Primary Care Update archive

Updated Cancer Care Review templates in EMIS Web, TPP SystmOne and INPS Vision

Macmillan has worked with each of the three major GP IT providers to develop a standardised, holistic Cancer Care Review template that is built into EMIS Web, TPP SystmOne and INPS Vision. The Cancer Care Review (CCR) is a holistic conversation that helps people to raise issues related to their cancer or treatment that affects their quality of life. With the support of a GP or Practice Nurse, the template helps them to create a plan to address their needs.

Using a standardised template during a CCR promotes consistency, so every person living with cancer can discuss their needs and get support to self-manage their needs, where possible.

Recent additions to the template

To enhance the existing Cancer Care Review template, Macmillan Cancer Support has developed a patient information leaflet, which can be printed out during a cancer care review and given to the patient to take away. This leaflet contains useful information on how to get support from us through the Macmillan Support Line, Online Community and local services. The information sheet also lists resources that may benefit the patient, and lets them know how they can order free information from be.Macmillan.

Alongside this information leaflet, we provide guidance on eligibility for prescription payment exemption, as well as a selection of one-page information leaflets on the most reported concerns from Macmillan’s electronic Holistic Needs Assessment (eHNA). These one-pagers cover anxiety, fatigue, pain, hot flushes and trouble sleeping. These can be printed out by the healthcare professional following a cancer care review discussion.

To find out more about how to access the Cancer Care Review template within your IT system, please contact macdocs@macmillan.org.uk


The next generation of cancer survivors: A GP's perspective

I first met Sarah five years ago in one of my Monday morning surgeries. She was 41 years old and, other than attending for minor illness, we hadn't seen much of her over the past few years. She told me she had started experiencing increasing shortness of breath while exercising and couldn't understand why.

Sarah had a BMI of 22, had never smoked, exercised 3-4 times a week and had no family history of heart or lung disease. There was nothing abnormal I could find upon examination, and a comprehensive set of blood tests were also normal. Over the next few months she had numerous tests, then one day when we were discussing what to do next, she said ‘Do you think it's anything to do with the lymphoma I was treated for as a teenager?’

One in two of my generation will get cancer at some point in their life [1]. My primary care colleagues are often shocked when I point this out to them. This is more than even the 'epidemic' of type 2 diabetes [2,3]. However, while in the UK diabetes is established as a condition managed in the community by primary care, with specialist management for only a few, cancer is still not viewed in the same way.

The initial management of most cancers will, rightly, need to be overseen by specialists. However, it’s the long-term consequences of cancer and treatment that can have the biggest effect on a person’s health and quality of life.

It is estimated that, in the UK, 90,000 people are currently affected by gastrointestinal problems; 350,000 people have sexual difficulties; 150,000 urinary problems; 6,300 lymphoedema; 350,000 chronic fatigue; 240,000 mental health problems and 80,000 have hormonal symptoms, as a result of cancer and treatment [4]. These numbers are likely to rise as more of us are treated for and live beyond cancer.

I have worked as a GP in the UK for 17 years and, for the last few years, also worked for Macmillan Cancer Support. Through my work, and the amazing work of research teams in the UK and internationally, I have realised a huge unmet need in patients living with the consequences of cancer and treatment – and of primary care colleagues and generalists in education and resources to support them.

In 2016, Macmillan Cancer Support worked with the Royal College of General Practitioners to develop a primary care toolkit to support patients with the late effects of cancer [5]. This toolkit, alongside the wealth of resources that support primary care professionals to recognise and treat consequences of cancer treatment, is testament to the growing recognition of the importance of primary care to support patients with long-term effects.

Once I had looked back in Sarah’s notes and realised she underwent radiotherapy to her chest, 25 years previously for a lymphoma, I referred her to cardiology for tests which showed single vessel coronary artery disease. After a stent insertion she could go back to her former levels of exercise, with no further symptoms. Sarah is of course now reviewed annually by our practice nurse for a cardiovascular and cancer chronic disease review.


This excerpt can be read in full in the Lancet Oncology Volume 19. We would like to thank The Lancet Oncology for allowing us to share this piece.

Clarke, Sinead (2018) Next Generation of cancer survivors- a GP perspective, The Lancet Oncology, Volume 19, Issue 5, P601, May 1st 2018.


Opinion piece: Is this the right time for GPs to have access to diagnostic investigations?

