Cancer

August 2014

Up front

Cancer and primary care

Volume 43, No.8, August 2014 Pages 501-501

Glenn Duns

Medical school is such a transformative experience that it can be difficult at times to recall one’s perception of illness and health prior to medical training. My family doctor was easily able to manage whatever medical problem I presented with as a child, whether it was a sore throat, broken clavicle or chin laceration. My sense was that if the family doctor could manage these problems with ease, then the vastly more resourced and technologically sophisticated hospitals at the periphery of my awareness would be able to cure anything.

The one disease that broke through this sense of medical omnipotence was cancer. Inevitably, we’ve all known, personally or professionally, someone with cancer: the childhood classmate who goes off to hospital and returns permanently disabled; the friend’s mother who loses her hair, loses weight, then is never seen again. These experiences can lead to the equation of cancer with death, and a sense of catastrophe in association with the diagnosis. Much has been written about societal fears and prejudices surrounding cancer, and doctors are not immune to these influences.1

Primary care and general practitioners (GPs) have a crucial role in the diagnosis and management of cancer. As described in the article by Emery and Chiang,2 an early diagnosis and referral for appropriate management can make the difference between life and death. The difficulty for general practitioners is to be able to recognise the patient with cancer when we see multiple patients on a daily basis with symptoms that could be due to cancer. This ability to identify life-threatening illness amongst myriad undifferentiated presentations is part of what makes general practice so challenging.

Once diagnosed, it is important to remember that the patient with cancer continues to require a holistic approach to their care and to not let their life be reduced to rounds of chemotherapy and radiation. Exercise, nutrition and ongoing assessment for other complications and medical conditions are equally important. Advances in medical care and changing demographics have resulted in increased numbers of patients surviving cancer. As the number of cancer survivors increases in developed countries, continued access to high-quality generalist care will be necessary in order to meet the needs of this group, needs that are arguably best met by the adoption of a chronic disease model involving general practice, as described in the article on cancer survivorship by Emery.3

Some patients will not respond to therapy and will progress to end-of-life care. Mitchell4 clearly identifies the similarities between the principles of general practice and palliative care, and how ‘end-of-life care brings all the skills of general practice into play’.4 Advanced care planning becomes crucial, and Bird5 further explores this topic in an article that considers the legislative landscape in Australia around advanced care plans.

Unfortunately, many GPs do not treat palliative care patients, for a variety of reasons. This may be partly related to the previously mentioned fears and prejudices surrounding cancer. Susan Sontag wrote that in advanced industrial societies, ‘As death is now an offensively meaningless event, so that disease widely considered to be a synonym for death is experienced as something to hide.’6 In my own experience with treating palliative care patients I have encountered many challenges but the one thing I have absolutely never felt is a lack of meaning. Working in conjunction with a high-quality community-based palliative care service, I’ve found that patients and their families can be properly supported and provided with comfort and dignity at home.

GPs are experts in multidisciplinary care and managing undifferentiated presentations. Cancer challenges and engages both these capacities, and will continue to do so for the foreseeable future. The holy grail of a cure for cancer may manifest at some point, but until then GPs will need to play an essential role in the management of cancer via the provision of comprehensive and continuous care, from diagnosis until the end of life.

References

  1. Barroso P, Osuna E, Luna A. Doctors’ death experience and attitudes towards death, euthanasia and informing terminal patients. Med Law 1992;11:527–33.
  2. Emery J, Chiang P. The role of risk tools in diagnosing cancer in primary care. Aust Fam Physician 2014;43:508–12.
  3. Emery J. Cancer survivorship – the role of the GP. Aust Fam Physician 2014: 521–25.
  4. Mitchell G. End-of-life care for patients with cancer. Aust Fam Physician 2014;43:514–19
  5. Bird S. Advanced care planning. Aust Fam Physician 2014;43:526–28.
  6. Sontag S. Illness as Metaphor and AIDS and Its Metaphors. London: Penguin, 1991.

Correspondence afp@racgp.org.au

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