Dr Pauline Love signposts some useful resources to help people diagnosed with cancer and their practitioners to recognise and manage the consequences of cancer

Dr Pauline Love

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Read this article to learn more about:

  • why primary care practitioners increasingly encounter cancer survivors whose conditions are a result of their cancer or cancer treatment
  • common cancer consequences and factors that influence their development
  • identifying and supporting people with conditions arising after cancer diagnosis or treatment.

Key points

Commissioning messages

There are an estimated 2.5 million people living in the UK who have previously been diagnosed with cancer, and this number is projected to grow to over 4 million by 2030.1 The predicted survival of half of all people diagnosed with cancer today is more than 10 years; however, these survivors report poorer health and wellbeing than the general population.2,3 As cancer survival lengthens, practitioners need to be vigilant for the longer‑term consequences of cancer and its treatments if they are to appropriately support patients and refer them to specialists when needed. Unlike treatments for many other chronic diseases, cancer treatments—such as surgery, radiotherapy, and systemic therapies—can have serious short-, medium-, and long-term consequences.4

Identifying consequences of cancer treatment

Factors that determine whether long‑term or late-onset consequences ensue from cancer treatment include:5

  • the treatment type, dosages, and frequency
  • the patient’s age and sex
  • lifestyle factors (e.g. weight, smoking status, diet, alcohol, physical activity)
  • pre-existing health conditions and/or medication
  • post-treatment incidents (e.g. arm trauma triggering lymphoedema)
  • social deprivation
  • the patient’s genetic profile.

A number of cancer patients will experience persistent problems affecting their quality of life that may not present until many years after treatment. There is an increased risk of second primary cancers occurring, as well as long-term conditions such as endocrine disorders, heart disease, and osteoporosis (see Table 1, below).5 Problems can arise from the physical, emotional, practical, and financial impact of cancer,6,7 with at least 1 in 4 patients facing long-term ill‑health or disability.5

Table 1: Estimated prevalence of common consequences of cancer treatment5
Adapted from: Macmillan Cancer Support. Throwing light on the consequences of cancer and its treatment. Macmillan Cancer Support, 2013. Available at: www.macmillan.org.uk/documents/aboutus/research/researchandevaluationreports/throwinglightontheconsequencesofcanceranditstreatment.pdf
Consequence of cancer treatment Estimated UK prevalence
(men and women) 
Chronic fatigue 350,000
Sexual difficulties 350,000
Mental health problems 240,000
Chronic moderate to severe pain 200,000
Chronic changes in urinary function 150,000
Chronic changes in lower GI function 90,000
Menopausal and hormonal symptoms at least 80,000
Chronic changes in upper GI function up to 50,000
Endocrine system disorders total could not be estimated
Loss of fertility could not be estimated 
GI=gastrointestinal

Consequences of cancer and primary care

Macmillan estimates that around 625,000 people in the UK are experiencing a significant health condition as a result of their cancer treatment, equivalent to up to 15 patients on a GP list size of 1500.8 Inevitably, this situation will place a responsibility on primary care professionals to support patients by:9 

  • identifying ongoing needs
  • providing information to support self-management where appropriate
  • giving healthy lifestyle advice
  • managing the consequences of cancer treatment.

Patients with low risk of recurrence are supported to self-manage by their GP in the community, as routine hospital‑based follow up is unsustainable; however, professionals in primary care may overlook the long-term consequences of cancer treatment.

Consequences of Cancer Spotlight Project and toolkit

Macmillan Cancer Support and the Royal College of General Practitioners (RCGP) recognised the need to highlight the consequences of cancer, and in 2015–2016 collaborated as part of the RCGP Consequences of Cancer Spotlight Project.10 

This project builds on the work carried out by Macmillan and partners as part of the National Cancer Survivorship Initiative11 and is raising awareness through the Consequences of cancer toolkit on the RCGP website.8 The aim of this toolkit is to help primary care professionals support patients with a cancer diagnosis and to give them an awareness of how consequences of cancer treatment may manifest.8 It will be of interest to anyone who provides or commissions services for people living with and beyond cancer.8

As well as patient information, the toolkit provides resources for primary care professionals to help them recognise cancer treatment consequences. Some important aspects of the advice contained in the toolkit are summarised below.8

Awareness of potential consequences

As part of a cancer patient’s recovery package, secondary care professionals can produce detailed treatment summaries about treatment received, prognosis, and an ongoing management plan highlighting potential consequences of cancer treatment and any specific actions for the GP.

