Background
The number of people living with or beyond cancer are expected to rise. General practice-led cancer survivorship plans have been proposed as a way to address ongoing healthcare needs (including physical and psychosocial care) and care coordination, as well as the prevention and management of other chronic illnesses.
Objective
The aim of this paper is to discuss the role of general practice in the long-term care of cancer survivors and provide a summary of recommendations for comprehensive cancer survivorship care planning in general practice.
Discussion
General practice provides cancer survivors with ongoing support within their community from pre-diagnosis onwards. It is recommended that comprehensive cancer survivorship care plans include the cancer treatment summary and follow-up care planning; the management of other comorbid chronic conditions; health promotion and disease prevention with tailoring to shared goals; and the cancer survivor’s unique situation.
Cancer survival rates are increasing, with Australia having some of the highest survival rates internationally.1–3 The number of cancer survivors exceeds one million and is projected to increase.4–6 General practice, which includes general practitioners, practice nurses and, in many instances, allied health practitioners, provides cancer survivors with ongoing support within their community from pre-diagnosis onwards.7–11 Its focus on whole-person patient-centred care is essential.7,9,10,12–14
General practice-led cancer survivorship plans have been proposed as a way to address ongoing healthcare needs (including physical and psychosocial care) and care coordination, as well as the prevention and management of other chronic illnesses.7–9,14–16 This paper discusses the role of general practice in the long-term care of people living with and beyond cancer, and provides a summary of recommendations for comprehensive cancer survivorship care.
The role of general practice and models of cancer survivorship care
The phase after primary cancer treatment is crucial to the care trajectory. General practice has important roles in the monitoring and early intervention of treatment-related effects, cancer surveillance, the prevention, screening and management of other chronic illnesses, and health promotion.17 Increasing the role of general practice in cancer survivorship care offers multiple advantages. The long-term therapeutic partnership that general practice has with patients places it in a unique position to support ongoing survivorship care in the context of the patient’s other care needs.9,10,16,18 Patients experience a higher level of trust and confidence when their general practitioner (GP) is involved.13 General practice facilitates a more collaborative team approach to respond to the patients’ care needs in a timely and resourceful manner.8,18
Various models of cancer survivorship care have been described based on the disease, care setting, healthcare discipline leading the follow-up care and the purpose of the care provided (Table 1).17,19 Long-term cancer survivorship care from the tertiary cancer services that provided the primary cancer treatment might not be sustainable, nor are they designed to provide comprehensive longitudinal care.9,20
| Table 1. Cancer survivorship care models |
| Model |
Focus |
| Disease-specific |
Tumour type (ie breast cancer, lung cancer) |
| Setting of care |
Where the follow-up will be conducted (ie oncology practices, survivorship clinics, primary care settings) |
| Type of clinician |
Who will lead the follow-up care (ie general practitioner-led, nurse-led, specialist-led care and shared care) |
| Purpose of care |
Intention of care (ie transition of care from tertiary care to primary care, development of long-term cancer survivorship care plan) |
Comprehensive cancer survivorship care planning
Survivorship care plans summarise the cancer history, goals and follow-up care. Patients find care plans helpful, especially when focused on shared areas of concern, such as the management of treatment-related effects and healthy lifestyles, and provide a clear follow-up treatment summary.21 Cancer organisations such as the Clinical Oncology Society of Australia (COSA) and the American Society of Clinical Oncology (ASCO) advocate for survivorship care plans to support communication and the transition to survivorship.22–24 More recently, the Australian Cancer Survivorship Centre (ACSC) launched mycareplan.org.au, an online resource that empowers survivors to manage their long-term care.25 Although it is not currently integrated with general practice information systems, it shows promise in improving patient engagement and self-management. However, as these care plans are disease-focused, they might not encompass the broader survivorship needs.