This article is an opinion piece written by one GP. It does not necessarily reflect the views of Macmillan.

One approach to reducing the number of people presenting in later stages of cancer in the UK is to ensure General Practitioners have direct access to investigations. These tests would be for patients with a lower, but still possible, risk of cancer being the cause of their symptoms. While patients with ‘red flag’ symptoms are intended to be referred through the fast-track pathways, NICE guidance recommends direct access for some symptoms [1].

There has been criticism of this approach, suggesting GP access to tests would mean an increased pressure on already limited resources for diagnostics in the country. Some also suggest that, without the ability of the specialist to triage first, GPs would be referring inappropriate numbers of patients for those tests [1].

In addition, GPs have commented on the appropriateness of such schemes, indicating that breaking news to patients following test results, referring patients for additional tests, and their level of skill dealing with inconclusive results, could lead to an increased workload [2].

This systematic review [3] of available literature reports that concerns about resource and appropriateness of GP direct access testing are not borne out. The GP direct access tests performed at least as well as the consultant triaged testing for disease detection, if not better. In addition, the time between referral to testing were equivalent and both patient and GP satisfaction with the process was high.

While this systematic review is important to show GPs are capable of using their own experience and skills to identify patients at low risk of cancer, it must not be used as a way of cost saving, for example by reducing referral rates. As GPs themselves have noted, diverting work away from secondary care may have an equal clinical outcome and greater satisfaction for patients, but the workload associated must be resourced appropriately in primary care to ensure GPs can carry out these new tasks effectively in the UK.


Case study: A patient’s perspective

A few days before I got my diagnosis, I attended a Buddhist teaching. The subject of the teaching was ‘impermanence’ – how all phenomena changes and how we can rely on nothing, because ultimately, everything falls away, is born and then dies. We were asked to contemplate and meditate on our death, to think about our lives and to realise the necessity of really living in the present, rather than worrying about the future or regretting the past.

Far from being Nihilistic, this practice was done by meditators and Yogis in Tibet and other places, who would sit in charnel grounds and graveyards in order to make the practice really strong, and to accept the fear, the grief and sadness of their lives – and to ultimately transform their lives through mediation practice.

The following Monday after receiving this teaching, I was diagnosed with stage three breast cancer.

After the panic and horror, I felt at the seriousness of my situation subsided, and after a great deal of reassurance from my medical team and the Macmillan nurse, who would be with me through my cancer journey, I thought about what had happened and was struck by the sheer comedy and coincidence of events. Was this a wake-up call? Was this my Universe shaking me out of a self-induced zombie-like existence? Well, yes, I believe it was. There are no coincidences, really. And I told myself that if I lived through this, everything was going to have to change because, like death and taxes, change is the only thing upon which we can truly rely.

I returned to my Buddhist centre and spoke to the Lama who had delivered the teaching on impermanence. I asked her to give me a practice to do throughout my treatment, which would support my need to accept what was happening to me, and which would bring me some peace and help combat the dreadful and all-consuming fear that I felt.

Ever in her wisdom, she taught me to do a meditation practice called Tong Len – whereby one ‘breathes in’ the suffering of the world and transforms the suffering, breathing out ‘loving kindness’ or ‘compassion’. ‘Don’t take in too much suffering when you breathe in,’ said the Lama ‘but on the outbreath, imagine your joy and love for all people who are suffering, like you are suffering, is filling the whole world.’

And this is what I did. And my joy at being alive filled the whole world and it filled me too.


Endocrine complications as a consequence of cancer and its treatment

Written by Dr Helen Simpson, Consultant Endocrinologist

This is the first of a two-part FAQ series to support Primary Care Professionals to recognise and treat endocrine complications as a consequence of cancer and its treatment.

There are approximately 2.5 million people living with and beyond cancer in the UK, and over 90% of children with cancer are now cured of their disease. Endocrine and bone issues are common consequences of cancer treatment. As much as 50% of childhood cancer survivors have endocrine consequences of their cancer treatment.

To support you in your role, we have developed an Endocrine late effects quick guide [PDF] into the consequences of cancer and cancer its treatment. We have answered some of the most common questions below.

Frequently asked questions

How can endocrine consequences present?

Endocrine consequences often present gradually. It can be difficult to get a clear idea from symptoms alone. Osteoporosis can go undiagnosed if assessments or DXA are not performed or worse, patients can present with a fracture. Ovarian insufficiency can be suspected in a female whose periods stop; they may have symptoms of hot flushes and vaginal dryness. Some young women never start their periods due to treatment in childhood. Men may have erectile dysfunction, suggesting gonadal insufficiency, or may present with infertility.

