A GP's Perspective of Cancer Survivorship - by Dr. Jane Crowe
“Jeanie*, a 53 year old married accountant with 3 kids (all still at home) comes in to see me (a GP) with a 5 week history of breathlessness, increasing rib pain and weight loss.
After I have assessed Jeanie and arranged some tests, Jeanie is diagnosed with advanced cancer.”
I was walking in my neighbourhood and chatting to a neighbour who is an experienced cancer researcher. They expressed excitement about the belief that there is going to be a massive change in the treatments of cancer with a resultant improvement in overall mortality in the next 10 years or so. In my 30 years of practice, there has been, and continues to be, a lot of change within the area of cancer. Don’t get me wrong, there is still a long way to go for advances in some of the rarer cancers, but I am hoping as new immune related treatments develop they may become applicable to the cancers that are still associated with poorer outcomes.
In the old days, cancer was often diagnosed in the late stages, associated with a dismal prognosis and toxic treatments for the “cancer patient”, and the treatments often only occurred within the hospital setting.
Of course nobody wants to receive a cancer diagnosis - however, I feel there is a lot more hope available now for people diagnosed with cancer.
What has changed?
Prevention
Vaccines, such as the Hepatitis B and HPV vaccines, have been developed and rolled out to prevent cancer
Screening programs
We now have population screening programs for early detection of cancers such as bowel cancer, breast cancer, and cervical cancer. This can enable a pre-cancerous person, or a person with early cancer, to be diagnosed and treated.
Better treatments
Treatments have improved due to past and ongoing massive investment in research. Surgery, radiotherapy, hormonal therapy, chemotherapy, immunotherapy; all of these treatments underwent expensive clinical trials. For many cancers now, there are multimodal options, and the benefits and toxicities of each treatment are weighed up. If one treatment is not suitable or tolerated by the patient, then there is often another option. Now, in “precision medicine” practices, even the DNA of the patient and the cancer’s genetic makeup are starting to be used to plan the most effective treatments for that particular patient. Without such a significant investment in research, we would not be able to improve and tailor our treatment options.
Outpatient care
I have observed patients receiving cancer treatments and living in the community, no longer isolated in inpatient care. They can now receive hospital treatment in the day care setting and go home afterwards.
Financial decisions
There appear to be more financial decisions facing both public and private patients than ever before. These decisions can determine what treatments a patient receives.
The internet
Don’t get me started…Patients have access to all the (potentially good) information and (plenty of) misinformation about their condition that they can handle. In worse cases this could include treatments without evidence and potentially dangerous, very costly options that a patient can access.
Distinguishing the individual
More often than not, the “Cancer Patient” is now referred to as the “patient with cancer.” Putting the individual first and acknowledging the patient as having needs distinct from the cancer treatment is an important part of delivering care
And finally,
The concept of “survivorship”
With all these changes and hopefully improvements in cancer treatments…where does the patient fit in? This is “survivorship”: people living with a cancer diagnosis and all that it entails.
People with a cancer diagnosis are living longer now and so the cancer treatment becomes an issue of chronic disease management, much like other conditions such as diabetes or arthritis.
To me, the term “survivorship” is used to engage the holistic care of the patient, starting from the time of diagnosis and continuing for the rest of the patient’s life. The patient is often, but not exclusively, diagnosed with cancer, and some doctors have even begun to talk about survivorship starting with preventive care and pre-diagnosis.
There are many aspects to survivorship, and probably too many to talk about in this article, but I personally divide survivorship into two broad groups:
What do the medical and allied health professionals need to help manage the patient and their condition?
What are the patient’s needs? How can we put all of this together for Jeanie and her team?
This is where a GP is perfectly placed to support Jeanie, and help co-ordinate her care and her priorities as they change or occur as she goes through her treatment and post treatment phases.
“Jeanie is devastated to receive her diagnosis. Her mind is reeling with fear and anxieties about her mortality, her husband and children. She does not know what her future brings, or how she will get through this.”
After a patient is newly diagnosed with a serious cancer, the focus is often on active treatment. This may include surgery, chemotherapy, radiotherapy, immunotherapy or monitored surveillance, depending on the type and stage of the cancer.
And so, Jeanie’s world goes into upheaval. Lots of appointments to handle: specialists, treatments, hospitalisations, drips, side effects, blood tests, imaging…
Jeanie wants to be able to navigate all of this, but her stress is rapidly increasing…
What about her work? Jeanie is a business owner, what is the best way forward for her and the business?
What about her family? How will they cope with the news?
What about her husband? Can he handle the care and the support she’ll need? How will this impact their relationship? There has been some tension between them for the past year or so, how is he going to handle her illness?
What about the kids? Her husband works long hours, how are they going to manage the needs of the kids and ensure the household duties are done?
What about her parents? Jeanie’s elderly parents rely on her to help with their care, how will they cope?
How is she going to get to her appointments? It’s exhausting to arrange and keep track of them all, let alone figure out how to get to them.
How is she going to balance her life? Jeanie enjoys going to the gym and playing golf, but without them how is she going to find ways to decompress?
Jeanie is scared about what this diagnosis means for her existentially. She is not ready to die.
As I said, her head is reeling…
“Survivorship” is an attempt to break all this down, considering all aspects of Jeanie’s condition in terms of the biological, the psychological, and the social. Then, these aspects are prioritised so they can become more manageable. As a GP it can help to work with Jeanie to figure out what this means:
Work with Jeanie to write down all these concerns and factors in her life
Look at what is a priority, what management has been advised by the treatment team, and what her needs are at any given time along her active treatment-post treatment continuum
Discuss each issue with Jeanie, and plan how to manage it
Proactively encourage things that help her maintain her optimal health and quality of life, such as exercise and physiotherapy, psychological therapy or counselling, and general and cardiac health measures.
What may not be a priority for Jeanie in the early stages after diagnosis may become more of a concern later on. Patients traverse the active treatment-post treatment continuum on an ongoing basis. Thus, their survivorship needs regular review and management so that hopefully Jeanie’s quality of life is as good as possible for as long as possible.
And that’s what a GP does.