Primary care
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Finding cancer at its earliest, most treatable stage gives patients the greatest chance of survival. For a number of cancers, screening tests allow for early detection and treatment, and thereby, reduce cancer-related mortality. However, many cancers are discovered by symptomatic presentation rather than screening. This article addresses several symptoms commonly reported in the primary care setting, including rectal bleeding, a breast lump, cough, lymphadenopathy, and weight loss, and offers an evidence-based approach to the consideration and possibly the diagnosis of cancer.
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Palliation of symptoms to optimize QOL is the foundation of cancer care regardless of stage of disease or level of anticancer treatment. Patients commonly experience pain, constipation, nausea, vomiting, dyspnea, fatigue, and delirium. Many valid clinical tools are available to the primary care clinician to screen for symptoms, assess severity, measure treatment response, and elicit the patient's subjective symptom experience. Although there is limited evidence regarding the relative efficacy of symptom interventions from randomized controlled trials, clinical practice guidelines are available.
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During the next decade, a rapid increase in the number of new cancer diagnoses in the population as well as a growing number of cancer survivors can be expected. Cancer is anticipated to exceed cardiovascular disease as the primary cause of mortality in the United States population. Despite efforts in tobacco control, the aging of the population and obesity epidemic will contribute toward the increasing incidence of cancer. ⋯ Drawing on a shared care model, primary care providers should collaborate with oncology specialists to determine if cancer-specific laboratory and radiographic studies are indicated to determine if the patient has a cancer treatment-related late effect or cancer recurrence. Health promotion and aggressive management of comorbid conditions should be a standard of care for cancer survivors, as with other patients in the primary care practice. With the growing number of cancer survivors, as well as the recommendations of the IOM report directing research and policy on this subject (see Box 1), it is hoped that in the future a better evidence base to direct health care management in cancer survivors will be built up.
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This article reviews research on end-of-life (EOL) decision-making in general and published guidelines on communicating with patients about EOL treatment options. The literature on EOL decision-making, most of which concerns advance care planning decisions, has identified several factors that influence treatment choices including race, religiosity, current health, and family conflict. This literature also documents widespread lack of understanding about dying and palliative care and fears of abandonment by health care providers. This article reviews guidelines for communicating with patients, stresses the role of prognostication in good decision-making, and provides numerous suggestions for initiating and structuring conversations with patients and families about EOL care.