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What does supportive care look like in practice?

Watch this video to learn more about the role of the PCP in identifying and managing the physiological and psychological needs of cancer survivors.
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6
Hello, I’m Jackie, I’m Justin’s GP nurse. Thank you for coming in for this meeting. Where we’re going to compare a general practise management plan, and through that plan, access some allied health services. That means things like maybe a dietitian, or a physiotherapist, or any of those professionals that you might want to see to help you through this phase, settling back from that acute hospital experience into the community, where your GP is your first person for you. Your main health support person, all right? OK. It will be good checking in. Good. So today, just to work out what you particularly need, I’d like to know how you are getting on since your treatment finished. I’m tired, constantly tired.
61.3
Yeah, I’m not surprised. Yeah, and I think Barry’s pretty run down, too. He’s been carrying a lot of the load at home. Yeah. I’m a bit worried about him. It’s been a little bit of a trying time, so you know, it’s been a bit rough. Yeah. Yeah. You’ve been the main carer and support person. Yeah. All this time, and you’ve got through, which is great. So it’s time to get well and reconnect with your GPs. I know you’ve had a lot of specialist care. So let’s start with you said both tired, What have you been doing to overcome your tiredness? Have you been managing it all?
102.1
Well, no, and I guess that’s where– I was telling with Justin, it was just like knowing– obviously there’s stuff available to us, it’s just knowing how to access that, because clearly we’re not figuring anything out on our own. So yeah. OK. Just a bit of direction on that, then. That’d be great. So with regards to the exercise, the best evidence we have at the moment is that some exercise of moderate intensity is going to keep you more healthy. And maintain your health, get you back to where you were. Get you back to a more normal balance and also help you sleep at night.
137.2
So that would be an advantage, too, to try and regulate sleep, which has probably been put out over the treatment time. So an exercise physiologists can help with that. And the best thing– I can go through the plan is get a couple appointments with an exercise physiologist, which will be subsidised. So you won’t have to pay for that. You mentioned, at the beginning, about diet. That’s something Justin talked about as well. Yeah, so how is your diet at the moment? Has it changed since over the last year or two? Well, a little bit, because she’s been on the therapies and things like that. But pretty standard, you know, been eating veg. OK. And who cooks at home?
180.9
It’s been me doing the– You do it. –the bulk of it. And you’ve been doing it for a while. Yeah, like something that’ll serve the whole week, so like a chilli con carne, or a big spaghetti, or something like that. All right. So you’re in charge of the menu. And it’d be nice for you to both consider your thoughts on that, because you’ve had this time changed. So if you think your diet’s not quite adequate at the moment for your needs– I think it’s more for me just making sure I don’t– the cancer doesn’t come back. So doing all the right things. That’s correct.
212.2
Yeah, so the best well-balanced diet for you might be important to set you on the right path again. So an appointment with the dietitian can be included. So that could be put on your plan. Great, yeah. All right. Anything else coming up? Anything else happening for you? Yeah, probably just you know I’m being worried about the cancer came back. And that’s taking its toll, I think, in helping add to my tiredness. But I’m also worried about how Barry’s coping. I think he’s doing the stiff upper lip and all that stuff, but, you know, yeah, I’m a bit– What do you think, Barry? –a bit worried about him.
250.5
Well, it’s been a long process and a long period, so it’s made me a little bit more tetchy than I would be, a little more frazzled. Irritable, you said before. And so what’s your mood like day to day? Probably a little more hot under the collar than I would like. A little more tired. And the tiredness gets up. Yeah. So just for you, though, I’d recommend you have an appointment with Justin himself. And consider your psychological needs. Your mood will start to feel– bring that mood up a little bit. OK. And so he’s a good person to talk to initially.
291.3
And I think you should have a separate appointment with him and see then if you also need some kind of plan for yourself. So that’s a possibility at this time to have that then. Yeah, yeah. I think that would be good. I’d be happy to do that. Let’s make an appointment before you leave today. Sure. Does it say something about the plan including psychology for me? It can do it, yes. We can incorporate that. It’s just one or two visits of psychology, but if you need more and you feel you need ongoing support, we might even have another way of going about that. So we can inform you of that as we go ahead.
329.8
And I just want a bit wanted to clear up– Justin had mentioned that I would probably need to be a bit more mindful of our alcohol intake. Yeah, So Justin covered that with you, he would prefer that you didn’t have an excessive intake, and try and reduce it. We’d like you to reduce your alcohol as much as possible, because there’s some evidence that’s come through about there being breast cancer recurrence in high alcohol intake. So be mindful of that. Yeah, the intake’s cut back a bit. That will be tough for you, won’t it? Yeah, maybe just being aware of that means that you can reconsider how much you’re having each night or each week. Cut it down.
376.8
So we might actually get healthy for Sheedy. Yeah. A tough way to do it. [LAUGHS] Yeah, this is true. You could dilute your alcohol a little bit while you’re drinking, whether it’s just habitual or whether you can supplement with something else or have something completely different. Is there anything else you’d like to bring up?
402.2
Well, it’s been a really challenging time. Yes. And Barry’s putting a lot for me, and I’m just– I’ve been having problems with sex at the moment. And, yeah, I’m starting to feel a little bit concerned, you know, that I can’t be there for Barry in the way he would like. And he’s been there for me so much, you know. It’s not like it’s your fault, love. I mean, look at the situation. OK. It’s difficult to manage this. And it’s difficult to broach this question. So I’d just say firstly, just be very patient with each other and be very– communicate as clearly as you can what your expectations are.
452
Barry may not expect that much of you, but you would like to give that and it be comfortable at the moment because of hormonal changes and body changes that Martina has gone through. It sounds like you’re very aware of those and you have been patient with those. I think our timing has just been a bit off. Yes. Yeah, when we’ve tried. Yeah. All right, so I’d suggest you just work at an intimacy level of the moment, but the doctor can certainly refer you for the sexual help, if you don’t find that’s changing and improving over time. So I have some brochures ready for you. So the first one’s on that subject of sexual well-being, from the Breast Cancer Network Australia.
499.2
And I think that would be very helpful for you to look at and consider the points that are made in that. And also, there is some self-help groups at the back. And that might be useful for you to share your story as well as, and learn what they’ve gone through and what’s worked for them. That might be very helpful. There are a couple of others here, too. And including from the Cancer Council Australia. And you can always ring their line for support. I’ll just remind you of that, it’s probably been presented to you before, but I’ll remind you that they’re there for you now, too. Fantastic. Into the future, all right. Thank you. Good, so I’ll write that plan up.
536.2
And I’ll ask you to come in and sign off, Martina. And then Let’s make that appointment for you today. And look forward to seeing how we go with those connections that we make. The exercise physiologist, dietitian, and psychologists for you. Great. All right. Thanks, Jackie. It’s a pleasure. Thank you very much.

