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When it comes to cancer, we are so focused on the specialist who’s treating you, and rightly so because your oncologist or surgeon or your urologist is absolutely crucial in getting you through it. But what about the general practitioner, the family doctors, what role do they play and how can they help you in your fight against cancer? Right now, you’re going to hear from Jon Emery, the professor of primary care cancer research at the University of Melbourne. Jon will reveal why the GP is your best ally in your war on cancer and is going to set the record straight on cancer and how it relates to primary care, including:
- Proven online resources to find the right information on cancer
- The fear of cancer recurrence
- The role of GP as advisor and counsellor
- How primare care can help after cancer
- How can primary care physicians pick up cancer early
- Why Big Data and artificial intelligence can help GPs to detect cancer
- Why the GP is your best ally in your war on cancer
Australian Cancer Survivorship Centre
Episode 009: Why The Oncologist Is Your Guide Through Cancer
Joe: Jon, first I really want to ask you, the family doctor, the general practitioner, this is really the first line of defence against cancer. It’s up to him or her to understand what’s going on, to send you for tests, to forward you to the right specialists. How can primary care physicians pick up cancer early?
Jon: There are two ways, really, to think about earlier detection of cancer. One is through screening tests. These are tests that are offered to people without symptoms and then they are obviously trying to detect people when they present with symptoms that may be due to cancer and investigating those symptoms. Maybe if we just start by thinking about screening tests. There are three national screening programs. They are the programs that the government funds because they’re very strongly based on evidence and they’re the screening programs for cervical, breast, and bowel cancer.
The GP has an important role in ensuring people are up to date with their screening tests. Particularly promoting some of the tests which are not being very well-used at the moment. The bowel cancer screen test is probably the most relevant in that context. At the moment, it’s sent in the post once you hit 50 and only 39 percent of people actually bother to do it.
Joe: Wow, that’s pretty crazy.
Jon: Yes. GPs can play an important role in reminding patients that the test will be coming soon and encouraging them to do it. It’s a very effective test and ensuring that your patients are up to date with those screening tests are an important strategy in early detection. The bowel screening test is the one that’s least well-used, it’s probably got the strongest evidence for it in terms of detecting cancers early and preventing early deaths from those cancers. If you think about symptoms, this is where it’s more challenging. The majority of cancers, even for those where we have a screening test, they present with symptoms.
Most of the patients, when they develop the symptoms, they go to see their GP. It’s challenging because the symptoms of most common cancers are also symptoms of much more benign, non-cancerous conditions. That’s where it becomes very difficult. In medicine, we talk about something called, “Red flag symptoms”. These are the symptoms that you really need to think about cancer is a possible cause of them. Things like obviously a breast lump, rectal bleeding, coughing up blood, blood in your urine, losing weight is particularly in the context of other symptoms.
Those are symptoms that should make you think about a possible cancer diagnosis and investigate. In general practice, those symptoms are actually quite common, most of the time, they’re not going to be due to cancer, so if you cough up blood, then you have a less than five percent chance of that actually being due to lung cancer. It’s much more likely to be an infection, but it’s a really important symptom to recognise. That’s true for some cancers, but some cancers present with these red flag symptoms. Other cancers present with much more subtle symptoms.
If you think about pancreatic cancer, that presents often with a bit of indigestion, bit of back pain, a bit of tummy pain, but quite intermittent, so a loss of appetite. As single symptoms, as a GP, you’re not immediately going to think about pancreatic cancer as a cause. Most of the time, it’s going to be due to something completely different. That’s why it’s the challenges of balancing out when to investigate somebody against waiting too long. Obviously, perceive delays in diagnosis. It’s difficult. Some of it’s about ensuring that you have strategies that patients know to come back if their symptoms get worse or they develop new symptoms, that’s something called, “Safety netting.” Some of it’s around using some simple blood tests to begin with. As it might, again, give you some clues that this is potentially a more serious cause for those symptoms. Sometimes it’s about giving some initial treatment, again, ensuring that patients know to come back if their symptoms persist. At that point, that might prompt you to think again and raise the likelihood that it might be actually this is an underlying cancer and therefore, you would go and investigate.
We know some cancers are harder to recognise early than others. They’re the ones that have these more non-specific symptoms signatures. Things like pancreatic cancer, myeloma, ovarian cancer, these are the ones that are harder to pick up early because their symptoms are not quite such red flag symptoms.
