Helping your patient navigate their cancer care during COVID-19: A guide for primary care providers
Although no cancer experience is universal, the diagnosis has life changing implications. From the emotional rollercoaster of worry, low mood, guilt and shame to the physical health changes brought on by surgery, chemotherapy and radiation therapy, cancer brings with it a heavy burden. Unfortunately, the challenges that our cancer patients encounter are further amplified by the global COVID-19 pandemic. Provincial governments have made recommendations on modifications to care during the pandemic, including deferred surgeries, virtual care, and modified hospital visitation policies, all of which have important ramifications for cancer care and impact on patient well being. Anxiety experienced by cancer patients is escalated further given their high risk status should they be exposed to COVID. Patients with cancer appear to be twice as likely to contract COVID-19, more likely to require intensive care, and significantly more likely to die of the disease.1
Family physicians are integral to the multidisciplinary cancer care team. Patients who had more involvement of their family physician in dealing with general medical problems, provision of cancer-related information and emotional support of themselves and their families during their cancer care reported higher quality of life scores.2 A unique opportunity exists during the COVID pandemic to further the collaborative role of the family physician in the provision of cancer care. The FP-ACCESS framework discussed below outlines important considerations which have the potential to improve the cancer care experience of our patients during the exceptional times of the pandemic.
1. Feedback should be solicited from cancer patients to help shape better systems around them during COVID. Many patients experience often debilitating physical and emotional side effects of their cancer journey that are often not being adequately addressed. According to the Canadian Partnership Against Cancer, 1 in 4 patients were not satisfied with the emotional support they received with outpatient cancer care and 7 in 10 patients reported having emotional challenges after treatment ended.3Providing supportive care and counselling to address anxiety can be a key role of the family physician during the pandemic. Patients fear becoming infected or suffering from severe complications of COVID-19 because of immunosuppression, and have concerns that potential healthcare-capacity issues may interfere with the optimal treatment of their disease.4 Communicating current information on the infection control practices implemented in your clinical setting enables you to be responsive to the concerns of your cancer patients.
2. Promote a variety of access points to the health care system to improve the delivery of care and to maximize safety. Given the potential risks of COVID exposure in the healthcare setting to immunocompromised cancer patients, efforts should be made to provide virtual care when safe and feasible. In a survey of urology patients, 96% reported a positive experience with a telephone visit during the pandemic.5 At an urgent care clinic in New York, patient satisfaction with telemedicine visits during the pandemic was high at 4.38/5, despite provider inexperience with use of technology for visits.6 In addition to virtual care, online access to imaging, laboratory results and clinical notes will empower to better understand their treatment plan, clarify with their care team when needed, and identify errors in their medical records should they exist. One recent study showed patients who read outpatient clinical notes online perceived a significant portion of those notes to have serious medical errors. Older and sicker patients were twice as likely to report a serious error.7 By collaborating with their care teams and having access to records, improvements in record accuracy and patient safety can be optimized.
3. Advocate to be included in correspondence with your patient’s cancer care team to ensure you are kept abreast of treatment and test results. A Canadian study highlighted that a communication issue frequently experienced by family physicians was not being copied consistently on patient reports by other cancer care providers.8 Distribution oftest results to family physicians will improve efficiency at follow up visits and prevent duplication of tests, which is particularly important during the pandemic when it is essential to minimize the in clinic and hospital visits of our cancer patients.
4. Continuity of care for ongoing medical issues, chronic problems and new complaints should be maintained and optimized, either virtually or in person when necessary. In one study of cancer patients, more than 70% had coexistent cardiopulmonary disease.9 Ongoing management of these comorbidities by the primary care provider is essential to minimize surgical complications and better cancer care. Familiarity with the patient’s cancer care plan will further enrich continuity of care. Given that patients may be attending appointments alone during the pandemic, there is an inherent risk they may not understand all aspects of the care plan, especially if there are language barriers.Given that the patient physician relationship is central to the role of the family physician,10 patients often seek clarification with their primary care provider prior to embarking on new treatments.
5. Collaborate actively with the cancer care team and your multidisciplinary colleagues. Given the potential delays in surgical care and diagnostic imaging, advocacy efforts and consultation with the cancer care team may be essential. Enlist your multidisciplinary team to enhance care. A large oncology unit in New York used the pandemic as the impetus to develop new multidisciplinary clinic strategies and to expand patient navigation with the objective of better appointment coordination to reduce the travel requirements patients may experience while managing their malignancy.11 Consider coordination of care for your cancer patients by an identified team member in your clinic in order to aggregate appointments on the same day with multiple providers when feasible.
