Supporting, continuous and networked care by the primary care physician

Early psychological support helps cancer patients and their families to cope with the disease and overcome possible fears. The primary care physician plays an important role in oncology patients as a bridge builder between the patient and the specialist team. However, primary care physicians are often hampered by interruptions in continuity over time. In the medical conversation, it is important to understand and respect the patient’s possible defenses against his or her disease. In about one third of those affected, actual mental disorders develop in the course of the disease, some of which can also be accompanied and treated in the general practitioner’s office. The so-called distress thermometer is suitable for recording the psychological stress situation: The patient rates the stress on a scale from 0 to 10.

The general practitioner plays a very important role in the care of oncological patients: he initiates cancer screening examinations, initiates diagnostic clarifications in case of suspicion, cares for the patient during oncological therapy and closely accompanies the patient in the terminal phase.

However, primary care physicians are often hampered by interruptions in continuity over time. This article attempts to show how the primary care physician plays an important role as a bridge builder between the patient and the specialist team.

Oncological diagnosis

The patient usually consults the general practitioner first with the first unclear and worrying symptoms, or suspicions are raised during a routine examination. Already at this stage, a great uncertainty of the patient is noticeable and the family doctor plays an important role for the psychological support of this difficult phase. The delivery of a cancer diagnosis also often occurs through the primary care physician. Often the news is experienced as if one is “beside oneself” and the dimension of the cancer is only gradually grasped. Patients nevertheless often remember the doctor’s statements in this first moment throughout the further course of the disease and experience them as very formative. It is therefore important that the patient has the opportunity to express any fears and questions. Otherwise, there is a great risk that he or she will only obtain information via the Internet, which often leads to misinformation and uncertainty.

Oncological therapy

At the beginning of the disease, the main focus for the patient is physical treatment with surgery, chemotherapy and radiation. This is usually done in a tumor center or other specialized oncological institution. Unfortunately, the primary care physician often does not learn how the patient is doing for some time, sometimes months. Communication between specialists and primary care physicians still varies in quality. Patients miss a continuous contact person, especially in the center hospitals, and often feel left alone with many questions.

The relatives are also unsettled and have fears. They consult the family doctor more than usual during this time. They are afraid of losing their partner and feel helpless and powerless over each other’s suffering. They need support in how to help the sick partner without getting into an overburdening situation themselves. Often there is also a redistribution of roles within the family, which leads to uncertainty.

Spectrum of mental stress reactions

The psychological processing of the disease is often difficult for the patient himself in the beginning due to the often demanding and stressful therapies and generally takes place later. In about one third of those affected, actual mental disorders develop in the course of the disease. The most common is depression (ICD-10 F32). Patients suffer from a sense of meaninglessness and hopelessness and have drive disorders and report joylessness. Often there are sleep disturbances and also cognitive losses. Suicidal thoughts with intentions to act may occur and are often concealed by the patient out of shame and fear. They must therefore always be specifically asked for by a doctor. In addition to the general practitioner’s support, psychological support and possibly also antidepressant drug therapy may be useful. If listlessness is the primary symptom, an SSRI such as escitalopram or even the SNRI venlafaxine is recommended. For pronounced sleep disorders, mirtazapine or trazodone help.

Some patients develop an actual anxiety disorder (ICD-10 F41), usually in the sense of generalized anxiety with so-called free-floating anxiety. They then report that they no longer have any ground under their feet, suffer from mental circles and frequent sleep disturbances. Initially, the fears mostly concern the further course of the disease and the possible consequences of the therapies, and later also the return to everyday life and work. Even if the cancer responds well to therapies, the fear of recurrence is very high for most patients.

Sometimes the cancer or its treatment is also experienced as actual traumatization and patients experience post-traumatic stress disorder in the course, often characterized by flashbacks (e.g., stay in hospital or situation during chemotherapy) and hyperarousal. In these cases, actual trauma therapy may be necessary.