Joe: Yes, got you. Absolutely. That makes sense. Jon, in terms of technology, can it help us to pick up things quicker and if so, how?
Jon: Yes, there’s a lot of interest in new diagnostic tests that might allow us to investigate people with symptoms or as new screening tests, even. If you think about there are different ways that this might be done, sometimes it will be a new blood test that’s picking up early markers of cancer in your blood and there’s a lot of research going on in these types of biomarker tests. Not many yet have been shown to have been specific enough to actually use them in general practice.
You get a lot of false positives. There’s a lot of funding going into blood-based tests, then there are new imaging tests, so ultrasounds and CT scans, PET scans, and better uses of those tests might allow us to detect things. Then there are even more interesting things, so there are these things called, “Volatile organic compounds”, these are things that you breathe in and out. Some colleagues of mine are working with a group in Cambridge who are developing a breath test for cancer. It picks up patterns of chemicals that come out in your breath that are potentially associated with a number of cancers in your lung but also in your digestive tract.
There’s some really interesting work. Still a bit early days’ yet to be using it in general practice. That’s another test that’s not invasive but might actually be a really interesting way of picking up both gut cancers and lung cancers a bit earlier than currently.
Joe: That’s fantastic. What about things like artificial intelligence?
Jon: Yes, that’s a really good question. The other thing is looking at large data that exists already. There’s been some early work around looking at large data sets from general practice, and electronic records in general practice and starting to mine those to look for patterns of symptoms, abnormal blood tests that might allow you to have recognised a cancer earlier on. We’ve been doing some early work in that area of diagnostic algorithms based on patterns of these tests that might prompt a GP to consider a cancer diagnosis sooner than they would.
Our brains are fallible, and we have various cognitive biases when we’re thinking about diagnosis. We think that this approach to using computerised algorithms are rising from artificial intelligence mechanisms might in the longer term pick up earlier signals based on symptoms and blood tests, particularly in these cancers that are harder to diagnose because of their non-specific way that they present, that just might prompt GPs to think sooner that this is a possible cancer diagnosis, and somebody might need an earlier investigation.
Joe: Absolutely. You know, Jon, as somebody who was really going through cancer, myself, and as you can imagine, I’ve done a lot of tests, and so I always imagine that there is obviously a person on the other end who’s looking at those tests with blood markers. Whether they are CT scans or x-rays or whatever it might be. How does that process work, and can technology perhaps help in that as well to pick up certain patterns?
Jon: Yes, again, that’s another big growth area in artificial intelligence, is automated image analysis in radiology. There’s some interesting work, for example, in mammography, and using automated analysis to pick up early signs of breast cancer that might have been missed by a radiologist. Again, another growth area of use of AI to more systematically analyse subtle changes on a CT scan or a mammogram or so on, that might detect early changes sooner than a radiologist might. Thinking about from a GP’s point of view, that may eventually lead to some automated image analysis of low-cost ultrasound machines.
A GP might have their own ultrasound machine and have automated analysis of that, as an example. The other interesting area in automated analysis is in skin cancer, and automated analysis of images of the skin using things like a domestic scope or even a mobile phone. AI is a really big growth area in terms of another key strategy to detect cancer earlier.
Joe: Would that help, also, with going for periodic check-ups and notifying people earlier about things that could potentially could be red flags?
Jon: Yes, so potentially, and there’s an interesting area in self-monitoring apps. Again, we’ve been doing some work in skin cancer about using apps on the phone to monitor changes in your moles as an early marker of change for melanoma. Similarly, there are these symptom check apps that you can use that, again, have symptom-based algorithms behind them to prompt patients to go and see their doctor if they have certain important symptoms.
Joe: Yes, that’s fantastic, especially for a hypochondriac like myself.
Jon: That’s the danger, of course, that they can cause too much anxiety and generate a lot of unnecessary worry, because we all have symptoms most days if we think about it.
Joe: Yes, absolutely. It makes it a really tough job for the GP, because how do you get the right balance between not jumping the gun and not leaving it late?
Jon: That’s right and that’s part of the skill of being a GP and they take into account a lot of other factors. Obviously, in the context of cancer, cancer is more common as you get older. You count for certain risk factors, as well, that you know put people at a higher risk of cancer, whether it’s their family history or if they smoke and so on. You use all of that information, obviously, the examination as well. All of these factors are used to help a GP weight up whether they should be investigating somebody sooner than others. It’s a difficult balance.