When a patient with a history of cancer presents to a GP with new symptoms, the possibility of consequences of treatment should be considered. For example, if a patient who has undergone treatment with a monoclonal antibody presents with new-onset shortness of breath, the GP should assess for heart failure, which might have arisen as an adverse effect of the treatment.12

Identifying patients at risk

It may take several months or years after treatment for any consequences of cancer to manifest and GPs need to remain vigilant and to put in place systems to help them recognise people at risk. One way to do this is to clearly code the cancer diagnosis and treatment and keep this information current within the patient’s records so that when accessed it ‘pops up’ as a reminder.

Cancer care review

Performing a comprehensive cancer care review at 6 months post diagnosis gives the opportunity to ask about treatment-related problems, physical and psychological effects of treatment, and financial implications.

It is then good practice to continue annual cancer care reviews, as in other areas of chronic disease management.

Self-management support

The offer of information about possible recurrence and consequences of treatment helps some patients to feel empowered to self-manage. The toolkit offers a wide range of patient information leaflets that can be printed, for example information about the toilet card13 or the RADAR national key scheme for urgency or incontinence; these can help improve quality of life.

The toolkit also emphasises that patients who have had cancer can reduce their risk of recurrence and improve their general health by adopting a healthy lifestyle and taking part in regular physical activity.8 Being active during and after cancer treatment can also help to maintain physical function and improve psychological wellbeing.14

Managing consequences of treatment in primary care

The range of potential consequences of cancer treatment is vast. Needs will vary depending on the type and severity of symptoms. For example, after radiotherapy to the prostate, patients may experience lower gastrointestinal or genitourinary symptoms and simple interventions such as dietary advice (avoiding excess fibre), pelvic floor exercises, and continence support are helpful. The toolkit includes a number of reference guides for managing a range of consequences of cancer treatment, covering key investigations, treatment options, and advice on referrals.8

Work and finance

Four in five people with cancer are £570 per month worse off because of their diagnosis of cancer. A recent Macmillan survey showed that 40% of people with cancer who have savings have used some of their savings to cover the financial impact of their diagnosis.15

The toolkit offers resources to help patients with cancer access advice and support during financial difficulties. A successful return to work is in everyone’s interests, so Macmillan has designed a useful guide for employers to help them support employees affected by cancer.

Talking about employment and benefits with patients is important for their health and wellbeing, but is not an area of expertise for many healthcare professionals; Macmillan has developed the Work support route guide16 to help healthcare professionals facilitate discussions on work and finances with people living with cancer.

Conclusion

It is clear that managing the consequences of cancer and its treatment will form an increasing part of the GP workload. The Consequences of cancer toolkit and Spotlight Project bring together best practice, clinical guidance, and patient resources to help identify, manage, and support these consequences. Further education, training, and resources are needed in primary care to increase knowledge and awareness of this under-recognised issue.

Key points

  • At least 2.5 million people have been diagnosed with cancer in the UK and the predicted survival of half these people is now more than 10 years
  • Cancer survivors report poorer health and wellbeing than the general population
  • Cancer treatments can have serious short-, medium-, and long-term consequences and these may not present for many years 
  • Macmillan Cancer Support and the RCGP aim to help primary care in supporting patients with a cancer diagnosis through the:
    • 2015–2016 Consequences of Cancer Spotlight Project
    • Consequences of cancer toolkit8 
  • The toolkit8 provides resources to help practitioners and patients to recognise consequences of cancer treatment:
    • when a patient with a history of cancer presents with new symptoms, GPs should consider the possibility of cancer treatment consequences
    • GPs need to remain vigilant to recognise people at risk, e.g. by coding the patient’s cancer diagnosis and treatment in their records and keeping it current as a reminder
  • Annual cancer care reviews are good practice
  • Patient information leaflets can help patients improve their quality of life and empower some to self-manage consequences of treatment
  • Information about adopting a healthy and active lifestyle can help maintain physical function during and after cancer treatment, improve psychological wellbeing, and reduce the risk of recurrence
  • Macmillan’s Work support route guide is an easy-to-use tool to help healthcare professionals have conversations about work with people living with cancer, including people who are in employment or on long-term sick leave, out of work, or self-employed.