The psychological stress situation in oncological patients can be assessed by means of questionnaires (e.g. HADS). However, these are often too costly in primary care practice. The so-called distress thermometer (DT) is proven and very practical for the consultation hour. Here, the patient rates the stress on a scale from 0 (none) to 10 (extreme). Psychological intervention is recommended above a cut-off of 4-5.

Cancer-Related Fatigue (CRF, ICD-10 G93.3) affects about one third of all cancer patients. This fatigue syndrome can occur both during treatment and immediately or years after completion, and is characterized by fatigue that is insufficiently improved by sleep and does not correspond to activity levels. At the same time, symptoms such as joylessness or sleep disturbances are less common. However, the listlessness of depressive stress disorder is often difficult to distinguish from fatigue. Persistent fatigue symptoms may in turn lead to depressive development. Unfortunately, there is usually no effective drug therapy. Moderate physical activity (especially aerobic muscle training such as walking) and a regular daily routine with several breaks are recommended. Although this exhaustion is a common cause of ongoing reduction in quality of life and ability to work, it is often under-recognized and not addressed. Patients then feel left alone with their complaints and develop feelings of insufficiency.

The medical interview

In the medical conversation, according to the principle of Rogers’ conversation guidance, the three cornerstones of authenticity (self-congruence), appreciative sympathy (encounter) and empathetic understanding (empathy) are decisive. It is important to understand and respect the patient’s possible defenses against their disease. The most common are denial, repression, intellectualization, regression, dissociation, but also turning against oneself. A common medical misconception is that these defenses need to be broken. Thus, some doctors try to contradict the denial of the patient in the opinion that they are thus serving the truth. It is often overlooked that this defense plays an important role in stabilizing the patient and that a breakdown can lead to the patient becoming severely overwhelmed and insecure. It is therefore important in the psychological support of oncological patients to be completely attuned to the current psychological condition of the patient.

Objectifying in particular should also be mentioned as an unfavorable intervention. Confronting the patient with objective facts and arguments is not very supportive. Rash suggestions for solutions are also unhelpful to the patient, devalue his or her previous efforts, and also promote dependency and a sense of helplessness. Difficult conversations often arise when the patient holds a hope that we as physicians do not share or when there is an aggressive, defensive response from the patient. Here, too, a gentle approach is important that respects the current individual inner world and the patient’s feelings.

It is often very valuable to ask about the patient’s subjective theory of illness. For example, many patients believe job stress is responsible for cancer and blame themselves. This can contribute to the development of psychological pressure or anxiety.

Terminal phase

If the cancer progresses and the patient no longer responds to any therapies in the palliative phase, he or she is often left to the care of the primary care physician. However, if he has hardly seen the patient beforehand, the general practitioner has a difficult position in this phase: he has the demanding task of providing comprehensive care to the patient and his relatives in the terminal phase without knowing the previous history. It is not uncommon that it was hardly possible for the patient to prepare for death during the illness, as this is often left out of the medical discussions with the oncologists – both on the part of those treating the patient and the patient. This leaves it up to the primary care physician to clarify important issues, such as writing an advance directive or whether the patient is better off at home, in a palliative care unit or in a hospice.

Many patients are not so much afraid of death, but of dying, they often fear pain or other agonies. Here, too, the primary care physician plays an important role in providing education and psychological support. Sometimes home visits are also very valuable, but these are becoming less and less possible.

The importance of euthanasia organizations such as Exit and Dignitas has increased significantly. They serve the increasing need for self-determination, even at the end of life. However, it is often overlooked that euthanasia is a very difficult and stressful situation for the relatives and they are deprived of an important process of saying goodbye. Here, too, the family doctor plays a mediating and supporting role, which requires a lot of time and sympathy.

Conclusion

Early psychological support helps those affected and their relatives to come to terms with the disease and overcome possible fears. It is precisely in this psychological support that the family doctor often plays a subordinate role, often unjustly. It is important that he is also involved in addition to the specialized psycho-oncological treatment. This is because it can offer supportive, continuous and networked care and, in particular, also assume an accompanying function when returning to work. Likewise, he accompanies and cares for the relatives of the cancer patient.