Joe: Yes, absolutely, because I guess when you’re dealing with cancer, you’re also in between test results and treatment options and you’re working with different specialists. What do you believe is the role of the GP, of the primary care physician in all of this?
Jon: Once a patient has had a diagnosis of cancer and they’ve started what is often a complex series of treatments, seeing lots of different specialists, it can be very overwhelming. Often, patients lose touch with their GP at that point. Actually, there’s still an important role we think for the GP during cancer treatment. They can help try and make sense of what is happening with that patient. They can provide a lot of important psychological support during their treatment. They’ll often be managing their other health conditions, a lot of patients with cancer will have other chronic conditions, as well.
The GP needs to be kept informed of what’s happening from a cancer point of view, from a specialist team, and to be aware of the side-effects that the patients might be experiencing. The impact that might have on some of their other chronic conditions, too. GPs can play an important coordinating role in showing that you’re seeing the right specialists that are managing some of the common side-effects that people might be experiencing. Providing that important support for both the patient and their family and then managing their other health problems at the same time.
Joe: Absolutely, that makes so much sense. We sort of touched on this, but many people go online to try to find answer when they’re in pain, maybe when they have side-effects from the treatment. Is that a good idea and when should you go to the doctor?
Jon: It’s difficult knowing when to go and see your doctor. There are some very reputable sites that Cancer Council, for example, has some very useful information about common symptoms that might be due to cancer and therefore, should prompt you to go and talk to your doctor about that and have that checked out. The Cancer Council websites are, from a cancer point of view, are very useful sources of information around both symptoms that are important. Also, if you’re during treatment, they have a very useful helpline, as well, and you can actually phone up and talk to one of their nurse educators and get some very useful advice from them, if they’re worried about all sorts of things.
The web is a difficult place because you can go searching and find yourself in areas where the information is not necessarily as accurate as you’d like it to be. Going to a trusted source. There are other trusted sources. There’s something called: The Better Health Channel, which is a much broader health and information resource about health matters in general. It can be useful to get a better understanding about existing health conditions. During treatment, if you actually have cancer and your receiving treatment, then hopefully your cancer centre will actually provide you with some written information, so that you understand your treatment and the side-effects and reasons to phone up one of the cancer nurses or something, if you have problems.
I think often it’s better to rely on some of the information that you’re provided with, or to contact the cancer centre that are treating you if you have concerns, rather than go Googling.
Joe: Yes, absolutely. That makes a lot of sense, Jon. I feel like after my all-clear, any sign of trouble and I immediately think it could be cancer. What do you think is the best way to deal with fear of cancer coming back?
Jon: Fear of cancer coming back is a very common thing for a lot of cancer survivors. We know that many people will struggle with this and particularly at times when coming up to a health check with their cancer specialist is a period when you’re obviously having tests to make sure you’re all okay. That’s a very common period where, obviously, the fear that the cancer might have returned really starts to cause problems. It is a difficult thing to manage. For some patients, it can become very troubling.
For a lot of patients, it’s about trying to ensure that patients are aware of the importance symptoms to look out for. The fact that actually recurrence for many patients and cancer survivors, their risk of recurrence is quite small. It’s partly trying to balance, so people aware that they often overestimate the risk that their cancer is going to come back. Some of that, just better information around their actual risk and the sorts of important symptoms to look out for can be reassuring. There have been a number of research studies that have looked at much more detailed psychological treatments. Particularly for people who fear cancer recurring, it becomes very troubling.
Group in Sydney, they’ve been running some trials of a course of psychological therapy for patients for whom fear of recurrence and become really very disabling. They’ve got some early results showing that this very specific theoretically-based approach to fear of recurrence is an effective strategy. Hopefully, that approach might gradually become available through psychologists more widely, as the results of that trial become more widely known. For a lot of patients, it is just going to see their GP and talking to them about their symptoms. GPs can often be quite reassuring, that actually the symptoms they’re experiencing are not an important sign of recurrence.
Joe: That’s a great sign, Jon. I guess a lot of the times, I never really thought about going to see my GP, even though she has been instrumental in terms of picking up cancer and supporting me through it. That’s a great point. Sometimes we don’t think of the general practitioner as someone who can really help get you through this.
