Cancer in General Practice By Shampa Sinha

Transcription

1 Cancer in General Practice By Shampa Sinha A physician is obligated to consider more than a diseased organ, more even than the whole man - he must view the man in his world. (Harvey Cushing). This is particularly true of the role general practitioners usually play in their patient s lives, but especially so in the context of cancer. General practice is usually the setting where cancer is first detected or suspected and if these suspicions are confirmed, the GP becomes crucial in coordinating their patient s care, providing psychosocial support for them and their family, assisting them to navigate all possible treatment options, managing follow-up to treatment, guarding against recurrence or overseeing their transition to palliative care. 1 In recent years, Australia s cancer landscape has been growing more complex due to the fact that our population is both increasing in size and becoming older. Between 1991 and 2009, the number of new cancer cases diagnosed almost doubled 2 and the majority of these diagnoses in 2012 were made in patients aged 60 and above. 2 Furthermore, an increasing number of patients are surviving cancer. The five-year survival rate is now about 60 per cent worldwide and there is a growing gap between cancer incidence and mortality 3 - to the extent that cancer has become, for many of its victims, a chronic disease 4. Many of these survivors however have continuing unmet non-medical needs ranging from psychological and financial issues that fail to be identified and addressed due to lack of adequate skills or resources. 5 Within the spectrum of medical specialists, the GP is best placed to identify the patient s medical and nonmedical needs due to his or her ongoing relationship with the patient and his or her family or carers. 4 The following discussion outlines the growing contribution general practitioners make during each part of the cancer journey, the challenges faced in fulfilling each of these roles and the implications these have for medical education and current medical students. I. The GP s role in the cancer journey Prevention and Screening As community awareness of various cancer screening programmes has grown, so has the demand for particular screening tests, most of which are undertaken in the general practice setting. For example, gynaecological check ups, such as breast examinations and Pap smears, increased from being performed at a rate of 0.1 per 100 encounters in to 0.3 in Orders for faecal occult blood tests (FOBTs) almost tripled between and Even in cancers such as melanoma where no national population screening programme currently exists, patients themselves have been proactive in requesting complete skin checks. These requests almost doubled from 0.8 per 100 encounters in to 1.5 in However challenges remain in ensuring screening programme uptake is uniform across all

2 populations. Response rates for example for FOBT tests are significantly lower for indigenous patients and people from non-english-speaking backgrounds 7 and socioeconomically disadvantaged groups relative to those for the rest of the population. 8 Furthermore, only 55% of people with positive FOBT result subsequently underwent a colonoscopy. 8 This places a greater onus on GPs to follow-up with these sections of the population a time and resource-intensive process. GPs also play a large role in cancer prevention by educating their patients about cancer risks. However time-constraints may often impede this from happening as frequently as it should. For example, a UK survey found that despite GPs beliefs in the importance of preventive efforts only 64% routinely inquired about their patients smoking status 9 and a similar American study found only 53% of patients had been advised to quit by their primary physician 9. Diagnosis and referral GPs play a critical role in diagnosing cancer and early diagnosis can maximise the chance of a cure. 10 Accurately diagnosing cancer in general practice, however, can be challenging. On the one hand, 85% of all cancer cases are initially diagnosed at the general practice level. 11 General practice is also usually the first point of contact for people with early symptoms of cancer 1. On the other hand, cancer constitutes a relatively small proportion of all GP consultations and the predictive value of even the most serious cancer symptoms is often below 5%. 11 Nevertheless, GPs can often be the focus of blame by patients for perceived delays in referral and subsequent adverse outcomes. As an aggrieved patient with breast cancer commented, He [her GP] should have referred me to the hospital the first time I consulted him... It was almost nine months before he referred me. 12 However in certain cases, particularly with regard to rural and indigenous patients, late presentation by the patient might be the key reason for diagnostic and referral delays. 13 Referral is also not always a straightforward process since the specialist the GP refers to may then make a secondary referral to another specialist. This process can be streamlined through programmes such as CanNET set up by Cancer Australia to facilitate the development of multidisciplinary cancer teams (MDTs) that assist the GP in identifying appropriate specialist teams for a particular patient. 10 MDT meetings can also help speed up patient care by informing GPs about what workup is required in advance of the specialist appointment. 10 GPs in rural and remote areas tend to play a much larger role in coordinating their patient s care and also in providing procedural care such as including chemotherapy. 13 Follow-up and surveillance Cancer survivors can experience a range of debilitating medical problems ranging from the side effects of their treatment to psychological distress to social