RCGP=Royal College of General Practitioners

GP commissioning take home messages for England

written by Dr David Jenner, GP, Cullompton, Devon

  • More people are living longer after a diagnosis of cancer and have many different physical, psychological, and medical needs
  • Commissioners should:
    • be alert to the need to support people with cancer once diagnosed and reduce recurrence. Current NHS targets focus on speed of referral and time to diagnose, thus inevitably putting the focus on initial diagnosis and treatment
    • consider working with local and national cancer charities to explore ways of providing support to people with cancer, in so doing relieving the burden on an already pressurised primary care sector
      • this could include community cancer support nurses, cancer support groups, and palliative care services, which cancer survivors can access directly
  • The number of hospital-based follow-up appointments could be reduced, and the resources used to provide care at home through schemes such as the PSA tracker system, which follows up men who have been treated for prostate cancer. This can also help improve the patient experience by reducing unnecessary hospital visits.

PSA=Prostate-specific antigen

References

  1. Maddams J, Utley M, Moller H. Projections of cancer prevalence in the UK 2010-2040. Br J Cancer 2012; 107: 1195–1202.
  2. Cancer Research UK. Cancer survival statistics—cancer survival for all cancers combined. www.cancerresearchuk.org/health-professional/cancer-statistics/survival#heading-Zero (accessed 10 June 2017).
  3. Elliott J, Fallows A, Staetsky L et al. The health and well-being of cancer survivors in the UK: findings from a population-based survey. Br J Cancer 2011; 105: S11–S20.
  4. Scottish Government. Beating cancer: ambition and action. 2016. Available at: www.gov.scot/Publications/2016/03/9784/0 
  5. Macmillan Cancer Support. Throwing light on the consequences of cancer and its treatment. Macmillan Cancer Support, 2013. Available at: www.macmillan.org.uk/documents/aboutus/research/researchandevaluationreports/
  6. Armes J, Crowe M, Colbourne L et al. Patients’ supportive care needs beyond the end of cancer treatment: a prospective, longitudinal survey. J Clin Oncol 2009; 27 (36): 6172–6179.
  7. Hoekstra R, Heins M, Korevaar J. Health care needs of cancer survivors in general practice: a systematic review. BMC Fam Pract 2014; 15: 94. 
  8. Royal College of General Practitioners, Macmillan Cancer Support. Consequences of cancer toolkit. www.rcgp.org.uk/clinical-and-research/toolkits/consequences-of-cancer-toolkit.aspx (accessed 5 June 2017).
  9. Royal College of General Practitioners, Macmillan Cancer Support. It’s not just about survival: equipping the primary care workforce to improve the quality of life of people living with and beyond cancer. Available at: www.rcgp.org.uk/~/media/6992FED5626945D9B44664FA72F828BC.ashx 
  10. Linden D, Love P, Bowman E, Maher J. Managing the consequences of cancer in primary care. Br J Gen Pract 2016; 66 (648): 348–349. 
  11. Richards M, J Corner, J Maher. The National Cancer Survivorship Initiative: new and emerging evidence on the ongoing needs of cancer survivors. Br J Cancer 2011; 105 (Suppl 1): S1–S4.
  12. Bovelli D, Plataniotis G, Roila F; on behalf of the ESMO Guidelines Working Group. Cardiotoxicity of chemotherapeutic agents and radiotherapy-related heart disease: ESMO clinical practice guidelines. Ann Oncol 2010; 21 (Suppl 5): v277–v282. 
  13. Be.Macmillan. Generic toilet card. be.macmillan.org.uk/be/p-22493-generic-toilet-card.aspx (accessed 10 June 2017).
  14. Macmillan Cancer Support. The importance of physical activity for people living with and beyond cancer: a concise evidence review. Macmillan Cancer Support 2012. Available at: www.macmillan.org.uk/documents/aboutus/commissioners/physicalactivityevidencereview.pdf 
  15. Macmillan Cancer Support. No small change. Macmillan Cancer Support, 2017. Available at: www.macmillan.org.uk/documents/policy/money-and-cancer-policy-report.pdf
  16. Macmillan Cancer Support. Work support route guide. Macmillan Cancer Support, 2012. Available at: www.macmillan.org.uk/documents/aboutus/health_professionals/macmillan_worksupportrouteguide_england_v3.pdf G

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