Primary care’s role in cancer care

September 30, 2019

Regular contact with patients is vital for successful treatment.

More than half of patients diagnosed with cancer have comorbid conditions. Yet once cancer treatment begins, patients sense that they don’t need to see their primary care physician, and that the oncologist should treat everything, says Jacqueline Winfield Fincher, MD, MACP, an internist in Thomson, Ga., and the ACP president-elect. “Everything health-related comes down to this one thing, which is a natural response,” she says. “You don’t want to survive cancer just to have a major stroke or heart attack because you did not continue to address and treat your cardiovascular risk factors.”

Primary care physicians (PCPs) have important roles during cancer care, though not all realize it. Once cancer is diagnosed, there’s a tendency for patients to be transferred to oncology rather than referred there, says Amy E. Shaw, MD, a family  physician specializing in oncology care at St. Joseph Health Medical Group in Santa Rosa, Calif. “I think this is a holdout from the days when most cancer was fatal,” she says.

Instead, oncologists and PCPs need to work together to address all the patient’s medical needs, and therefore PCPs need to stay in touch with the patient during active treatment.

Communicating with patients during treatment

Often, a PCP is the referring physician for a suspected cancer. Fincher says her office tracks referrals, and follows up if her office hasn’t heard back from the oncologist. The specialist’s consult report makes it easier to identify if a patient has a new cancer, as some patients may not inform the PCP of their diagnosis. Fincher also tells patients with comorbid conditions to return at their regular intervals, and what to look for during active cancer treatment that could impact their health.

The PCP should reach out periodically to patients getting cancer treatment, even if they don’t have other medical issues. “I hear over and over how much patients appreciate it when they got a call from their PCP during their cancer treatment,” says Shaw. She also hears how disappointed patients are when they don’t hear from their PCP, and that the patient may not want to return to their care as a result.

“Patients know you’re not an expert in cancer. When they’re going through something terrible, at least acknowledge what they’re going through,” she says.

Shaw recommends calling the patient to say something like, “I’m sorry you are going through this. Is there anything I can do to help?” The best times to call are at transition points, when the patient is starting or finishing a treatment. “I know doctors have 2,000 patients, and you’re not going to call every time someone breaks a leg or gets a sore throat. But cancer is uniquely terrifying.”

Sometimes the patient may have difficulty getting a specialist appointment, and the PCP can make a phone call to help. Shaw also recommends giving priority to calls from a patient undergoing cancer treatment. “We have this sign posted in our office for staff and doctors: ‘Just because we see it commonly, does not mean it is common for the patient,’” she says.

Shaw sometimes hears from patients that their PCP immediately refers them back to their oncologist when they call the PCP’s office with a medical problem during cancer treatment. Even if the PCP doesn’t have oncology expertise, they should find out a patient’s issue before referring them back to the oncologist.

“If I haven’t personally spoken with the patient to determine that they are having a problem that only the oncologist can address, then I shouldn’t be telling them to go elsewhere for care,” Shaw says.

Ways to stay involved

Both the PCP and oncologist should encourage patients undergoing cancer treatment to see their PCP for existing health issues, especially as cancer treatment can impact these conditions. “We know that high blood pressure, heart disease, heart failure, and diabetes are profoundly affected by cancer treatment, particularly chemotherapy and steroids that sometimes accompanies chemo,” says Fincher.

For example, she says, she might need to increase a patient’s diabetes medications due to steroid use, or decrease blood pressure medications if they’re losing weight and their blood pressure is dropping, or if they have significant treatment-related fluid losses or gains. Oncology treatment can be delayed if the patient’s glucose levels or blood pressure aren’t controlled.

Shaw has seen many oncologists renew a patient’s blood pressure or diabetes prescription because the patient hasn’t seen their PCP in years. “This is understandable, but renewing a prescription is not the same as managing the condition,” Shaw says.