3 issues such as maintaining ongoing employment, access to insurance. They may often be left with permanent disabilities and impaired function. 14 Within the plethora of health care professionals involved in the patient s cancer journey, the GP usually has the most comprehensive knowledge of patient s history and is therefore best placed to address these issues and oversee follow-up to treatment and ongoing surveillance against recurrence in conjunction with the specialist team 15. Where the course of active treatment has finished, the GP s role might be primarily supportive, dealing with the anxiety caused by surveillance visits and proactively assess psychological status and develop a mental health plan to assist with these issues. 10 They also have to continue to treat the patient s other comorbidities including non-cancer-related illnesses. Palliation The transition from active treatment to palliative care can be extremely traumatic for the patient and their family. The GP may have to provide care and support for the patient s carers as well as the patient themselves. 10 Many carers however feel that GPs do not understand their needs. Conversely GPs and district nurses may feel that they lack the time, resources or relevant training in order to play a more substantive and pro-active role at this stage of the patient s journey. However this is the step in the journey where the patient and their carers might feel the most helpless and isolated and rely on the GP to provide not only empathy but also guidance on tasks they can focus on such as crisis management plans, advanced directives and do not resuscitate orders. 16 Policy, Research and Advocacy There are many aspects of the role or impact of primary health care in cancer care as a whole about which there are still many unanswered or inadequately answered questions. For instance despite widespread interest in shifting the locus of cancer follow-up from secondary or tertiary to primary care in order to reduce costs, there is lack of evidence about for example, whether this would result in equal or improved outcomes for the patient across all cancers. 17 There is some evidence to indicate that there might be no difference in outcomes between postsurgical colon cancer patients undergoing either GP-led or surgeonled follow-up. 17 Within primary care, there is potential for further research in exploring various models of cancer care such as the question of whether better outcomes can be achieved by specialised primary care practices relative to generalist practices. Some research shows that in the case of melanoma and non-melanocytic skin cancers, diagnostics accuracy and excision rates by GPs in generalist practices were equivalent to that by GPs in skin cancer clinics but that the latter had a higher rate of biopsy and complex skin closures 18. These differences in management between two different general practice care models warrants further investigation.

4 Research of this nature is important in order to inform decisions about policy and funding allocation. An exercise in 2004 by the National Cancer Control Initiative to identify priorities, resources, needs and gaps in support for primary health care professionals, for instance, provided important insights into some of the barriers to achieving better survival outcomes among indigenous women affected by breast and cervical cancer. This study led to improved systems for coordination and access, better cultural awareness amongst GPs, recall and reminder systems and health promotion. It also led to indigenous community participation in planning and delivery of primary health services and increased participation in screening programmes. 19 Another purpose of research is to identify and remedy knowledge, training and service delivery gaps within general practice with regard to the care of cancer patients. A Danish study found, for instance, that many cancer patients experienced poor coordination in the cooperation between their GP and the hospital and would have liked their GP to be better informed so as to be able to adequately coordinate the different agencies and individuals involved in their treatment. 12 General practice-specific research and data can fill in important gaps in the current evidence base used for treatment of cancer. The knowledge base describing symptoms in cancer patients such as alarm symptoms is derived from hospitalised patients and does not necessarily describe cancer symptoms encountered in general practice. 20 Research can also serve as a tool of patient advocacy to improve and standardise the care offered to patients. For example, by assisting in development of protocols and guidelines that outline what symptoms to look for and what tests to undertake and what to do when problems arise so that the GP is better placed to provide both practical and psychological support to their cancer patients. 11 II. Implications for medical students Given that cancer was the second most important cause of death in 2010 in Australia 2 and is consuming an ever-increasing share of the burden of disease, medical students, as members of Australia s future health workforce, need to develop their capacity to better manage and support cancer patients. Along with general practitioners, all medical students in their initial years following graduation will, as interns and residents, form part of the primary care frontline as it were in cancer care and management. There are three particular areas that the current medical curriculum needs to emphasise in order to adequately equip medical students with the skills and knowledge necessary to undertake this role. Firstly, better training needs to be provided to develop expertise in early detection of cancers. Whereas most basic medical curricula provide students with substantial training to detect breast, prostate, skin and bowel cancers, there is less emphasis placed, for example, on developing the ability to detect oral cancers one of the easiest cancers to detect clinically. 21

