Course:PostgradFamilyPractice/ExamPrep/99 Priority Topics/Cancer
Cancer - Key Features
1. In all patients, be opportunistic in giving cancer prevention advice (e.g., stop smoking, reduce unprotected sexual intercourse, prevent human papillomavirus infection), even when it is not the primary reason for the encounter.
2. In all patients, provide the indicated evidence-based screening (according to age group, risk factors, etc.) to detect cancer at an early stage (e.g., with Pap tests, mammography, colonoscopy, digital rectal examinations, prostate-specific antigen testing).
3. In patients diagnosed with cancer, offer ongoing follow-up and support and remain involved in the treatment plan, in collaboration with the specialist cancer treatment system. (Don’t lose track of your patient during cancer care.)
4. In a patient diagnosed with cancer, actively inquire, with compassion and empathy, about the personal and social consequences of the illness (e.g., family issues, loss of job), and the patient’s ability to cope with these consequences.
5. In a patient treated for cancer, actively inquire about side effects or expected complications of treatment (e.g., diarrhea, feet paresthesias), as the patient may not volunteer this information.
6. In patients with a distant history of cancer who present with new symptoms (e.g., shortness of breath, neurologic symptoms), include recurrence or metastatic disease in the differential diagnosis.
7. In a patient diagnosed with cancer, be realistic and honest when discussing prognosis. (Say when you don’t know.)
Note: For pain control, see the key features on chronic disease and palliative care. See also the key feature on depression.
Approach to Cancer
Identifying populations at risk
- o This may include demographic features such as age or sex, or may be risk factors such as smoking, other exposures, or family history.
- o Screening guidelines are readily available from multiple sources online.
- o Key historical questions: family history of malignancies (and age at diagnosis); radiation/sun/toxin exposure; smoking; alcohol.
Choosing a screening method
- o Multiple screening options mean approach needs to be tailored to individual. For example, screening for colon cancer with FOB + DRE vs colonoscopy.
Further testing
- o A positive screening test does not constitute a diagnosis of cancer; in nearly all cases, further testing is required.
- o For example; an abnormality on breast exam and screening mammography would require a diagnostic mammogram and/or ultrasound. The abnormality may be a benign finding.
Pursuing a tissue diagnosis
- o Whenever a diagnosis of cancer is entertained, the aim of further testing should be to obtain a tissue diagnosis. This will guide any possible surgical, chemotherapeutic, or radiation interventions.
- o For example, a patient with a history of smoking is found to have a nodule on CXR that is further characterized on CT. The next step would be to obtain a biopsy, whether through bronchoscopy, CT-guided biopsy, or excisional biopsy by a thoracic surgeon.
Awareness of context/goals of care/advance care planning
- o Not all cancers need to be treated. Ideally, the time to discuss what a patient might want to have done about a potential cancer is when any investigation for it is ordered.
- o Clarifying what the next step would be if a positive screening result is returned helps to unify patient and physician expectations and can alleviate anxiety regarding the direction of care.
Treating symptoms
- o Patients undergoing treatment for cancer also require special attention to pain, gastrointestinal symptoms including nausea and bowel habits, mental health, and other symptoms in the context of their malignancy. Treatments aimed at the cancer itself are only a small part of the overall therapeutic effort.