Cancer during COVID: Clinical implications and the GP’s role

What happens when someone with cancer gets COVID?
 
This was the first question posed to high profile oncologist Dr Ranjana Srivastava by GPs during a recent COVID-19 GP webinar hosted by the Department of Health.
 
Battling one life-threatening illness is already daunting, but the added complication of a potentially immunosuppressed patient contracting a separate new and unpredictable disease that has killed more than one million people since January presents an almost unprecedented challenge.
 
According to Dr Srivastava, the first step is trying to deal with the immediate threat.
 
‘Once a patient has COVID, I think the priority obviously is ensuring that they recover from that illness and providing them with the supportive care that you would provide any other patient,’ she said.
 
‘And then, really, depending upon the severity of symptoms, the age, the individual circumstances of what sort of cancer they have etcetera, another discussion needs to take place about the risks and benefits of recommencing cancer therapy.
 
‘Cancer treatment has become so many things these days that it really does need to be an individualised discussion about what happened. But, in general, those would be … the broad principles that I would be thinking about.’
 
Associate Professor Joel Rhee, Chair of the RACGP Specific Interests Cancer and Palliative Care network, says GPs have an important role to play in discussing treatment with any cancer patient, as even healthy people miss or forget things during a consultation, let alone those with serious medical illnesses.
 
‘GPs can support patients’ decision-making by helping to “debrief” the patient after oncologist or other non-GP specialist appointments, especially ones involving important decisions such as the decision to delay some treatments or less aggressive chemotherapy,’ he said.
 
‘Just asking the patient to talk through what happened during the consultation using their own words is useful, [as is] checking to see if they are still happy with the decisions.
 
‘GPs can also encourage patients to involve a support person, even via the phone, when seeing an oncologist or other non-GP specialists.’
 
While many patients have been faced with the difficult choice of whether or not to delay treatment during the pandemic, Dr Srivastava says one of the biggest challenges has been helping patients who don’t have that option to stay safe – physically and mentally – in locked down areas with community transmission.
 
‘Our job as medical practitioners is to empathise, to support people as best as possible, but also to not put everybody in the same category,’ she said. ‘That kind of requires a little bit of a nuanced approach to exactly what a person is getting.
 
‘Without going into too many details, targeted therapy isn’t the same as chemotherapy and isn’t the same as immunotherapy. So trying to have an understanding, and working with the oncology providers to have an understanding of a person’s individual risk and what is or is not recommended is a good idea.’
 
Associate Professor Rhee says in his experience most oncologists are happy to speak with GPs, and that now is a good time to build a relationship with the local cancer centre.
 
‘GPs are really good at advocating for patients, and it’s important that we continue to do this during the COVID-19 pandemic,’ he said.
 
‘This might mean going the extra mile to discuss the patient’s concerns directly with the oncology team.’
 
Deputy Chief Medical Officer Professor Michael Kidd, who facilitated the GP webinar in which Dr Srivastava participated, said it is also ‘really important’ GPs talk to patients about how they are mentally coping in order to help them balance the risks of potentially contracting coronavirus with looking after their overall health and wellbeing.
 
Dr Srivastava says she has had patients go to – often unnecessary – extremes to avoid contracting coronavirus and that where possible GPs should encourage the continuation of healthy habits, such as physical activity.
 
‘Exercise is such a vital part of any illness, but especially cancer therapy,’ she said. ‘It would be so unfortunate if people were tying themselves to the house because they were so very worried, that they weren’t getting fresh air and sunshine and all those other things that are important to wellbeing.’
 
One area of cancer care that has been well-documented since the pandemic is the declining participation rate in screening programs.
 
General practice been described as ‘central’ to efforts aimed at reversing this trend and Dr Srivastava encouraged GPs to continue raising the issue with patients.
 
‘The public health messaging has been quite strong around this, and needs to continue to be strong around the fact that it is safe for people to visit their doctors,’ she said.
 
‘It is safe to get an overdue check or a check about a concerning symptom. And I think the more of us who speak about this and reassure the public, hopefully [the more] the situation will improve.’
 
Likewise, she encouraged GPs to continue having discussions with patients around end-of-life care wishes and advance care directives.
 
‘I know that many do, and this is just an encouragement for everybody to get their patients thinking about those difficult decisions,’ she said.
 
‘[A] public hospital in the time of an emergency is just so not a place to initiate those discussions to the uninitiated. It goes badly in so many ways.
 
‘There is a general duty of care on the part of hospitals, too, to keep general practitioners in the loop and to communicate better overall. But I think we all have to play a part in ensuring that people are simply more familiar with what ICU means and what ventilator means and so on.
 
‘That would go a long way towards making end-of-life care better for people all over.’
 
Associate Professor Rhee says interested GPs and general practice nurses may find the Advance Project useful for helping to facilitate these conversations.
 
‘It’s a training package designed specifically for general practices to help them initiate advance care planning,’ he said. ‘Having early discussions about treatment preferences and limitations of life-prolonging treatments is really important.’
 
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