Abstract

This short review seeks to draw attention to the growing care needs of cancer patients whose numbers are growing today due to new methods of early diagnosis and screening (and many other factors). For better care especially of patients living with this disease and by virtue of the principle of patient-centered medicine, the role of the family physician (FPS) in the oncology patient treatment team needs to be better defined. In this sense, we presented some approaches from several health systems, including the one in Romania. The conclusion is that FPS must be involved in the management of cancer patients, but there is no unanimity of opinion regarding the attributions that FPS may have in the team of diagnosis, treatment and follow-up of the cancer patient.

Introduction

As the number of cancer patients has increased year by year with new methods of early diagnosis and screening, diagnosing an increasing number of patients, their care needs have also increased. We are also witnessing an increase in the survival of these patients obtained through the new therapeutic procedures Care for that growing number of cancer patients poses more and more problems to health systems and is often shared between primary and secondary care providers. Specialists in oncology are primarily responsible for the active treatment and management of cancer patients; however, after diagnostic the specific role of family physicians (FPS) is still not well defined despite that is constantly evolving.

The Conceptual Role of FPS in Cancer Patients’ Care in Romania

In Romania, the role of the family doctor in the treatment and monitoring of cancer has not been precisely establisher. Thus, we have the point of view of palliative care specialists and the point of view of general practitioners (family doctors). In the latter case, we don’t have a position paper of family doctors that provides for their involvement in cancer management. The point of view of palliation specialists is well outlined by several medical institutions, including “Casa Sperantei” which is the first center in Romania dedicated to hospice palliative care, with involvement in training doctors of various specialties in acquiring competence in palliative care. From the beginning, when palliative care was provided only to patients who were no longer receiving active antitumor treatment and to those in terminal condition, it was concluded that palliative care should be started in the early stages of the disease, right from diagnosis. Thus, the position of “Casa Sperantei” is that palliative care can go hand in hand with curative treatment. The benefits of early initiation of this type of care are primarily for the patient but also for the family and are mainly related to communication and acceptance of the diagnosis, knowledge of the disease and the changes it brings, awareness that symptoms can be treated, knowledge of social rights. The “Casa Sperantei” palliative care recommendations involve family physicians. Unfortunately, these recommendations are not applied in medical practice in Romania.
Cancer patients with non-complex needs will receive basic palliative care provided by:
a) Family physicians trained in basic palliative care
b) Nurses trained in basic palliative care
c) Family members educated by family doctors or nurses
d) Specialized palliative care services, at the request of the patient or family doctor. Cancer patients with complex palliative care will receive specialized care:
1. Directly by transfer to a specialized service
2. Indirectly, though advice provided to the family doctor through the support telephone line, by presenting the case in monthly meetings, telemedicine, or directly joint consultation with palliative doctor and family doctor [1].

The Conception of The Role of FPS in Other Countries

Compared to this conception that ignores the existing tumor board, ESMO provides that patients in need of palliation be examined by a commission that will decide on therapeutic conduct. This commission consists of medical oncologists, doctors who have competence in palliative care, an intensive care specialist, a surgeon, a radiotherapist, and any other specialist that the commission may convene for consultation [2]. In a palliative care system, the role of the family doctor is more in monitoring the cancer patient and providing a part of the palliative care network. The situation in England can be assessed from the results of the study carried by “ALLGAR V.L. & NEAR R.D.”: There was not much clear information about the role of the GP in the team involved in primary prevention, early diagnosis, patient follow up at all stages of treatment, as well as palliative care. The study showed that the presence of the GP is fully justified and requires increased access to primary and specialized medical care. [3] The opinion of German oncologists on the role of the family doctor in cancer management can be assessed by analyzing the study supported by WINHO, the Scientific Institute of Office- Based Hematologists and Oncologists. The analysis showed that there are big differences between the oncological sphere based mainly on treatment and the sphere of the general practitioners based on psychosocial treatment. It seems that in order to benefit of complete care, the patient had to initiate the joining the two [4].
A report compiled for the National Office of the Cancer Society of New Zealand indicates the lack of clarity about the role of GPs in ongoing care. GPs’ and oncologists have different expectations and opinions about the role of the General Practitioner in the follow-up and support of cancer patients and their families after completing specialist care. In conclusion, GPs’ want active involvement in patient support. They consider cancer to be a chronic condition that requires continuous surveillance. GPs’ claim that this can be achieved by forming an interdisciplinary team. [5] The role of the general practitioner has been researched in other studies as well. The study of Kadri Suija and his contributors from Estonia, reveal the cancer patients’ perception of the general practitioner and its interaction. It also reveals the communication that proved necessary between the family doctor and the oncologist. In conclusion, oncologists should know the history of patient. Better communication is needed between the oncologist and GP and its involvement in cancer care. [6] A study by Swedish researchers also reveals the importance of the family doctor both in the diagnosis of cancer and in the follow-up during therapy (management of side effects, treatment of concomitant diseases) as well as during posttreatment supervision. The connection between the oncologist and the general practitioner is insufficient according to this study [7].
Coexistence of cancer with other chronic diseases an element that increases the complexity of the FPS intervention Comorbidities that generally affect cancer patients are another situation that a general practitioner encounters in practice. Because cancer affects the older population (over 60 years), cancer patients may have other morbidities that need to be treated. The general practitioner has to deal with the association of cancer with the pathology that the patient had before the diagnosis of cancer and this, with the challenges involved, has been studied by several researches. One of the researchers found that in the interval of two to five years from the diagnosis, the cancer patient goes to see his GP more often, even if he does not have other chronic diseases. What makes the care of cancer patients complex is that most of them have co morbidities. For this to happen, the oncologists should work with GPs’ and develop methods to address cancer and create surveillance programs for cancer patients in order to meet their needs adequately [8].

