The price of freedom is eternal vigilance.
– Archbishop Desmond Tutu1
Once described as ‘the emperor of all maladies, the king of terrors’ by an anonymous 19th century surgeon,2 cancer remains one of society’s most feared diseases.3,4 Murtagh emphasises that early detection of cancer can be challenging, as the presentation can be vague and can masquerade as other common and less serious conditions.5
While a general practice registrar, my training featured frequent reminders of red flags, systemic symptoms and the importance of appropriate safety netting to ensure that early presentations of cancer were not missed. Although a relatively recent arrival in general practice when compared with more experienced colleagues and mentors, I have diagnosed both new cancer presentations and cancer recurrence in my patients. For some this led to acute treatment, and for others eventually to palliative care. A late diagnosis, for whatever reason, may have devastating effects on the patient and their loved ones. Like many others, I also have the lived experience of a family member diagnosed with cancer; my father’s malignancy was detected by his own vigilant general practitioner (GP). All of these learnings remain in my mind as each new patient comes through the door.
Timely consideration, investigation and referral is crucial to the early detection of cancer and potentially enhanced survival for our patients. Yet, simultaneously there are considerable pressures on GPs to avoid unnecessary investigations, which carry their own risks and costs to our patients and to the wider health system. This balancing act is a cornerstone of general practice, where, as clinicians, we regularly see undifferentiated illness and need to make efficient decisions about when to investigate and when to watchfully wait.
The subtlety of early signs can make them difficult to perceive unless we are watchful for their appearance. Hence, it is important to remain aware of the crucial signs that should point us to further investigation or referral, and the tools that can assist in decision making. One example from the UK is the online QCancer tool, which allows for calculation of risk of a number of cancers on the basis of a combination of risk factors and clinical symptoms.6
The first Focus article this month considers the diagnosis and current management of pancreatic cancer, which has the highest cancer mortality rate.7 The authors emphasise the need for rapid referral, as any delay reduces available treatment options and worsens outcomes. They also acknowledge the inherent difficulty in detection of this disease, with no screening test or pathognomonic clinical presentation. Unfortunately, late diagnosis led to the early death of a loved one for a family who subsequently contacted Australian Journal of General Practice. The family requested we highlight the importance of early diagnosis of pancreatic cancer, a responsibility we undertake in this issue.
Closely linked with cancer diagnosis is consideration of cancer survivorship. As survivorship improves, caring for those with a history of cancer will be increasingly required. This brings with it additional opportunities for the patient and GP to work together in balancing both careful surveillance with management of the emotional and psychological impact of the threat of recurrence. In this issue, we present a model for survivorship care that recognises the key role of primary care in the multidisciplinary team.8
Early detection of cancer requires us to maintain both knowledge of insidious warning signs and vigilance in seeking these out, so that our patients can benefit from ongoing advances in cancer management. As we see cancer shift towards a chronic disease care model, GPs remain essential to the patient journey from first suspicion to survivorship.