lung Disease) for British Lung Foundation describes the importance of this research: “COPD can be incredibly life-limiting for people. Think about the last time you were out of breath and imagine being in that state just doing everyday tasks like brushing your teeth. There remains an urgent need to provide people with better treatments, but this is dependent on us gaining a better understanding of how the condition develops and progresses. This study will be invaluable in helping us answer these questions.”

The importance of studying young people

During the initial pilot of the study, which has never been done on such a young cohort of individuals, the participants were monitored through the use of CT scans and post bronchodilator spirometry. 

Presenting the initial findings at the American Thoracic Society’s annual conference, Andrew Ritchie described the results: “This cross-sectional analysis of 30-45-year-old individuals who are deemed at risk of developing COPD found that a large percentage show CT airway abnormalities. This demonstrates how important it is to study the younger age group to understand the beginnings of the disease.”

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Finding solutions to support patients, doctors and nurses through COVID-19 and beyond.

By exploring innovative healthcare technology to help identify, prioritise and prepare patients for review, GSK want to support the NHS to address the backlog of respiratory patients caused by the challenges of the pandemic.

Identifying the challenges and opportunities

During the COVID-19 pandemic, GSK has considered how it can support the NHS to meet the demands and the backlog of patients, especially as winter is approaching with additional pressures to the system. We are doing that by asking ‘how’ care is administered as well as ‘what’ care is administered for respiratory patients.

The NHS is providing an incredible level of care during this time, demonstrating solutions for patients and medical professionals But we’re also aware of the demands on time, resources, and the challenge of how to identify, prioritise and review patients to ensure respiratory care can continue across the UK.

We’ve seen alternative approaches adopted quickly, with GPs taking appointments onto the phone and online. Now it’s time to look at how we can use innovation to improve respiratory care in these new circumstances and beyond. Whilst these cannot replace an in-person review, how can they be evolved to bring benefits to patients and the NHS long term?

We firmly believe the innovation and change we are seeing across healthcare will help the NHS during the pandemic.

Identifying the patients most at risk

We saw opportunities to share our expertise and sponsor the development of practical tools and solutions to support medical professionals to identify patients and prioritise them.

The co-ordination of annual reviews for patients with asthma and chronic obstructive pulmonary disease (COPD) requires a lot of time and resources but are key to maximising patient care and prioritising limited resources. GSK have sponsored the development and delivery of an Asthma and COPD Audit and Review Toolkit.

Developed in partnership between the Midlands Practice Pharmacy Network and Prescribing Decision Support Ltd at the Centre for Medicines Optimisation team at Keele University, this free toolkit is a resource designed to help medical professionals identify those patients who are at greater need for a review. It works by tracking a series of avoidable risk factors. Detecting recognised symptoms as warning signs allows doctors and nurses to take pre-emptive action to reduce preventable symptoms.

Completing COPD assessment tests remotely

In addition to identifying patients most at risk, we also found a method to help acquire information on how patients are managing their COPD. Alongside a multi-disciplinary group of international experts in COPD, GSK supported the development of the COPD Assessment Test (CAT), a clinically validated questionnaire.

We co-developed and sponsored the delivery of a COPD Florey survey with accuRx, which integrates CAT and the modified Medical Research Council (mMRC) test into the survey, built within the existing accuRx platform. Sent as a text message, patients are able to complete the assessment and send the results back directly to the GP, allowing them to review and decide on the next steps in their care and acquire relevant information in advance of any patient review. It has been designed to help medical professionals quickly identify how patients with COPD are currently managing their condition remotely.

Looking to the future of respiratory care

GSK are investigating future respiratory care. We created the Remote Reviews Resource Hub, a dedicated space for medical professionals that covers considerations for remote reviews. We also funded two national surveys of patients and medical professionals on remote respiratory care, and sponsored a roundtable facilitated by Wilmington Healthcare to discuss further solutions to support respiratory patients.

We firmly believe the innovation and change we are seeing across healthcare will help the NHS during the pandemic, reducing the demand on medical professional time and resources, and taking us towards a future where health technology can support patient care.

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Doreen shares her story of her lung cancer diagnosis and why she is taking it in her stride.

Five years ago, I went to see my GP about a cough I’d been living with for over 12 months. There didn’t seem to be anything wrong, but I was referred to a chest specialist anyway – just in case.

The lesion in my lower right lung was discovered after I had a CT scan, and further tests confirmed it was cancer. They also confirmed that the disease had already spread from my lung to my brain.

I was amazed. Even though I felt so well and have never even smoked before, I was being told I had stage 4 lung cancer.

Nothing much has changed

After radiotherapy, to tackle the tumours in my brain, I was put on a targeted cancer drug which I’ve been on ever since.

Strangely, my father had also been diagnosed with lung cancer when I was younger. This was in the ‘70s and he’d lived for ten years, so I was hopeful treatment would have greatly advanced since then – and it has!

Being on targeted treatment has kept me fit, healthy and symptom-free for which I am so grateful. Cancer is just part of my life now.

My current treatment is brilliant. Nothing much has changed since my diagnosis. I have always felt well, and I still do.

Being on targeted treatment has kept me fit, healthy and symptom-free for which I am so grateful. Cancer is just part of my life now.

I take cancer in my stride

I can still go out walking all the time. I’m lucky that my treatment lets me, quite literally, take cancer in my stride.

Since being diagnosed, I’ve walked three Caminos, the Hadrian’s Wall Path and the Cleveland Way, and I am continuing to complete other long-distance walks in stages.

My disease will eventually progress – I know that – but I don’t tend to dwell on it. Charities like The Institute of Cancer Research, London, are working hard to stop cancer developing resistance to drugs, and I hope that they will find a way to outsmart it.

At the moment, I’m just enjoying feeling healthy and well, and I’m very much living in the present.

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