3.6 Support and communication

3.6 Support and communication

Cancer prehabilitation uses a multidisciplinary approach combining exercise, nutrition and psychological strategies to prepare patients for the challenges of cancer treatment such as systemic therapy and radiation therapy. Team members may include anaesthetists, oncologists, surgeons, haematologists, nurses, clinical psychologists, exercise physiologists, physiotherapists and dietitians, among others.

For patients with low-grade lymphomas who may undergo multiple treatments over many decades, prehabilitation may be an ongoing intervention that becomes increasingly relevant as the patient ages and experiences additional medical, physical and psychological limitations.

Patient performance status is a central factor in cancer care and should be frequently assessed. All patients should be screened for malnutrition using a validated tool such as the Malnutrition Screening Tool (MST). The lead clinician should refer obese or malnourished patients to a dietitian preoperatively or before other treatments begin.

Patients who currently smoke should be encouraged to stop smoking before receiving or during treatment. This can include an offer of referral to Quitline in addition to smoking cessation pharmacotherapy if clinically appropriate.

Evidence in solid cancers indicates that patients who respond well to prehabilitation may have fewer complications after treatment. For example, those who were exercising before diagnosis and patients who use prehabilitation before starting treatment may improve their physical or psychological outcomes, or both, and this helps patients to function at a higher level throughout their cancer treatment (Cormie et al. 2017; Silver 2015).

For patients with low-grade lymphomas, including those who will initially undergo close observation in a ‘watch and wait’ approach, the multidisciplinary team should consider these specific prehabilitation assessments and interventions:

  • conducting a physical and psychological assessment to establish a baseline function level, including assessing coping strategies/abilities
  • identifying impairments and providing targeted interventions to improve the patient’s function level (Silver & Baima 2013)
  • an integrated and structured approach to self-care enquiry – identifying Social Health, Exercise, Education, Diet and Sleep Hygiene (SEEDS) is one such practical tool (Arden 2015)
  • referral to a psycho-oncology service to improve their knowledge and motivation towards healthy self-care care behaviours and to emotionally regulate throughout the course of the disease and treatments
  • reviewing the patient’s medication to ensure optimisation and to improve adherence to medicine used for comorbid conditions.

Following completion of primary cancer treatment, rehabilitation programs have considerable potential to enhance physical function.

Cancer and cancer treatment may cause fertility problems. This will depend on the age of the patient, the type of cancer and the treatment received. Infertility can range from difficulty having a child to the inability to have a child. Infertility after treatment may be temporary, lasting months to years, or permanent (AYA Cancer Fertility Preservation Guidance Working Group 2014).

Patients need to be advised about and potentially referred for discussion about fertility preservation before starting treatment and need advice about contraception before, during and after treatment. Patients and their family should be aware of the ongoing costs involved in optimising fertility. Fertility management may apply in both men and women. Fertility preservation options are different for men and women and the need for ongoing contraception applies to both men and women.

The potential for impaired fertility should be discussed and reinforced at different time points as appropriate throughout the diagnosis, treatment, surveillance and survivorship phases of care. These ongoing discussions will enable the patient and, if applicable, the family to make informed decisions. All discussions should be documented in the patient’s medical record.

More information

See the Cancer Council website  for more information.

See validated screening tools mentioned in Principle 4 ‘Supportive care’.

A number of specific challenges and needs may arise for patients at this time:

  • assistance for dealing with psychological and emotional distress while adjusting to the diagnosis; stigma; treatment phobias; existential concerns; stress; difficulties making treatment decisions; anxiety or depression or both; psychosexual issues such as potential loss of fertility and premature menopause; history of sexual abuse; and interpersonal problems
  • physical distress caused by breathlessness and coughing, which may be alleviated through a referral to allied health professionals (physiotherapy, occupational therapy, exercise physiology or pulmonary rehabilitation); non-pharmacological strategies may be beneficial in breathlessness management (CareSearch 2019a) (note: if oxygen is medically indicated, this can be arranged through the relevant state aids and equipment program)
  • hoarseness may require referral to a speech therapist or ENT specialist for palliative procedures
  • management of physical symptoms such as pain, fatigue, cough and breathlessness (Australian Adult Cancer Pain Management Guideline Working Party 2019; Johnson & Currow 2016)
  • delays in help-seeking for symptoms and psychological distress due to stigmatisation of Low-Grade Lymphomas associated with smoking (Cancer Australia 2020b)
  • having issues with family and friends because of the association of tobacco use and Low-Grade Lymphomas (Carmack Taylor et al. 2008)
  • malnutrition or undernutrition, identified using a validated nutrition screening tool such as the MST (note that many patients with a high BMI [obese patients] may also be malnourished [WHO 2018])
  • support for families or carers who are distressed with the patient’s cancer diagnosis
  • support for families/relatives who may be distressed after learning of a genetically linked cancer diagnosis
  • specific spiritual needs that may benefit from the involvement of pastoral/spiritual care.

Additionally, palliative care may be required, particularly following an advanced stage Low-Grade Lymphomas diagnosis (stages III–IV) or to assist with pain management.

For more information on supportive care and needs that may arise for different population groups, see Appendices A and B, and special population groups.

In discussion with the patient, the lead clinician should undertake the following:

  • establish if the patient has a regular or preferred general practitioner and if the patient does not have one, then encourage them to find one
  • provide written information appropriate to the health literacy of the patient about the diagnosis and treatment to the patient and carer and refer the patient to the Guide to best cancer care (consumer optimal care pathway) for low-grade lymphomas as well as to relevant websites and support groups such as Cancer Council, the Leukaemia Foundation.
  • provide a treatment care plan including contact details for the treating team and information on when to call the hospital
  • discuss a timeframe for diagnosis and treatment with the patient and carer
  • explain the principles of ‘watch and wait’ if active surveillance is planned rather than commencing treatment
  • discuss the benefits of multidisciplinary care and gain the patient’s consent before presenting their case at an MDM
  • discuss progress in the cycle of quitting and refer to Quitline (13 7848) for behavioural intervention if the patient currently smokes (or has recently quit), and prescribe smoking cessation pharmacotherapy, as clinically appropriate
  • recommend an ‘integrated approach’ throughout treatment regarding nutrition, exercise, sleep hygiene, cognitive function (commonly affected by steroids) and minimal or no alcohol consumption, among other considerations
  • communicate the benefits of continued engagement with primary care during treatment for managing comorbid disease, health promotion, care coordination and holistic care
  • where appropriate, review fertility needs with the patient and refer for specialist fertility management (including fertility preservation, contraception, management during pregnancy and of future pregnancies)
  • be open to and encourage discussion about the diagnosis, prognosis (if the patient wishes to know) and survivorship and palliative care while clarifying the patient’s preferences and needs, personal and cultural beliefs and expectations, and their ability to comprehend the communication
  • encourage the patient to participate in advance care planning including considering appointing one or more substitute decision-makers and completing an advance care directive to clearly document their treatment Each state and territory has different terminology and legislation surrounding advance care directives and substitute decision-makers.

The lead clinician has these communication responsibilities:

  • involving the general practitioner from the point of diagnosis
  • ensuring regular and timely communication with the general practitioner about the diagnosis, treatment plan and recommendations from MDMs and inviting them to participate in MDMs (consider using virtual mechanisms)
  • supporting the role of general practice both during and after treatment
  • discussing shared or team care arrangements with general practitioners or regional cancer specialists, or both, together with the patient.

More information

Refer to Principle 6 ‘Communication’ for communication skills training programs and resources.