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Cancer Fundamentals and Communication and Coordination of Care

What role do primary care practitioners have in cancer survivorship? Watch this video by Professor Jon Emery to find out.
So in this presentation, we’re going to be discussing the importance of cancer survivorship and the growing prevalence of cancer survivors and how we’re beginning to recognise cancer more as a chronic disease and the role of primary care in cancer survivorship care and what the essential components of that survivorship care looked like. So these are some Australian data. There in 2018, there will be roughly 138,000 people newly diagnosed with cancer. And about 48 and 1/2 thousand people die from the disease. So that means roughly 1 and two people will have been diagnosed with cancer by their 85th birthday. These are some of the common cancers in Australia. So breast cancer is commonest in women. Prostate cancer is commonest in men.
And then colorectal, melanoma, and lung are also common cancers in Australia. When we think about primary care across the cancer continuum, then historically, primary care has played mainly a role in prevention, screening, and early detection and much less during acute cancer treatment or following cancer treatment. And so survivorship care to now has been largely specialist-based. But with the growing numbers of long term survivors and the skills of general practice, then it’s becoming increasingly recognised that primary care has an important role in survivorship. So there are a growing number of people living long term after a diagnosis of cancer in Australia as demonstrated in this diagram. So there are now nearly a million Australians living long term after a cancer diagnosis.
Cancer survivors face a range of term medical, psychosocial, and practical needs. And increasingly, we’re recognising cancer as a chronic illness. And therefore, we need to be applying models of chronic disease care in the way we treat patients after a cancer treatment. So for example, I have a patient of mine, he’s a 78-year-old man, who’d been treated several years ago for prostate cancer. He also has a number of chronic health conditions. He has hypertension and diabetes. Unfortunately, he was recently diagnosed with a recurrence of prostate cancer. And so he’s now on androgen deprivation therapy. But this is causing him a number of side effects. He’s putting on weight. And this is affecting his diabetes and his blood pressure control.
And it’s also worsened his sexual function, which is the most concern to him. And so it just demonstrates how his prostate cancer is like a third chronic disease and how we need to be considering the complexity of his care. The US Institute of Medicine published a report several years ago, which really highlighted a number of key components to cancer survivorship care. These cover prevention, surveillance, interventions of the consequences of treatment, and coordination of care. So if we think about this in the context of a patient of mine with breast cancer who was treated 18 months ago, she’s on Tamoxifen and is experiencing side effects that she doesn’t like.
And so we have to talk about the importance of compliance to reduce her risk of recurrence. But I can also emphasise the role of physical activity and limiting her alcohol intake as further ways of reducing her risk of recurrence and ensure sure she’s up to date with her mammograms in her clinical examination and that she’s had a bone density check to test for the consequences of her Tamoxifen treatment. And she’s showing early signs of lymphoedema so I refer back to the lymphedema clinic. And then finally, we discuss the model of shared care and ensure sure she knows whether it’s her specialist or me that she is due to see for her next follow up visit.
We also need to cover these six principles of wellness so that we don’t focus just on the physical consequences of cancer but also the social, intellectual, spiritual, emotional, and any occupational consequences of cancer. Thinking now about communication and coordination of care, of course, communication is always a key aspect of quality of care when thinking about communicating with your patients. But it’s equally important when communicating between health professionals, particularly in the context of cancer where there are often many specialists involved. And this is why we need to think more clearly about models of care in cancer survivorship, the role of risk stratification, and survivorship care plans. There is, of course, no uniform model that suits all cancer survivors.
And so we need to think about a number of factors, including the type of cancer, the availability of health care resources locally, the risk of cancer recurrence in the type of symptoms that person is experiencing, and their own personal preferences. And therefore, assessing their needs and also assessing their risks are important aspects of returning which model of care is best for that person. This is the COSA model of survivorship care, which highlights the risk stratification process– recognising that certain patients are most suitable for specialists only care. But for people who are low in moderate risk, then there are clear rows of primary care.
And so increasingly, we’re considering shared care models of follow up where there’s an explicit role for primary care as part of a partnership with specialist care in the delivery of follow up and survivorship care. So in order to have a good model of shared care, there are some key components.
Clearly, communication has to be excellent and supported through a survivorship care plan with clear and explicit roles and responsibilities for the GP and a clear mechanism to re-access specialist care if needed, which brings me on to survivorship should care plans as a key method of communication between the specialists and the GP, in which you find a surveillance plan– so knowing when and how to detect recurrence and look for later adverse effects– ways to manage the consequences of cancer and its treatment but then more importantly, think about the broader health care needs, including other cancer screening and health promotion, and then finally, how best to access specialist care. And so you should receive a survivorship care plan.
And it’s an important tool to discuss with your patient so that they are fully understanding of what’s occurred to them and any problems that they may be having. And you can also use it within general practise to help develop a chronic disease care plan as well. And so through this presentation, I hope you’ve now understood the importance of survivorship, the growing prevalence of cancer survivors, and how we recognising cancer as a chronic disease and what the role of primary care is and the essential components of survivorship care.

As you will have just seen in the video above, as detection methods and treatment for cancer continue to improve, an increasing proportion of the population is living beyond their cancer diagnosis and treatment. What is clear is that we are now faced with a new challenge – how can we best support cancer survivors in the community? And what role do primary care practitioners play in this transition?

The statistics presented in this video come from Australia, but if you live and work in a different location, take some time now to look up cancer statistics on your region and report back your findings in the comments section below. Are there any comparable differences?

Historically, primary care was largely seen as peripheral, but with the increased emphasis on prevention, diagnosis, survivorship, palliative, and end of life care, the role of the primary care practitioner is becoming more integrated and complex. Primary care can be delivered through multidisciplinary teams in general practices, which contributes unique professional expertise to support the cancer patient. These multidisciplinary teams may include; general practitioners, general practice nurses, pharmacists, psychologists, exercise physiologists and others. More traditional models of survivorship care must be reconsidered as the number and complexity of patients living beyond cancer increases. With this increase in number and complexity of patients, having patients attending outpatient clinics for up to three years post-treatment completion is no longer sustainable.

Read the COSA Model of Survivorship Care (pages 8-12) and consider the fundamental principles underpinning all aspects of the COSA Model of Survivorship Care to discuss the following areas:

  • How it is done (coordinated, survivor-centred, integrated care across all service levels at every time point)?
  • What is done (promote, prevent, manage)?
  • Is available care accessible and equitable?
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Cancer Survivorship for Primary Care Practitioners

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