5 Secondly, lack of empathy by general practitioners is highlighted by cancer patients as one of the areas that results in the greatest dissatisfaction. Medical students therefore need to understand the importance of expressing empathy and improving their communication skills in this area. 12 Thirdly, students can also be instrumental in reshaping health care models in cancer care. Since cancer, more so than most other diseases, requires good coordination between different levels of health care and the formation of multidisciplinary teams, new graduates can advocate for a flatter system of healthcare with better information flows between general practitioners and specialists and an emphasis on team management. 10 Conclusion As the preceding discussion highlights, GPs wear many hats when it comes to dealing with cancer. As coach and educator, they steer their patients towards healthy behaviours and lifestyles. As detective, they maintain a high index of suspicion regarding cancer with all their patients even though the actual number of patients who actually have cancer is relatively small. As conductor of the patient s large orchestra of health professionals they coordinate and supervise their care. As counsellor they assist the patient with deciphering and processing large amounts of medical information. Finally, as advocate they lobby for adequate resources and training in order to enable them to provide a high quality of care to their patients based on evidence provided through research. 1 Cancer Australia website: 2 AIHW, Cancer in Australia: An overview Phillips, Jane Louise, and David C. Currow. "Cancer as a chronic disease." Collegian: Journal of the Royal College of Nursing Australia 17.2 (2010): McAvoy, Brian R. "General practitioners and cancer control." Medical journal of Australia (2007): Wolff SN, Nichols C, Ulman D, et al. Survivorship: an unmet need of the patient with cancer implications of a survey of the Lance Armstrong Foundation (LAF) [abstract] ASCO Annual Meeting. 6 Fahridin, Salma, and Helena Britt. "Cancer screening in general practice." Australian family physician 38.4 (2009): Department of Health and Ageing, Bowel Cancer Screening Pilot Monitoring and Evaluation Steering Committee. Australia s Bowel Cancer Screening Pilot and beyond: final evaluation report Canberra (2005) 8 Ananda, Sumitra S., et al. "Initial impact of Australia's national bowel cancer screening program." Medical Journal of Australia (2009): 378.

6 9 Dietrich, Allen J., et al. "Cancer: improving early detection and prevention. A community practice randomised trial." BMJ: British Medical Journal (1992): Mitchell, Geoffrey K. "The role of general practice in cancer care." Australian family physician 37.9 (2008): Vedsted, Peter, and Frede Olesen. "Early diagnosis of cancer-the role of general practice." Scandinavian journal of primary health care 27.4 (2009): Lundstrøm, Louise Hyldborg, et al. "Cross-sectorial cooperation and supportive care in general practice: cancer patients experiences." Family Practice 28.5 (2011): Bowers, E Jackson and Kalucy, E (ed). RESEARCH ROUNDup: The primary role for people with cancer. Primary Health Care Research & Information Service. (2009). Adelaide: PHC RIS, Issue 5, March. 14 Hewitt, S. Greenfield, M. Stoval (Eds.), From cancer patient to cancer survivor: Lost in transition, The National Academy Press, Washington, DC (2006) 15 Grunfeld E, Primary care physicians and oncologists are players on the same team Journal of Clinical Oncology, 26 (14) (2008), pp Marie Fallon and Geoffrey Hanks (eds), ABC of Palliative Care. Blackwell Publishing (2006) 17 Wattchow, David Anthony, et al. "General practice vs surgical-based follow-up for patients with colon cancer: randomised controlled trial." British journal of cancer 94.8 (2006): Byrnes, Patrick, et al. "Management of skin cancer in Australia--a comparison of general practice and skin cancer clinics." Australian Family Physician (2007): Reeth J, Carey M. (2008). Breast and cervical cancer in indigenous women: Overcoming barriers to early detection. Australian Family Physician. 37(3). 20 Hamilton W. Five misconceptions in cancer diagnosis British Journal of General Practice 2009;59: Wade, J., et al. "Conducting oral examinations for cancer in general practice: what are the barriers?." Family Practice 27.1 (2010):