“Food just sticks — I’ve started cutting it up small”

Progressive dysphagia to solids is a red flag for oesophageal/upper-GI malignancy until proven otherwise — and the NICE NG12 rule is unambiguous: dysphagia at ANY age warrants a suspected cancer pathway referral for oesophageal or stomach cancer (this replaced urgent direct-access endoscopy in the 2025 amendment), with no requirement to trial a PPI first (the NICE CG184 reflux pathway does not apply once dysphagia is present); he also meets the second limb (55 or over with weight loss and reflux). Do not accept a "reflux/getting older" reframe or simply escalate antacids. Supporting features sharpen the urgency: unintentional weight loss, long-standing reflux (Barrett’s risk), smoking and alcohol. Characterise the dysphagia (solids vs liquids, progressive vs intermittent, odynophagia, regurgitation), check an FBC, and know the emergency escalations (complete obstruction, food bolus, haematemesis). The examinable hidden agenda is fear masked by humour — a friend who died of "throat cancer" that "started with food sticking" — plus guilt about a smoking/drinking history. Surface the fear gently, address lifestyle without shaming, balance honesty with the fact a cause will be found and treated, and complete the suspected cancer pathway referral with a clear safety-net.