Jon: Yes, I think they play a very important role in that broader support and can be quite reassuring that you don’t necessarily need to be worried about a particular symptom.
Joe: Yes, absolutely, continuing on the mental side of cancer, most folks go through fear and anxiety, maybe when they are going through treatment. What’s your advice on dealing with that and if you think it might be all a bit too much, where do you turn to for help?
Jon: A lot of cancer centres and all GPs, as well, will have access to psychologists who can be very helpful in providing strategies to help with anxiety and depression, which we know are quite common both during treatment and after treatment for cancer. The GP alone, they’re very experienced with dealing with mental health issues. Again, going to talk to your GP, if you’re beginning to experience signs of anxiety or low mood, they alone can be very helpful in both assisting how severe it’s got. Whether psychological treatments might be helpful and therefore, referring you through Medicare to see a psychologist can be helpful. They may just provide some counselling themselves and give you some other strategies to help with your mental health.
There are some sort of broader lifestyle things you can do, physical activity is actually very helpful for a lot of reasons for cancer survivors. Including in improving their mental health. Getting into a regular physical activity regime can help with many of the side-effects of the fatigue, as well as the anxiety or the depression. Meditation some people find very helpful, yoga, that sort of thing. There are a whole range of different ways to help with some of those mental health issues. For some, it’s about finding the ones that work well for the individual patients.
Again, it depends on how severe things become. There are obviously some drug therapies that some people may need to go on for a period of time, particularly for depression. Often in combination with psychological therapies, as well. Again, a lot of this can be access through your GP, but also the cancer centre will often have a team of psychologists and psychiatrists for people with some severe problems with their mental health during their treatment.
Joe: Yes, that makes so much sense, Jon. Is it common that some physicians are better than others? Is that true and how do you find one which is suited to you and your needs?
Jon: Yes, unfortunately, there probably is a variation in the healthcare system, a variation in personality type, quite apart from variation in quality in general of the delivery of care. That’s one of the things, that as a medical researcher is one of the focuses of how you reduce some of that variation. It is a fact that we do see variations in the quality of care sometimes. I think the issue of finding a doctor who you get on well with and trust is really important. Particularly, finding a GP who you develop a longer-term relationship with, who gets to know you over a period of time. That continuity of care is one of the strengths of a good general practice.
For a lot of reasons. We know that actually that developing a trusted, long-term relationship is actually a marker of good long-term care and is associated with better outcomes. Sometimes you do have to shop around a bit, unfortunately. In Australia, general practice, of course, because you have the option to go and see any GP you like, recommendation is often good. Personal recommendation. Of course, there’s increasingly stuff on the web where you get reviews of practices, as well. I think it is important to try and find a GP who you can talk to, who you think will listen to you, who will give you the time when you need it, and who you feel you want to develop that longer-term link with. Sometimes it’s not always possible to see the same doctor every time.
Actually, just even being in the same practice where they’ve got your records and all the information about you from your specialist, as well, all in one place is also important. Going to see the same practice, even if you can’t always get to see the same doctor is also another way of trying to improve the quality of the care that you receive.
Joe: Yes, that makes so much sense to me, Jon, that if you invest the time up front to find a good doctor and build up relationship with them. Then it’s a preparation for eventually dealing with something like cancer. It’s a really important investment. I know I was lucky to have a fantastic GP and great specialists. At the same time, Jon, I don’t think they said a word to each other. I guess in my case, it worked out well, but I think sometimes that conversation might be needed. How do general practitioners stay in the loop and how can we make that process work better?
Jon: We know that communication between different doctors is often not ideal. There are problems getting – with our current system – of sharing information that is often reliant on a still very old-fashioned systems of dictation. Then the letter goes off to a secretarial pool and it might take weeks before it eventually gets typed. It sounds extraordinary that hospital systems still rely on those rather old-fashioned methods of produced letters, even, let alone we have much better methods of communicating electronically in other businesses and so on. It is recognized that there are structural problems in a lot of the healthcare system that rely on old-fashioned methods of communication.
We know from a cancer survivorship point of view, there has been quite a lot of work around trying to improve communication between healthcare providers. There’s been a lot of interest in what is called: Survivorship care plans. Which are much more structured methods of communication, both to the patient and also to the GP. The information that’s most relevant about providing care for that patient. We’ve done some trials of providing that type of information to GPs in models where the care is more explicitly shared between the GP and the cancer specialist.