Now that you had a general introduction to supportive care, it’s time to take a closer look at what it looks like in practice. If you have already watched the scene above, you will have seen that Martina meets with her practice nurse (Jackie) for the first time. At this point in the case, Martina is concerned about her husband’s welfare – particularly his concerns about the possibility that Martina’s cancer may return.

The important thing to note here is that support is available to patients and their families. This activity focuses on the types of services available, including the psychosocial aspects of supportive care.

The psychosocial aspect of supportive care

Up to 25-30% of cancer patients develop some form of psychological distress during the survivorship phase. The most common disorders include:

  • Adjustment disorders
  • Post-traumatic stress
  • Depression
  • Anxiety

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These are generally triggered by:

  • Fear of cancer recurrence
  • Body image issues
  • Sexuality and fertility concerns
  • Stigmatisation and discrimination
  • Social relationships
  • Returning to work
  • Anger and guilt

An experience of cancer can serve to trigger or exacerbate pre-existing psychological conditions in patients, their family members and carers. Risk factors for psychological disorders in cancer patients include:

  • History of psychiatric illness in the individual or family
  • Poor social networks
  • Personality factors such as social introversion
  • Stressful life events

Part of the PCP’s role in cancer survivorship is identifying and managing the range of emotions that come with a cancer diagnosis and survival, be it directly or indirectly. By recognising risk factors associated with psychological distress, PCPs can help facilitate early interventions and provide referrals, where appropriate.

It is also important that PCPs pay attention to the needs of carers, family members and children of people living with cancer because they can experience similar distress levels to cancer patients themselves. Research has shown that 25-35% of caregivers develop symptoms of emotional distress, and 15% may experience depression, irrespective of age, sex, ethnicity or stage of the disease.

Yet, fewer than 10% of cancer patients and/or their family with identified psychological needs are referred to help, with reasons including:

  • Inappropriate timing of referrals
  • PCPs not completing the necessary follow up including: * asking about supportive care needs * skillfully introducing supportive care services * being aware of the supportive care services in their area.

Finding a way to discuss physiological and psychological difficulties can be very difficult. A useful tool is the National Comprehensive Cancer Network Distress Thermometer, which is validated and widely used for identifying such issues. A tool like this can be used as a prompt by the PCP to encourage open and positive communication, and it may also guide clinical decision making and lead to identifying issues and referring as necessary.

Now that you have had a brief introduction to supportive care, read pages 7-10 of the Australian Clinical practice guidelines for the psychosocial care of adults with cancer – Summary of Evidence.

Consider exploring one of the guidelines listed by reading the background evidence that supports the statement. eg. If you chose to explore the statement from Chapter 3.3 – Emotional and social support, on “Appropriate counselling improves the well-being of people with cancer”, to find the evidence that supports this statement refer to reference 15 by Devine et al on “The effects of psychoeducational care provided to adults with cancer: meta-analysis of 116 studies.

If you’re interested in learning more about psychosocial care, please refer to the resources in the ‘See Also’ section below.

Reference: Rubin G, Berendsen A, Crawford SM, Dommett R, Earle C, Emery J, de Wit N, Zimmermann C. (2015). The expanding role of primary care in cancer control. The Lancet Oncology, 16(12), 1231-1272. DOI: 10.1016/S1470-2045(15)00205-3

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This content is taken from The University of Melbourne online course
Cancer Survivorship for Primary Care Practitioners
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