Elsevier

The Lancet Oncology

Volume 16, Issue 12, September 2015, Pages 1231-1272
The Lancet Oncology

The Lancet Oncology Commission
The expanding role of primary care in cancer control

https://doi.org/10.1016/S1470-2045(15)00205-3Get rights and content

Summary

The nature of cancer control is changing, with an increasing emphasis, fuelled by public and political demand, on prevention, early diagnosis, and patient experience during and after treatment. At the same time, primary care is increasingly promoted, by governments and health funders worldwide, as the preferred setting for most health care for reasons of increasing need, to stabilise health-care costs, and to accommodate patient preference for care close to home. It is timely, then, to consider how this expanding role for primary care can work for cancer control, which has long been dominated by highly technical interventions centred on treatment, and in which the contribution of primary care has been largely perceived as marginal. In this Commission, expert opinion from primary care and public health professionals with academic and clinical cancer expertise—from epidemiologists, psychologists, policy makers, and cancer specialists—has contributed to a detailed consideration of the evidence for cancer control provided in primary care and community care settings. Ranging from primary prevention to end-of-life care, the scope for new models of care is explored, and the actions needed to effect change are outlined. The strengths of primary care—its continuous, coordinated, and comprehensive care for individuals and families—are particularly evident in prevention and diagnosis, in shared follow-up and survivorship care, and in end-of-life care. A strong theme of integration of care runs throughout, and its elements (clinical, vertical, and functional) and the tools needed for integrated working are described in detail. All of this change, as it evolves, will need to be underpinned by new research and by continuing and shared multiprofessional development.

Section snippets

Part 1: Introduction

Cancer control in high-income countries has long been dominated by highly technical, disease-centred interventions intended to save or prolong life. This is changing as health policies drive an increased emphasis on public awareness, screening, and early diagnosis of symptomatic disease as a means to further improve outcomes. At the same time, more people are surviving cancer and will live with the long-term effects of their disease and its treatment. This is not a unique problem for the

Part 2: Prevention, screening, and promotion of help-seeking

PCPs are at the front line of health-care services and have important roles in primary prevention and screening for cancer. In this section, we review the evidence for the effectiveness of their involvement, although these efforts should be ideally coordinated with broader public health efforts.

Part 3: Early diagnosis in children, teenagers, and young adults

Cancer is the leading cause of disease-related death in children in high-income countries. The prompt and early diagnosis of cancer in children, teenagers, and young adults (younger than age 25 years) has long been of concern to caregivers, physicians, and policy makers. In this section, we review the effect of prolonged times to diagnosis, common presentations of cancers arising in this age period, the role of PCPs in the diagnosis of such malignancies, the challenges they face, and possible

Part 4: Early diagnosis in adults

Even for cancers for which screening programmes exist, the great majority of cases present symptomatically in primary care. Most patients with symptoms that could signal cancer have a benign cause. PCPs should assess the probability of cancer in these patients, their need for referral for further investigations, and the urgency with which referral and investigation should be done. The conceptual framework (pathways to treatment; figure 3) within which diagnosis of cancer should be considered

Part 5: Cancer survivorship care

The number of cancer survivors is rising rapidly, mainly as a result of improvements in cancer outcomes because of advances in screening, early diagnosis, and treatments for cancer, coupled with an increased number of cases resulting from an ageing population. In the UK, for example, roughly 2 million people (around 3% of the population) are cancer survivors, and this number is predicted to rise to 4 million by 2030.4 Traditional models of follow-up in which patients continue to attend hospital

Part 6: Palliative care in advanced cancer

A third of patients diagnosed with cancer will die from their disease.203 The conceptual approach to the transition from curative to palliative treatment has changed from occurring at a discrete point in time to being a gradual introduction of hoping for the best, but preparing for the worst. As the chance of cure diminishes, oncology treatments have less of a role and palliative care becomes more important. Patients frequently want to spend most of their time at home, and most express a

Part 7: Integration of primary and specialist care

Integration of services between primary and specialist care is vital to optimise the quality and outcomes of care,253 but is known to be problematic.254 Patients often need to consult many health professionals across several health-care settings, which can lead to fragmented and uncoordinated care,193, 254 jeopardising care quality and patient safety.255 Accordingly, introduction of models and tools to improve integration is essential to optimise the role of primary care along the breadth of

Part 8: Health policy on primary care and cancer control

While the incidence of cancer is increasing, partly as a result of a rapidly growing ageing population, the number of cancer survivors is also increasing because of improvements in diagnosis and treatment. However, these gains are not experienced in every health system or social group, with some countries performing much better than others and some population groups having better care and outcomes than others. The reasons for this variation are complex and, for the most part, remain poorly

Part 9: Equipping primary care for its growing role in cancer care and control

Barton and colleagues316 discussed cancer as a growing public health problem and emphasised the crucial role of PCPs in providing patient-centred care for people affected by cancer. PCPs are involved across the cancer care continuum from screening to end-of-life care. A 2009 survey of PCPs in the USA showed that more than 90% provided general medical care for people with cancer, more than half assisted patients with decisions about treatment options and use of surgery, and 19% reported heavy

Part 10: Conclusions and recommendations

Primary care is continuous, coordinated, and comprehensive care for individuals and families, from the first contact for health care through to the end of life. It is an integral part of the care of all disease and at different stages of an illness. Crucially, the PCP works at the key interface between the patient and specialist care, facilitating timely and appropriate access and sometimes protecting the patient from unnecessary or inappropriate interventions. At the same time, the PCP is the

References (346)

  • P Brawarsky et al.

