General practice, mental health and the care of people with cancer

People living with cancer report significant unmet mental health needs. Over half of respondents in a recent survey conducted by the Cancer Council of New South Wales reported that their emotional needs are acknowledged less frequently than their physical needs.¹ People with cancer and their caregivers report that their healthcare practitioners, inclusive of all health professionals involved in their care, fail to recognise and understand their psychosocial needs, including mental health, and are unaware of, or do not refer to, available resources. General practice is integral to the coordination of cancer care supporting the patient journey from prevention, screening/early detection, diagnosis, treatment planning, treatment, post-cancer follow-up and surveillance.² This aligns with the remit of the general practitioner (GP) in providing holistic, person-centred healthcare. Despite their significant existing training and capabilities in providing mental healthcare, many GPs describe reduced confidence in managing the unique aspects of meeting mental health needs of people with cancer, especially those in survivorship.³ Mental health, from a GP perspective, might be a sub-optimally addressed component of holistic cancer care.²

Rates of cancer diagnoses in Australia are rising, from 383 to 503 per 100,000 people in 1982 and 2023, respectively.⁴ It would not be unreasonable to expect a commensurate increase in the number of mental health presentations related to cancer care. Providing this care heralds a potentially greater emotional and cognitive caseload for GPs, with the associated increased demand in time and capabilities unlikely to be matched with appropriate resources, finances and education. The low prevalence of integrative oncology services, being available at only one-quarter of Australian healthcare organisations,⁵ is coupled with a decline in psychologist availability for new patients in Australia. It can be challenging for Australian GPs to navigate and bridge the service gap of timely psychological care for people with cancer. This difficulty in accessing appropriate mental healthcare is exacerbated in priority populations, including the culturally and linguistically diverse.

GPs are in a unique position, given their generalist skillset, broad-based training in mental health conditions and knowledge of the sociocultural context of their patients, to deliver mental healthcare if these same patients have cancer. This holistic and integrative approach also incorporates lifestyle interventions with mental healthcare. GPs identify a need to be better equipped to manage the mental health, psychosocial and physical issues that accompany their patients through their cancer journey.³

Cancer and mental health

The association between cancer and mental health issues is bidirectional. There are unique mental health issues precipitated by a cancer diagnosis, as well as poorer outcomes for patients with pre-existing mental health issues who are subsequently diagnosed with cancer. Mental health issues affect at least 30–35% of people with cancer during all phases of the disease trajectory, and differ in nature according to the stage and tumour stream.⁶ A smaller proportion (15–20%) of people with cancer might experience psychosocial challenges including demoralisation, health anxiety and loss of meaning, which might not be recognised as ‘disorders’ but are nevertheless distressing and clinically relevant.⁶ Cancer survivors also experience high rates of trauma related to the experience of cancer and its treatments, fear of cancer recurrence and fear of disease progression.

Despite the higher incidence of mental health issues in people with cancer, their use of GPs, psychiatrists and mental health professionals was no greater than people without cancer. This suggests that there is a high degree of untreated, or under-treated, mental health issues in people with cancer.⁷ There is a particular urgency with identifying and managing mental health issues as part of cancer care, especially when considering the significant life challenges that a diagnosis of cancer poses and the often-rapid movement through the treatment journey from diagnosis to cancer survivorship or palliation. This can include the emotional and physical considerations associated with return to employment, long-term side effects from treatment, changes in social interactions, infertility, intimacy, and premature menopause and andropause, among others. Nine per cent of people with cancer express suicidal ideation at diagnosis, escalating to 36% in end-of-life stages.⁸ Suicide risk is greatest within the first year of diagnosis⁹ and can remain elevated through the transition from the acute treatment phase to GP-led care.

The path ahead

There is professional under-recognition of, and under-investment in, the psychological care of people living with and beyond cancer. GPs and community-based mental health networks need to be supported educationally, financially and resource-wise to continue to screen for and provide mental healthcare for their patients with cancer. GP capacity, both in time and skills, needs to be carefully considered and provided for. Care pathways should be informed by further Australian-based research, given our unique healthcare system, population and geography, with the latter itself being an impediment to care access.¹⁰ Improvement in communication between tertiary cancer care centres and GPs, ideally using liaison oncology services, will optimise both physical and psychological care coordination. It will assist GPs in managing the complex multimorbidity, including psychological sequelae, of cancer diagnosis and management. A better understanding of unmet mental health needs among people affected by cancer would help integrate the work of clinicians, educators and researchers in providing timely and effective mental healthcare.