Patient case study

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Frank had a gastroscopy 10 days later which showed oesophageal cancer. His GP called him to acknowledge his diagnosis and offer support. 

Frank explains that he feels ‘floored’ by the diagnosis. It has kept him awake at night and he is worried about how to break the news to his wife. He has concerns about who will look after his wife during treatment and whether he’s going to die. He is concerned about burdening family and friends.

What support can be offered to Frank?

	Allow Frank the time to share his concerns, actively listen, acknowledge and empathise, as this alone can help Frank process his diagnosis, and feel more supported. Use screening questions to ensure Frank has had the chance to name all his concerns before moving into any advice or reassurance. Explore Frank’s feelings of being a burden, and help him look at what social support he has. Consider discussing which support groups and charities may be able to offer additional support to him.
	Encourage Frank to be open and honest with family members, as sharing this important information will enable others to help and support him. Discuss options for arranging support for his wife while he undergoes surgery. Consider what other options for support Frank might need, including local social prescribing services.
	Check Frank’s physical health and ask whether any symptoms are concerning him. Attempt to address them through the use of painkillers or dietary supplements, for example.

Whilst primary care professionals are not involved in oncology multidisciplinary team meetings, it is useful for them to
understand how decisions on patient treatments are made. Dr Sarah Taylor, GatewayC GP Lead, speaks to Dr Pauline Leonard, Consultant Medical Oncologist, to discuss the role of the multidisciplinary team (MDT) in making treatment decisions.

Key points

• All patients that present with a confirmed cancer will have their case discussed at a site-specialist MDT
• Each team will include a range of healthcare professionals all associated with the patient’s treatment and diagnosis pathway
• This means that a team of people make the best evidence-based recommendation for a patient’s treatment.

Frank has made a decision about the best treatment option. He feels confident that he has been able to explore all options with the hospital team. Frank asked his practice nurse if there is anything he can do to prepare himself for treatment. Frank has expressed that he feels anxious about starting treatment and wants to be as fit as possible before he starts.

What support can be offered to Frank?

	Listen to Frank’s worries, acknowledge his concerns and identify if there are any information needs. As required, share information and back this up with resources (e.g. leaflets, printed copies) regarding support available and the treatment that Frank will be undergoing so that he is well informed.
	Check with Frank that he is comfortable with the support that has been arranged for his wife while he is undergoing treatment, and discuss any concerns.
	Discuss the principles of prehabilitation with Frank. Inform him of the support that is available locally.

Preparing your patient for treatment

The importance of preparation ‘Prehabilitation’ and active recovery pathways in cancer are being increasingly recognised by cancer patients and healthcare providers around the world. Click on the tabs below to learn more.

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Prehabilitation

Prehabilitation prepares patients for cancer treatments by optimising physical and mental health through exercise, nutrition and psychological support. This can help build resilience psychologically and physically. Research suggests that patients who undergo prehabilitation should have improved clinical outcomes, survival rates and greater tolerance to treatment, all of which will lead to reduced time spent in hospital.

In this video, Dr Sarah Taylor talks to Zoe Merchant, Programme Lead for the Prehab4Cancer and recovery programme, and Dr Karen McEwan, Primary Care Lead for Prehab4Cancer.

Key points

• Prehabilitation is the process of preparing patients for cancer treatment and improved recovery using exercise, nutrition and psychological wellbeing
• Good individualistic assessment is essential to help clinicians understand a patient’s need. This preparation can help to provide the best clinical outcomes and quality of life for patients with a diagnosis of cancer
• Provide information on the patient’s comorbidities and functional status on referral forms
• Advise patients that optimising their fitness, nutrition and psychological wellbeing is an important part of treatment, and provide information and support on how they can do so
• Reassure patients who are on a formal prehabilitation pathway they can expect a graded approach to prehabilitation.

Smoking cessation

Smoking is known to reduce the effectiveness of chemotherapy and radiotherapy. During cancer treatment, smoking increases the risk of infection, nausea and anxiety. It is also essential to support patients to endeavour to stop smoking ahead of surgery to reduce anaesthetic risks, improve wound healing, and promote recovery.

Smoking during treatment also increases the risk of:

Becoming smoke-free is the most important step a patient can take to improve the chances of their cancer treatment working, to reduce the side-effects of their treatment and any cancer recurrence, and prevent other comorbidities, for example lung and heart diseases.