    Effect of physician recommendation and patient adherence on rates of colorectal cancer testing

    Cancer Detect Prev

    (2004)
  • CC Wee et al.

    Factors associated with colon cancer screening: the role of patient factors and physician counseling

    Prev Med

    (2005)
  • JF Brasme et al.

    Delays in diagnosis of paediatric cancers: a systematic review and comparison with expert testimony in lawsuits

    Lancet Oncol

    (2012)
  • ML Tørring et al.

    Evidence of increasing mortality with longer diagnostic intervals for five common cancers: a cohort study in primary care

    Eur J Cancer

    (2013)
  • AS Ahmad et al.

    Trends in the lifetime risk of developing cancer in Great Britain: comparison of risk for those born from 1930 to 1960

    Br J Cancer

    (2015)
  • Aftercare of cancer patients: the role of primary care

    (2011)
  • J Maddams et al.

    Projections of cancer prevalence in the United Kingdom, 2010–2040

    Br J Cancer

    (2012)
  • F Olesen et al.

    Delay in diagnosis: the experience in Denmark

    Br J Cancer

    (2009)
  • D Weller et al.

    The Aarhus statement: improving design and reporting of studies on early cancer diagnosis

    Br J Cancer

    (2012)
  • F Walter et al.

    The Andersen model of total patient delay: a systematic review of its application in cancer diagnosis

    J Health Serv Res Policy

    (2012)
  • L Elliss-Brookes et al.

    Routes to diagnosis for cancer—determining the patient journey using multiple routine data sets

    Br J Cancer

    (2012)
  • JD Emery et al.

    The role of primary care in early detection and follow-up of cancer

    Nat Rev Clin Oncol

    (2014)
  • G Lyratzopoulos et al.

    Rethinking diagnostic delay in cancer: how difficult is the diagnosis?

    BMJ

    (2014)
  • FM Walter et al.

    Symptoms and other factors associated with time to diagnosis and stage of lung cancer: a prospective cohort study

    Br J Cancer

    (2015)
  • R Raine et al.

    Social variations in access to hospital care for patients with colorectal, breast, and lung cancer between 1999 and 2006: retrospective analysis of hospital episode statistics

    BMJ

    (2010)
  • A Bottle et al.

    Association between patient and general practice characteristics and unplanned first-time admissions for cancer: observational study

    Br J Cancer

    (2012)
  • JR Sheringham et al.

    Comparing primary and secondary health-care use between diagnostic routes before a colorectal cancer diagnosis: cohort study using linked data

    Br J Cancer

    (2014)
  • M Biswas et al.

    Symptom lead times in lung and colorectal cancers: what are the benefits of symptom-based approaches to early diagnosis?

    Br J Cancer

    (2015)
  • Suspected cancer: recognition and referral

    (2015)
  • A Ford et al.

    UK guidance on diagnosis of ovarian cancer: its impact on services in an acute hospital. European Cancer Congress; Amsterdam; Sept 29, 2013. 3098

  • C Gerada et al.

    The 2022 GP—a vision for general practice in the future NHS

    (2012)
  • HL Neville-Webbe et al.

    The impact of a new acute oncology service in acute hospitals: experience from the Clatterbridge Cancer Centre and Merseyside and Cheshire Cancer Network

    Clin Med

    (2013)
  • SJ Sammut et al.

    Management of febrile neutropenia in an acute oncology service

    QJM

    (2012)
  • CG80 Early and locally advanced breast cancer: diagnosis and treatment

    (2009)
  • E Senkus et al.

    Primary breast cancer: ESMO clinical practice guidelines for diagnosis, treatment and follow-up

    Ann Oncol

    (2013)
  • Major resections by cancer site, in England; 2006 to 2010

    (2014)
  • LF Forrest et al.

    The role of receipt and timeliness of treatment in socioeconomic inequalities in lung cancer survival: population-based, data-linkage study

    Thorax

    (2015)
  • Framework for professional and administrative development of general practice/family medicine in Europe

    (1998)
  • SH Taplin et al.

    Teams and teamwork during a cancer diagnosis: interdependency within and between teams

    J Oncol Pract

    (2015)
  • B Starfield et al.

    Contribution of primary care to health systems and health

    Milbank Q

    (2005)
  • N Goodwin et al.

    Improving the quality of care in general practice

    (2011)
  • DJ Hunter et al.

    Noncommunicable diseases

    N Engl J Med

    (2013)
  • J Smith et al.

    Securing the future of general practice—new models of primary care

    (2013)
  • SW Mercer et al.

    The inverse care law: clinical primary care encounters in deprived and affluent areas of Scotland

    Ann Fam Med

    (2007)
  • SM Crawford et al.

    Social and geographical factors affecting access to treatment of lung cancer

    Br J Cancer

    (2009)
  • E van Doorslaer et al.

    Inequalities in access to medical care by income in developed countries

    CMAJ

    (2006)
  • RH Glazier et al.

    Universal health insurance and equity in primary care and specialist office visits: a population-based study

    Ann Fam Med

    (2009)
  • M White et al.

    How and why do interventions that increase health overall widen inequalities within populations?

  • LF Forrest et al.

    Factors associated with timeliness of post-primary care referral, diagnosis and treatment for lung cancer: population-based, data-linkage study

    Br J Cancer

    (2014)
  • Cited by (0)

    View full text