By Dr Rose Fok
Division of Medical Oncology, NCCS

During our 2nd National Cancer Centre Singapore – General Practitioner (NCCS-GP) symposium in July last year, I was invited to share my experiences as a GP working in NCCS.   One of the aims of this session was to encourage more GPs to come forward for training and education, as well as to contribute more towards continuity of cancer care. 

Before coming to NCCS, my impression was that family physicians ceased to have a role in patient care once cancer was diagnosed, as the oncologist would take over for the entirety of the patient’s care trajectory.

I also had the misconception that it was unsafe to treat cancer survivors as they were high risk patients constantly in imminent danger of relapse. I have realised that this is not always true.

Contrary to popular opinion, the family physician has an important role throughout a patient’s cancer journey, by virtue of having built a long-term relationship with the patient in the setting of primary care.   In particular, it became evident to me that GPs would be of great value in negotiating several key areas in cancer care.

Early Diagnosis and Cancer Screening

While assisting in the NCCS outpatient clinic, I was impressed by an experienced GP who referred two newly diagnosed cancer patients without histology directly to the oncologists.   One was a senior lady with a persistent cough and a new onset hemiparesis.   He sent her for a chest X-ray which showed a shadow, and a CT-Brain which showed  ontracranial space occupying lesions.

At the NCCS clinic, the oncologists scheduled her for bronchoscopic biopsy and staging and she was diagnosed with Adenocarcinoma of the lung with brain metastases.   Another equally impressive referral was an elderly gentleman with persistent back pain and symptoms of prostatism.   The GP ordered a Prostate Specific Antigen which was 200 times higher than the upper limit of normal, and a lumbar spine X-ray showed osteoblastic lesions.

Further investigations at NCCS revealed the GP’s initial diagnosis of prostate cancer with bone metastases to be correct.   Yet another meticulous GP noted anaemia and  presence of stool occult blood in a senior gentleman on health screening and strongly advised a colonoscopy.   The patient was promptly diagnosed to have a stenosing sigmoid  colon cancer.

Such cases illustrate how a knowledgeable and competent GP can do a lot more for the patients by ordering the right tests to arrive at an accurate diagnosis early.   This not only has the potential to provide a better chance of cure for the patient diagnosed at an earlier stage of disease, but also leads to significant savings, both in direct costs of investigations and treatment, as well as opportunity costs to the patient and family by reducing time taken off to accompany the patient for procedures and therapy.

Evidence based cancer screening, like for Hepatitis B Carriers are routinely carried out by GPs. With improved understanding of genomics, familial cancer screening is gaining importance. 

Before coming to NCCS, my impression was that family physicians ceased to have a role in patient care once cancer was diagnosed.

GPs can help to identify at risk familial patterns and refer patients with polyps or early cancers for further evaluation.

Cancer Prevention, Education & Guidance 

GPs generally place a greater emphasis on health promotion. This focus, coupled with their close relationship to the patients built over many years, places them in a unique position to effect lifestyle changes that can help prevent cancer.   These include smoking cessation, decreased consumption of red meat, exercise, as well as obesity and stress management.

GP's focus on health promotion, coupled with their close relationship to the patients built over many years, places them in a unique position to effect lifestyle changes that can help prevent cancer.

In our IT-savvy era, there is often information overload in the internet. In addition, patients can be misled by social media.   GPs can provide the guidance and help them to interpret these materials.

GP Involvement in Survivorship Care

With the increasing numbers of cancer survivors as a result of improvements in cancer diagnostics and therapeutics, there is no doubt that the family doctor will have more encounters with cancer survivors in the clinic.

Cancer survivors stand to benefit if their family doctor is also part of the team following them. 

Two randomised controlled trials – one conducted in the UK and one in Canada, published in the British Medical Journal, compared family physician versus hospital-based  specialist care of patients with cancer.   The study revealed no statistically significant differences in cancer recurrence rates, survival, patient well-being or patient  satisfaction, suggesting that the primary care setting could be just as effective in managing cancer.

Cancer survivors stand to benefit if their family doctor is also part of the team following them up to monitor for recurrence, manage adverse effects of treatment, detect  and address psychosocial problems, and continue the management of comorbid conditions.   With proper training, family doctors can give reliable and up-to-date advice on  matters like cancer screening and basic genetic counselling for family members of the cancer survivor.

Potential barriers to the successful incorporation of GPs into the cancer care team include patient perceptions of incompetency amongst GPs, and gaps in knowledge, skills and communication in cancer care amongst GPs.   These will certainly need to be addressed, through training and engagement of all parties, to ensure effective delivery of care.

Home and Palliative Care

Following acute cancer treatment, many cancer survivors have significant unmet needs, especially with regards to psychosocial care.   Being readily accessible, and having an intimate knowledge of the context of a cancer diagnosis in the patient’s life and overall health, the GP is well placed to integrate cancer care, particularly at the end of life.

This patient-GP relationship often extends to the family, who often turn to their family doctors to seek support, clarification and advice. 
Some hospice teams like HCA Hospice Care have a programme to bring GPs into the palliative care network with the patient’s consent.

They keep the GPs in the loop on the patient’s care and progress, provide the necessary help and training, develop a  clinical management plan, and maintain an open channel of communication with the GPs.

During cancer treatment, home care teams can co-manage patients who may experience complications from blocked tubes and drains, skin reactions and rashes. Such endeavours  certainly go a long way towards realising the vision of seamless care for patients.

As we move on to our next stage of GP development and training in Oncology, NCCS will be developing a structured programme to enhance knowledge and skills in oncology. We  welcome all interested Primary Care Physicians to walk this journey with us.

This article was first published in Salubris, Issue 32.