A comprehensive survivorship care plan in general practice should consider long-term care needs using a patient-centred approach, to encompass the patient’s needs and diversity, as well as their cultural, family and social context.26 This is especially important for under-served populations such as those living in rural or remote areas, who come from culturally or linguistically diverse or Aboriginal and Torres Strait Islander backgrounds, people with disability, and other priority populations as outlined in the Australian Cancer Plan.27–31 The plan should consider incorporating the cancer survivor’s relevant demographics, cancer treatment summary and follow-up care planning, including both physical and psychosocial effects, as well as care of other comorbid chronic conditions, health promotion and disease prevention that is tailored to shared goals, and the cancer survivor’s unique situation (Table 2).21,26 Additionally, to provide for a supportive patient and caregiver experience, the plan should promote effective care delivery, collaboration, care coordination and communication.26 Engaging in shared decision making to align with the patient’s goals, priorities and expectations will likely improve patient empowerment and satisfaction.32 Patient education plays an important role in influencing knowledge, attitudes and behaviour towards more favourable health outcomes.33
The GP might consider accessing existing Medicare funding arrangements, such as chronic disease management plans (MBS item number 721), team care arrangements (MBS item number 723) and multidisciplinary care planning (MBS item number 729), to prepare, coordinate and review cancer survivorship plans.34,35 Eligible cancer survivors could receive funding for up to five consultations with allied health practitioners each year as part of chronic care planning. For example, a cancer survivor with post-cancer fatigue might benefit from a consultation with an exercise physiologist.36 However, there are limitations with the current Medicare funding arrangements, as the provision of only five allied health visits might not be adequate to meet the complex needs of cancer survivors. In addition, the failure of Medicare rebates to align with rising practice costs leaves cancer survivors vulnerable to increasing out-of-pocket health expenses, especially as there are often other comorbid chronic conditions to be managed.37–39 Cancer survivorship care would benefit from additional financial support to assist with meeting holistic care needs, and policy change is required to adequately provide for survivorship care in general practice.
| Table 2. Summary of recommendations: Survivorship care plan |
| Dimensions |
Sections |
| Demographics |
Patient details, general practitioner details, medical history, current medication, allergies, immunisations |
| Cancer treatment summary |
Oncologist details, diagnosis, treatment, familial cancer
risk assessment |
| Cancer follow-up care plan |
Additional cancer treatment, schedule of clinical visits, cancer surveillance and recommended tests, current treatment side effects, possible late- or long-term effects, referrals |
| Physical effects |
Symptoms assessment, referrals, treatment/risk-reducing strategies |
| Psychosocial effects |
Symptoms assessment (psychological, financial and/or employment, interpersonal), referrals, treatment/risk-reducing strategies |
| Other chronic conditions |
Evaluation and treatment, referrals, treatment/risk-reducing strategies |
Health promotion and
disease prevention |
Prevention-focused visits and testing, age- and gender-appropriate cancer screening, vaccination advice |
| Care goals |
Patient’s goals of care, practitioner’s goals of care (for cancer and other chronic conditions) |
Potential barriers to implementing comprehensive survivorship care plans
Several important factors might impact the successful implementation of care plans for cancer survivors in general practice. Patients might not recognise the role that general practice plays in their ongoing care after completing cancer treatment, potentially leading to delayed or inadequate access to follow-up care.17 Additionally, insufficient information and communication from tertiary services might limit the ability to produce a comprehensive plan with all the required diagnosis and treatment details.9 This, combined with the current fee-for-service model in general practice, which does not reward longer consultations needed for comprehensive survivorship care, makes it difficult to create and implement effective care plans. Although GPs might perceive that they lack the confidence in, and knowledge of, how to care for cancer survivors and, in general, receive little training on cancer survivorship, it is important to note the importance of holistic whole-person care in survivorship care.9,15,40 Identifying and addressing these challenges to ensure the successful implementation of survivorship care plans in general practice is critical to improving the quality of care and outcomes for cancer survivors.
Conclusion
GP-led cancer survivorship care, developed in collaboration with patients with contribution from cancer services, offers a patient-centred and sustainable approach to meet the long-term care needs of cancer survivors. We recommend that comprehensive cancer survivorship care plans include the cancer treatment summary and follow-up care planning, the management of other comorbid chronic conditions, health promotion and disease prevention, tailored to shared goals and the cancer survivor’s unique situation. Policymakers should review funding arrangements to provide additional support for cancer survivorship care in general practice.
Key points
- Cancer survivorship is projected to increase in Australia.
- The increasing role of general practice in cancer survivorship care offers multiple advantages.
- Developing a comprehensive cancer survivorship care plan in collaboration with the patient would help to address long-term care needs.
- A comprehensive cancer survivorship care plan in general practice should consider cancer follow-up care planning as well as care of other comorbid chronic conditions, health promotion and disease prevention.
- The general practitioner might consider accessing existing Medicare funding arrangements to prepare, coordinate and review cancer survivorship plans.