Tools for The Practice Of FPS

Some authors try to define the usual tools for practice of GP. In this respect Marianne Cuisinier and collaborators realized fallowing a study: a checklist that defines points of attention for the general practitioner in cases of cancer. The authors used a variant of the Delphi method and the principal findings are discussed. The literature regarding this problem was first examined for definitions of ‘elements of adequate care’. In important issue was the validity of the panel results, by indicating how far a random sample of general practitioners did share the opinions of the panel. Based on the checklist, the points of attention and discussion for the proper care of the results on the declared actual performance of general practitioners suggest that their cancer care needs to be improved [9].

The Role of The General Practitioner in Cancer Screening

General practitioners are quite often involved in the screening team for certain cancers that have been shown to be effective in screening. However, one aspect of the preventive activity carried out by general practitioners is related to establishing the risk factors that patients present. We support the assertion of the study conducted in Australia [9]. This study has shown that many patients who see a general practitioner have risk factors for cancer. It is also found that only a small proportion of these patients had a preventive action from the family doctor. But considering that this study is from 1994, we believe that today things have changed. [10] Pain control and relief of symptoms are part of the responsibility of the general practitioner. Thanks to increasing survival rates and new methods of care, the role of GP is evolving and a constant restructuring of the management for cancer patients is required to provide them with proper care [11].

Conclusion

In this short review of the role of FPS in the trajectory of cancer patients we find that FPS it is or should be involved in all stages of the disease that these patients go through. Thus, FPS has a role in determining the risk factors that the cancer patients have and thus in preventive. FPS also could have a role in early diagnosis and screening, in the treatment of oncological side effects and in palliative care. However, the attributions of the family doctor are not very clear, at least in Romania, regarding his involvement in oncology. There are many conceptions on the role of FPS but, at least in Romania, they are not put into practice in conclusion, the opinion shared by the authors cited in this review, and in our opinion must be considered a restructuring of prevention planning, screening, diagnosis and explanation of the patient, active and palliative treatment with the establishment of an active place of the FPS in the multidisciplinary team.

References

1. http://www.studiipaliative.ro/dezvoltare/ingrijire-paliativa-de-baza-prin-medicii-de- familie/modelul-de-ingrijiri-paliative-de-baza/
2. Cancer centres which provide comprehensive services in supportive and palliative care as part of their routine care can apply to receive the ESMO recognition as an "ESMO Designated Centre of Integrated Oncology and Palliative Care".
3. Allgar V L, Neal RD (2005) General practictioners’ management of cancer in England: secondary analysis of data from the National Survey of NHS Patients – Cancer. European Journal of Cancer Care 14: 409-416.
4. Jennifer Englera, Insa Konea, Christine Holmberg, Walter Baumann, Andrea Siebenhofera, et al. (2017) Oncologists’ views on the importance of general practitioners for cancer patients: a qualitative interview study from Germany. Family Practice 34(6): 730-734.
5. J Kane M, Jasperse R, Egan S PullonL, McBain E, McKinley, et al. (2013) EP-1111: The role of General Practitioners in supportive care of cancer patients after completion of specialist oncology care, Available online 30 June 2015, Part of special issue: 2^nd ESTRO Forum 19-23.
6. Kadri Suija, Tanel Kordemets, Kadi Annuk, Ruth Kalda (2016) The Role of General Practitioners in Cancer Care: A Mixed Method Design, J Canc Educ, Department of Family Medicine, University of Tartu, Puusepa 1a-2120, 50406 Tartu, Estonia, Published on line 31(1): 136-141.
7. Birgitta Johansson, Gunilla Berglund, Katarina Hoffman, Bengt Glimelius, Per-Olow Sjo, et al. (2000) The role of the general practitioner in cancer care and the effect of an extended information routine. Scand J Prim Health Care; 18: 143-148.
8. MJ (Marianne) Heins, JC (Joke) Korevaar, G A (Ge´) Donker, PM (Mieke) Rijken, FG (Franc¸ois) Schellevis, et al. (2015) The combined effect of cancer and chronic diseases on general practitioner consultation rates, Cancer Epidemiology 39(1): 109-114.
9. Marianne Cuisinier, Marleen van Venrooij and Jacques van Eijk (1988) Care Provided by the General Practitioner to Cancer Patients. Patient Education and Counseling 12: 131-144.
10. Alison Heywood, M Med Sci, Rob Sanson-Fisher, Ian Ring, Peter Mudge, et al. (1994) MB.BS., F.A.F.P.H.M, Risk Prevalence and Screening for Cancer by General Practitioners, Preventive Medicine 23: 152-159.
11. Danny Buckland (2016) Role of primary care in the management of cancer patients, Cancer in primary care, Prescriber 45, April 2016.

Summary

This short review seeks to draw attention to the growing care needs of cancer patients whose numbers are growing today due to new methods of early diagnosis and screening (and many other factors). For better care especially of patients living with this disease and by virtue of the principle of patient-centered medicine, the role of the family physician (FPS) in the oncology patient treatment team needs to be better defined. In this sense, we presented some approaches from several health systems, including the one in Romania. The conclusion is that FPS must be involved in the management of cancer patients, but there is no unanimity of opinion regarding the attributions that FPS may have in the team of diagnosis, treatment and follow-up of the cancer patient.