To recognise the consequences of treatment, it is critical to know if a patient has had a cancer diagnosis and their treatment history – these should be clearly recorded in an end of treatment summary and in medical records. We have developed the Endocrine late effects quick guide [PDF] – a useful resource that covers major endocrine and bone consequences for people living with cancer. The guide includes pituitary, ovarian, testes, thyroid and bone issues, as well as managing hot flushes when oestrogen and testosterone are contraindicated.

If a patient is at risk of endocrine complications, should it be documented in their treatment summary?

Absolutely. End of treatment summaries are crucial, informing patients of their future risks and providing documentation for healthcare professionals. They are provided as standard for childhood cancer patients and are becoming more widespread for adult patients.

Bone problems and osteoporosis

While people living with cancer are at risk of poor bone health, are there certain groups we should be particularly vigilant about?

Yes, all cancer patients are at risk of poor bone health. However, patients with gastric cancer and haematological malignancies have been shown to be at particularly high risk. Other risk factors include:

  • post-menopausal women
  • men over 50 years old
  • low Body Mass Index (BMI)
  • immobility
  • smoking cigarettes
  • people who consume more than 3 units of alcohol a day
  • a history of parental hip fracture
  • a history of rheumatoid arthritis
  • people with inflammatory bowel disease
  • people who are at risk of falls.

Is osteoporosis managed differently in patients with cancer?

Generally, management is the same ranging from lifestyle advice to drug treatments such as bisphosphonates and denosumab. Secondary causes should be managed in the usual way, providing there are no contraindications, such as for treatment of hypogonadism in hormone sensitive malignancies. Radiation-induced bone disease or fractures warrants referral to appropriate specialist services.

Pituitary insufficiency

Which cancers and treatments are associated with pituitary insufficiency?

Any tumours in the vicinity of the hypothalamus and pituitary can themselves cause pituitary dysfunction as can complications such as hydrocephalus. Treatments such as surgery, radiotherapy and proton beam therapy can result in hypopituitarism. Patients who underwent cranial irradiation for the treatment of ALL can develop GH deficiency, as can patients undergoing total body irradiation as conditioning for bone marrow or stem cell transplants.

What symptoms may indicate pituitary insufficiency?

Symptoms of pituitary insufficiency can be vague, and many patients have few symptoms. They include fatigue, weakness, depression, anorexia and weight loss, sexual dysfunction (reduced libido, erectile dysfunction), irregular or lack of periods, vaginal dryness, hot flushes, fertility problems and symptoms of hypothyroidism.

How is pituitary insufficiency diagnosed?

Screening tests include 9am cortisol, TSH, fT4, LH, FSH, oestradiol, and 9am testosterone. However, if a patient has had cancer or a treatment which could have affected the pituitary, we recommend referral to an endocrinologist for investigations and follow-up.


Topical highlights

GPs found to be at higher risk of work-related stress, burnout and mental health problems

The mental health of doctors is recieving increased media coverage, including the recent personal perspective from the President of The Royal Australian and New Zealand College of Obstetricians and Gynaecologists Professor, Steven Robson [1], but what research evidence exists? A review of the literature has been undertaken by academics in occupational health and organisational psychology to inform the debate [2].

The findings are that 'doctors are at considerable risk of work-related stress, burnout and mental health problems such as depression and anxiety', greater than that of the general population, with a higher rate of suicide. GPs are reported as being of at particular risk, higher than their counterparts in other specialities.

The report calls for increased support for UK doctors at every stage of their career, 'from recruitment to retirement'.

Artificial intelligence (AI) in oncology

Can big data help us treat complex conditions like cancer?

AI is a (not that) new technology that can learn, predict and advise based on vast amounts of data. While AI is not yet advanced enough to replace a clinician, it is undoubtedly much better than humans in searching through, processing and analysing huge amounts of data.

There are multiple examples of the use of AI in many aspects of cancer care. AI is being used to perform automated mammography analysis. [1] AI is being used to pinpoint gene mutations behind cancers to assist doctors in forecasting future genetic changes and prescribing the best treatment [2],[3].

AI has the potential to learn from tremendous amounts of real world data and apply it to the design of clinical trials in oncology, significantly reducing the cost.