For patients without comorbid conditions, PCPs can help with treatment decisions, care coordination, and managing treatment side effects. Shaw has helped patients understand each clinician’s role on the team, and get treatment authorizations and referrals. “Not every (oncology practice) has a patient navigator. The primary care doctor sometimes has to help,” Shaw says.

Especially in rural communities, PCPs can take control of drains and manage general side effects. It’s best when the oncologist communicates this with the PCP, which isn’t always done well, says Eben Rosenthal, MD, director of Stanford Cancer Center in Palo Alto, Calif.

As a PCP in a rural town, Fincher says her patients are usually at least 45 minutes away from their oncologists. Patients come to her for issues that develop between chemotherapy treatments. And while not all PCPs have oncology expertise, patients still may want their opinion on recommended treatments.

“There’s a level of trust,” Fincher says. The patient often has an ongoing relationship with the PCP, while only seeing the cancer specialist for a short time. “Our patients come back to us and say, ‘this is what the doctor recommended, what do you think?’” That’s common. A 2016 study in the Journal of Clinical Oncology showed that 35.4 percent of women with newly diagnosed breast cancer consulted their PCPs about treatment options.

Shaw says she’s talked with patients who didn’t want a recommended treatment because of the side effects. She discusses the patient’s personal goals, how potential side effects would be treated, and why it was recommended to give a more thorough perspective for making a decision.

Communication with specialists

While experts say that it’s the specialist’s responsibility to share updates with the PCPs, the PCP plays a role as well.

PCPs often complain that oncologists don’t send their notes, says Shaw, but PCPs also don’t always send their notes to the oncologist, forcing patients to act as the messengers between various doctors. Giving the patient access to their notes via a patient portal makes communication easier.

“Cancer providers should be reminded to send office notes to PCPs at a minimum, or better yet, have the EHR automatically route office notes to the PCP,” says G van Londen, MD, a medical oncologist at UPMC Hillman Cancer Center, and director of the Women’s Cancer LiveWell Survivorship Center at UPMC’s Magee-Womens Hospital in Pittsburgh.

Developing relationships with specialists helps as well. Shaw says that when she was a family practitioner-she now practices primary care oncology-she sometimes accompanied her patients to the oncologist. “I learned so much, and the oncologists got to know me,” she says.

Of course this isn’t practical for most PCPs, but there are other ways to develop relationships. Stanford’s Rosenthal recommends that PCPs attend courses about oncology care, and visit facilities where they refer patients.

This can help PCPs understand which cancer treatment-related symptoms to expect, screen for, and manage. Communication also helps eliminate duplication of efforts, says van Londen, and decreases the risk of the bystander effect, where everyone thinks someone else is tackling the problem.

“We travel and have dinners (with PCPs), do grand rounds at community hospitals about treatments, and talk about what to expect,” Rosenthal says. “It’s old fashioned communication.”

Ideally, specialists would also refer patients back to their PCP to manage quality of life issues such as anxiety, depression, sleep disturbances, and treatment-related pain, Fincher says, adding that primary care physicians are in a better position to treat patients’ pain.

Given the problems caused by opioid addiction, PCPs knowing the patients and the community give better context to treatment options, and PCPs also treat the patient holistically, rather than treating just the cancer.

For example, Fincher recalls one patient who had intense pain from bone metastases, and the oncologist was not responsive to the patient or Fincher when approached about the issue several times. The patient maxed out on her pain medication but was still in severe pain. Fincher referred the patient to a radiation oncologist, who began radiating the area. Within a week, the patient’s pain decreased, she was sleeping  and feeling better.

Patients expect that PCPs will be available to help them when there’s a serious medical issue, including cancer, says Shaw.
“We stay closely involved when there are other medical crises like a CVA, car accident, myocardial infarction, Parkinson’s, or dementia. But for partly historical reasons, we treat a cancer diagnosis differently,” Shaw says. “Most of our patients now survive their cancer and these patients will return to our practices, so it’s best to stay in contact with them so a gap doesn’t open up.”

download issueDownload Issue : October 10, 2019 edition