The role of the GP

Primary care professionals play an important role in treating tobacco addiction because they are ideally placed to advise people how to quit and about the support options available to them.

NICE guidance (NG92)  on interventions and services to stop smoking recommends that at every opportunity, healthcare professionals should ask people if they smoke and advise them to stop smoking in a way that best suits their preferences.

There are a number of interventions to help people stop smoking. Different cessations tools, including prescribed medication, nicotine replacement therapy (NRT) and e-cigarettes, will work better for different individuals, but we know that quit attempts are more likely to be successful with behavioural support, such as the Very Brief Advice (VBA) intervention.

The ‘AAA’ framework

NICE guidance recommends that primary health care practitioners deliver Very Brief Advice (VBA) to patients that smoke, which takes less than 30 seconds. VBA uses the ‘AAA’ framework as shown below.

• Ask patients about smoking to establish their smoking status, and record their response
• Advise patients on how they can stop smoking
• Act by offering help to support them to quit. This includes referring patients to stop smoking services (SSS) or prescribing pharmacotherapy with brief advice.

Personalised care and social prescribing 

The focus of personalised care is on tailoring the care and support provided to people with cancer to help them to live as well as possible during and after treatment. This involves identifying what matters most to them and then providing that support
– or signposting them to social prescribers or relevant services to address these. Evidence shows that patients have improved health outcomes and better experience if they are actively involved in their care. The NHS Long Term Plan is committed to
giving every cancer patient (where appropriate) access to personalised care interventions including a full assessment of their needs, an individual care plan, a treatment summary, and information and support for their wider health and wellbeing.

Dr Sarah Taylor, speaks to Dr Anthony Cunliffe, Macmillan GP Advisor about personalised care for cancer patients.

Key points:

• The aim of personalised care is identifying and addressing what matters to the individual
• The core of personalised care is supportive conversations which identify the individual’s needs and provides care that is tailored to their needs throughout the different stages of their cancer journey.
• It is important that primary care professionals are aware of which support organisations and referral pathways exist, both locally and nationally, to signpost patients to access support (e.g. emotional, psychological, social, and/or financial support)
• It is useful for patients to have a clear point of contact if they have any concerns.

Holistic Needs Assessment

A Holistic Needs Assessment (HNA) should be offered around the time of diagnosis. This can help identify and address the needs and concerns of people living with cancer, and support the development of a personalised care plan.

While patients may feel overwhelmed and not understand the benefits of a HNA and supportive conversation, it gives primary care professionals the opportunity to identify areas of concern and signpost patients to services that may support them. These can include financial support, physical education or simply more information and resources.

Holistic Needs Assessments can empower patients to talk about what they need and get the most out of what is available to them. It can allow them to build on their existing relationships with primary care, or develop trust with the secondary care services that they are directed to.

Psychological support

A cancer diagnosis can bring many challenges with fear, loss of self-esteem, independence, and isolation all having an impact. In addition, psychiatric disorders are most prevalent in cancer patients. A recent study revealed that 74% of cancer patients suffered from psychiatric morbidity at some point during their illness. This is often overlooked and normalised by healthcare professionals caring for them and means patients do
not receive the support they require. It is vital primary care professionals are aware of the emotional and mental health needs of people living with cancer and how patients can be best supported.

Dr Rebecca Leon, GatewayC GP Lead, speaks to Robin Muir, Clinical Psychologist, about the impact of a cancer diagnosis and treatments on patients’ mental and emotional health.

Key points:

• Patients can experience different levels of stress, anxiety and low mood throughout their cancer journey and some patients may require formal psychological support
• Pre-existing mental health conditions are likely to worsen with a cancer diagnosis
• A cancer diagnosis affects the individual diagnosed; it also has an impact on their family and friends. Primary care professionals need to assess the needs of the whole family
• There can be specific difficulties within a support network when these people have different coping strategies that are at odds with each other.

Madeleine’s story

Additional resources

Link: Psychiatric Morbidity in Cancer Patients, International Society for Contemporary Medical Research (2019)
Link: Personalised care for people living with cancer, Macmillan Cancer Support
Link: Sharing good practice: Social prescribing, Macmillan Cancer Support
Link: Primary Care 10 Top Tips for Social Prescribing, Macmillan Cancer Support (2021)
Link: Prehab4Cancer
Link: Smoking cessation: Practical resources for healthcare professionals, Cancer Research UK (2020)
Link: Video Information for People Affected by Cancer, Cancer Wellbeing London (2019)