Undoubtedly, there is still a lot of fantasy around the use of AI in medicine, but there is no denying that this is surely one of the concepts which holds tremendous potential to change the landscape of cancer care in the near future.

Uptake of the English Bowel Cancer Screening Programme (BSCP)

The initial roll-out of the English Bowel Cancer Screening Programme, during 2006 and 2009, found the uptake to be low (54%) and socially graded [1].

Data analysis between 2010 and 2015 showed a small but significant decline in the uptake (53%, 54%, 52%, 50%, 49%, 49% respectively) and it continued to be socially graded. Uptake ranged from 43.03% in the most deprived quintile to 56.96 % in the least deprived quintile. Uptake among women (56.08%) was higher than that among men (47.30%).

Regional differences in uptake, in particular the persistent and strong social gradient in London is very striking. The results do not suggest that the barriers to CRC screening have been reduced over time. However, after recent evidence from pilot studies testing a new and improved type of home-based test, there is a suggestion that the implementation of the Faecal Immunochemical Test (FIT) is a more promising route to eliminate at least some of the root causes of the low uptake [2].

There is an urgent need to implement the FIT test in the BCSP to avoid further exacerbation of social inequalities in screening uptake and its consequences on Colorectal Cancer outcomes.

New data links route to cancer diagnosis and treatment

Data from Public Health England show that patients diagnosed through screening, GP referral or two week wait have access to more treatment options.

Those diagnosed through screening were likely to have a greater number of treatment options available to them, and receive treatments aimed at curing the cancer. This strongly supports the benefits of screening as a way of diagnosing cancer early, which leads to better patient outcomes and ultimately saves lives.

Compared to patients who were diagnosed through an emergency presentation, those diagnosed through screening, GP referral or a two week referral saw potentially curative treatment [1].

While the percentage of cancers diagnosed through emergency presentations is improving, the people diagnosed this way could miss out on potentially curative treatment compared to those diagnosed via a screening programme.

This reinforces the importance of early diagnosis through screening and GP referral, and underpins the statement that the earlier a person is diagnosed with cancer, the better the treatment options and outcomes.

References

Opinion piece: Direct Access Diagnostics

The next generation of cancer survivors: A GP's perspective

  1. Maddams J, Utley M, Moller H. Projections of cancer prevalence in the UK 2010-2040. Br Cancer 2012;107:1195-1202.
  2. Diabetes Facts and Stats: 2015. Diabetes UK, published 2015 
  3. Macmillan Cancer Support. 'Throwing light on the consequences of cancer and its treatment'. 2013, London.
  4. Macmillan and Royal College of General Practitioners 'Consequences of Cancer Toolkit'. Available at www.rcgp.org.uk/coc.
  5. Macmillan Cancer Support booklet for primary health care professionals 'Managing Heart Health During and after cancer treatment' - A quick guide for primary care health professionals available at www.macmillan.org.uk/cot.
  6. Global Cardio-Oncology Summit 2017. Held at Royal College of Physicians London 20/21 September 2017, contact info@cardiaconcology.ca.

Close

Topical highlights

Mental health for doctors

  1. Professor Steve Robson opens up about suicide attempt (news.com.au article).
  2. Kinman G. & Teoh K. (2018) What could make a difference to the mental health of UK doctors? A review of the research evidence.

Artificial intelligence (AI) in oncology

  1. Therapixel wins the Digital Mammography Challenge (Download PDF).
  2. Artificial intelligence used to predict cancer growth (BBC News article).
  3. G Caravagna, et al. Detecting repeated cancer evolution from multi region tumour sequencing data. Nature Methods 15, 707-714 (2018).

Uptake of the English Bowel Cancer Screening Programme (BSCP)

  1. Wagner C von, Baio G, Raine R, Snowball J, Morris S, Atkin W, et al. Inequalities in participation in an organized national colorectal cancer screening programme: results from the first 2.6 million invitations in England. Int J Epidemiol 2011;40(3):712e8.
  2. Chambers JA, Callander AS, Grangeret R, O’Carroll RE. Attitudes towards the faecal occult blood test (FOBT) versus the faecal immunochemical test (FIT) for colorectal cancer screening: perceived ease of completion and disgust. BMC Canc 2016 Dec; 16(1):96.

New data links route to cancer diagnosis and treatment

  1. New data links route to cancer diagnosis and treatment (Gov.UK).

Close