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THE Lancet Oncology Commission on the expanding role of primary care in cancer highlights the complexity of the care of people with a cancer diagnosis in the weeks, months and years after curative therapy is prescribed.
It also highlights the lack of a defined role for primary care in usual cancer care guidelines, in spite of the position that primary care has at the centre of the health system and the role GPs play in delivering comprehensive, lifelong care.
Post-treatment surveillance to identify recurrence is, interestingly, not the first thing discussed in the commission report, in spite of being most commonly considered the primary role of ongoing care. However, the report points out that, for most patients, early detection of recurrences does not make a difference to mortality and morbidity.
The report emphasises the strengths of primary care — its continuous, coordinated, and comprehensive care for individuals and families — making it best placed to deal with the short-, medium- and long-term consequences of cancer treatment.
Long-term sequelae of both surgical and medical treatments on physical functioning are numerous, including bladder, bowel and psychosexual functioning. Some adverse effects of cancer treatments may not become apparent until years after the treatment has finished.
The impact on the psyche of having cancer can be long-term and debilitating, with more than a quarter of people suffering anxiety, depression and post-traumatic stress disorder.
The carers of cancer patients can also suffer psychosocial distress.
It is clear that a well informed GP can be on the lookout for these adverse effects. Moreover, a GP can assist in a transition back to the non-cancer world.
Cancer patients still have non-cancer diseases, like hypertension and arthritis. Good advice on diet and exercise can assist in maintaining good health and staving off disease, delivering proven survival advantages at the same time.
Systems that facilitate support from specialist oncology colleagues ensure the best quality outcomes for patients. Clear guidance on post-treatment surveillance and the sequelae of cancer treatments is essential, and clear referral pathways will reassure both patients and carers that specialist help is available when needed.
In spite of vast the improvements in outcomes for patients with cancer in recent years, about one-third of patients will die of their disease.
Primary care has much to offer patients with cancer facing death. GPs can encourage patients (and their immediate carers) to live life to the full.
However, GPs also need to recognise that end-of-life care is central to their role. At the same time, their place as part of an end-of-life team must be recognised and encouraged by specialist oncology and palliative care colleagues.
While there are many high-quality resources available to community-based GPs, having a supportive specialist on the end of the phone is invaluable. That sort of help may be the difference between a GP deciding to care for future patients at the end of life or not. Hence, this direct support of primary care colleagues when they accept the responsibility of a person’s care at the end of their life should be core business of palliative care specialists, and will be an excellent investment.
The way the health system supports GPs who deliver end-of-life care is critical in determining the nature of the care offered.
Palliative care takes time, and is best delivered when practitioners are willing to undertake home visits and provide advice and treatment out of hours. This must be remunerated properly.
Specialist advice and appropriate availability of essential medicines such as opioids are essential.
Primary care is also the ideal place to treat carers of patients with cancer, so that their needs can be identified and managed. Perhaps, this is a singular role for primary care that can be encouraged across the whole cancer care spectrum.
Primary care has much to offer patients in the post-treatment phase. It is time to examine models that can facilitate seamless care for patients with cancer across the primary–secondary divide.
Professor Geoffrey Mitchell is professor of general practice and palliative care at the University of Queensland and head of the palliative care stream of the Primary Care Cancer Collaborative Trials Group. Professor Mitchell was an author on The Lancet Oncology Commission on the expanding role of primary care in cancer control.
In an accompanying article in this issue of MJA InSight, Professor Jon Emery, the Herman Professor of Primary Care Cancer Research at the department of general practice, University of Melbourne, discusses the role of GPs in early diagnose of cancer and care of cancer survivors.
This week’s MJA features a series of articles on cancer.
Geoff Mitchell is well worth listening to, having been one of the prime movers in setting up the unique hospice in Ipswich, where GPs are encouraged to visit their own patients, and contribute to their care. There is good cooperation between the hospital palliative care unit and the hospice, and specialist advice is readily available. He continues to practice “grassroots” General Practice, as well as his Academic career.