6. Educate patients about the rapidly changing information on COVID and the resulting changes in health services provision. Understanding provincial guidelines on healthcare service provision during the pandemic will allow meaningful discussions about changes in care plans and potential treatment delays. Knowledge of up to date and reputable resources that you can refer patients to for information about COVID-19 will also assist in addressing patient questions. The Canadian Cancer Society website has important information on cancer and COVID that can be a useful resource for patients and their families.
7. Supports for cancer patients have transitioned to online formats and should continue to be recommended. Evidence exists that telephone support from community agencies is highly received, with one study rating patient satisfaction with the telephone exchange of 4.8/5.12 Agencies such as Wellspring and Gilda’s Club have transitioned their services to a virtual format, however, these valuable online support services are inaccessible for patients lacking internet services. Online multilingual reputable resources may be insufficient and may represent an important barrier to patients whose first language is not English or French.
8. Stratify risk for cancer patients planning to return to work during the pandemic. Family physicians have the ideal skills to address the anxiety around return to work, given the long term relationship and knowledge of the patient’s occupation. Familiarity with risk stratification tools that evaluate both the occupational and patient specific risks of severe COVID-19 infection13 can enable family physicians to have meaningful, patient-centred discussions.
Family physicians are uniquely positioned to play an important collaborative role in the care of their cancer patients during the COVID-19 pandemic. Utilizing technology to optimize virtual and shared care, responding to patient feedback, and understanding community resources, as outlined in the FP-ACCESS framework will enable family physicians to adapt their care nimbly in light of the ever changing recommendations related to the pandemic.
Dr. Jennifer McCabe: Family Physician, St. Michael's Hospital; Assistant Professor, Department of Family and Community Medicine, University of Toronto
Dr. Karim Vellani: Family Physician, St. Michael's Hospital; Lecturer, Department of Family and Community Medicine, University of Toronto
References
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2. Sisler, J., Belle Brown, J., Stewart, M. Family physicians’ roles in cancer care: Survey ofpatients on a provincial cancer registry. Can Fam Phys 2004; 50: 889-896.
3. Canadian Partnership Against Cancer. Living with cancer: A report on the patientexperience. Canadian Partnership Against Cancer 2018. Available from:https://s22457.pcdn.co/wp-content/uploads/2019/01/Living-with-cancer-report-patient-experience-EN.pdf . Accessed 2020 Jul 7.
4. Van de Haar, J., Hoes, L., Coles, C., Seamon, K., Frohling, S., Jager, D., et al. Caringfor patients with cancer in the COVID-19 era. Nature Medicine 2020; 26: 665-671.
5. Locke, J., Herschorn, S., Neu, S., Klotz, L., Kodama, R., Carr, L. Patients’ perspectiveof telephone visits during the COVID-19 pandemic. Can Urol Assoc J 2020 Jun 25;Epub ahead of print. http://doi.org.10.5489/cuaj.6758 . Accessed 2020 Jul 7.
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7. Bell, S., Delbanco, T., Elmore, J., Fitzgerald, P., Fossa, A., Harcourt, K., et al..Frequency and Types of Patient-Reported Errors in Electronic Health RecordAmbulatory Care Notes. JAMA Network Open.2020;3(6):e205867.doi:10.1001/jamanetworkopen.2020.5867
8. Easley, J., Miedema, B., Carroll, J., Manca, D., O’Brien, M., Webster, F., et al.Coordination of cancer care between family physicians and cancer specialists. Can FamPhys 2016; 62(10): e608-615.
9. Ko, C., Chaudhry, S. The Need for a Multidisciplinary Approach to Cancer Care.Journal of Surgical Research 2002; 105: 53-57.
10. The College of Family Physicians of Canada. Four Principles of Family Medicine.Available from: https://www.cfpc.ca/en/about-us/vision-mission-principles#four .Accessed 2020 Jul 7.
11. Shah, M., Emlen, M., Mayer, S., Goldstein, P., Scrimenti, L., Hidalgo, M. AdaptingHematology and Medical Oncology Clinical Care in the Epicenter of the Covid-19Pandemic. NEJM Catalyst 2020. Available from:https://catalyst.nejm.org/doi/full/10.1056/CAT.20.0329 . Accessed 2020 Jun 27.
12. Fitch, M., Pang, K., VandeZande, D. Identifying patient-reported outcomes oftelephone-based breast cancer support services. Can Oncol Nurs J. 2017; 27(1):115-123.
13. Larochelle, M. Is It Safe for Me to Go to Work? Risk Stratification for Workers duringthe Covid-19 Pandemic. NEJM 2020. Available from:https://www.nejm.org/doi/full/10.1056/NEJMp2013413 . Accessed 2020 Jun 30