We’ve shown that that is an effective way of improving communication. Increasingly, cancer centres are thinking about how to implement this much more structured method of communicating between the specialist, the patient, and their GP, and other healthcare providers in that more structured way, and in a timely way. There are well-recognised problems. There are attempts to improve both the way the information is provider in a more structured and more useful way and ensuring that GPs are better kept in the loop. In the longer-term, there is now something called: My Health Record, which is a federally funded approach to have a single core electronic health record.
That will at least have a lot of the core information around health conditions, tests results and so on, that will be assessible to any healthcare provider. Therefore, in a much timelier way. That’s gradually being rolled out and from I think about August this year, the vast majority of the patients within the Australian healthcare system, even if they’re not aware of it, will actually have access to My Health Record, which is an electronic record, that will have information about the drugs they’re being prescribed, all the tests that they’ve had ordered on them and so on.
GPs will have a core role in helping patients to ensure that that record is reasonable up-to-date about their various health conditions. That, in the longer-term, we hope is a way of improving the communication around what’s happened to a patient between the different parts of the healthcare system. It’s got a way to go still. We think from a cancer survivor point of view, actually having an up to date My Health Record is a really important part of trying to improve that communication between different healthcare providers.
Joe: Yes, that makes so much sense, Jon. I know that medical experts can take a complicated case to a panel of experts to get their input, is there a process in place to allow a general practitioner to get a second opinion, like if they’re not sure about what is the best way to go?
Jon: Yes, that’s interesting. Obviously, in cancer care, there are these what are called: Multi-disciplinary meetings, where you have different specialists who will get together and discuss what the best treatment plan is for that individual patient. Probably in cancer, that’s been the best developed model of really having good expert input from an oncologist, a radiologist, a surgeon, and a whole range of allied healthcare specialists, as well, to really plan what the best treatment is for that individual patient. In general practice, obviously, it’s slightly different. The GP is often seeing patients in quite an isolated way.
Particularly in group practices, so where you have, increasingly doctors are not single-handed doctors, they work as part of a group of doctors in a practice with a whole team of nurses as well and other allied healthcare professionals. That practice model, if we have a team of doctors, does actually allow better opportunities to seek a second opinion. Whether it’s informally, just talking to one of your colleagues about a patient that you’re not quite sure what’s going on. Sometimes it will be a more formal route, where there’s subspecialisation with a practice of GPs.
You might find some GP saying, “Well, actually a colleague of mine has a particular interest in this area.” You might be offered that opportunity to see another GP in the practice because that’s their special interest. I think as general practice becomes more complex and they take on a greater role in managing a lot of chronic diseases, then we might see a bit more of that subspecialisation within a general practice and within a team of GPs, so that different GPs have different areas of expertise, so you’ve got that potential for in-house second opinions.
Joe: Yes, that makes a lot of sense, Jon, because I know from even personal experience that as we moved around and lived in different areas, you go and look at a website for a particular practice and you start to read about the doctors, and you can read about their different areas of interest and expertise, and you go, “Yes, that might be the person for me or for my son” or whatever. That really makes a lot of sense to me. Also, I know that survivorship is an area that’s really close to your heart. What are some of the challenges that some folks have after treatment and what is the role of the general practitioner in all of this?
Jon: Sure, I think increasingly the GP will have a growing role in cancer survivorship, as we move more toward what is called: Models of shared care between the hospital specialist and the GP, and in much more structured ways. This comes back a bit to what we were talking about having better showing of information, with clearer guidance to the GP about their specific role in terms of caring for the cancer survivor, knowing which tests to order, in terms of monitoring a recurrence. Knowing how to get rapid access back to see a specialist if they’re concerned. In terms of the core cancer survivorship care, I think we will see a growing role for doing some of what would have been traditionally offered by the cancer specialists, but actually the GP will take on a greater role there. As well, of course, as providing that much broader holistic care from a psychosocial point of view, and also managing other chronic conditions that cancer survivor may also have.
Joe: Cool. Thank you so much, Jon, for your insight and for your advice. I really appreciate it.
Jon: Well, thank you very much for asking me to. Thanks, Joe.