A Plan for Primary Care to Help With Rising Cancer Demand

Liam Davenport

October 01, 2015

With a projected shortfall of oncologists and a doubling in the number of cancer survivors in some high-income countries by 2030, primary care clinicians will be increasingly relied upon to play a larger role in cancer care, says a major new commission composed of experts from North America, Europe, and Australia.

The group's report was published online in Lancet Oncology September 30 and will be presented at the Royal College of General Practitioners annual congress in Glasgow, United Kingdom, on October 2.

The document sets out a series of proposals to improve the integration of care and better equip primary care physicians to identify and follow cancer patients.

Primary care has a lot to offer cancer control and treatment efforts, said the group's leader, Greg Rubin, MD, professor of general practice and primary care, Durham University, UK.

"Cancer control in high-income countries has mainly focused on highly technical treatments intended to save or prolong life, while the contribution of primary care has been seen as marginal," said Dr Rubin in a press statement.

There has been a "growing emphasis" in recent years on early diagnosis and the patient experience during and after treatment, he said, adding that "the vital role of primary care doctors has become clear" in that time

 
The vital role of primary care doctors has become clear. Dr Greg Rubin
 

Primary care physicians need to become cornerstones in prevention, early detection, survivorship, and palliative care, said Dr Rubin.

Dr Rubin told Medscape Medical News that urgent action is needed because "survivorship is increasing as we speak."

For example, the number of survivors in the Netherlands is predicted to increase by around 60% from 2010 to 2020. "That's a substantial change," he said.

The new report is based on cancer data in primary care and community care settings from Canada, Australia, and most of Northern Europe, as well as expert opinion.

The authors of the report found that approximately half of all cancer patients currently survive at least 10 years, compared with a quarter of those diagnosed during the 1970s.

It estimated that in the UK alone, the number of survivors will have doubled from today's figures to 4 million.

The demand for cancer care is predicted to increase by 40% during the next 20 years, whereas the number of oncologists will grow by only 25%. At the same time, patients want care that is close to home and that is coordinated between primary care, hospitals, cancer settings, and palliative care services.

"It is too simplistic to assume that providing more oncologists is the solution," Dr Rubin commented in a release. "It is the way that healthcare providers work together that holds the key to meeting this need."

 
It is too simplistic to assume that providing more oncologists is the solution. Dr Greg Rubin
 

To improve integration between primary and secondary care, the authors of the report propose a series of measures to ensure that primary care physicians have the necessary information and skills to have an active role in cancer care. These include the following:

  • Better access to diagnostic tests recommended by comprehensive guidelines

  • Improved education and support

  • New models of shared care between primary care and oncology

  • Greater communication with specialists and easy referral back to hospital care

  • Robust monitoring systems to detect recurrence and the adverse treatment effects

Dr Rubin highlighted the fact that there was a notable degree of variation in the way in which primary and specialist care work together in the high-income countries that they analyzed.

"What we see are examples in some places of how that might be achieved, and I think the Canadians have probably given more thought to this than is apparent in other parts of the world," he said.

The UK also has admirable iniatives in early cancer diagnosis "that are starting to prompt greater integration between primary and secondary care," Dr Rubin added.

However, a recent report outlined the difficulties of detecting advanced lung cancer in primary care in the UK, as reported by Medscape Medical News.

Improved education is singled out in the report as the long-term key to improving primary care performance.

Over the shorter term, physicians need tools to support their decision making so that they can make "sense of symptoms that often have low predictive values in themselves but in combination may require investigation."

More efficient use of the currently available facilities is important as well. "It is about making the facilities available for a wider range of patients, in particular, patients where they don't have 'barn door' alarm symptoms but where the GP has a suspicion that the person may have cancer," Dr Rubin said.

Denmark has been a leader in creating facilities where patients with less obvious cancer symptoms can be sent by the general practitioner for investigation.

Another area of concern is that of palliative care.

"It's very important to patients, of course, who want to die at home, and they want to die in comfort," he said, adding: "I think it's done pretty well in this country in primary care compared to some other countries, but there's no doubt that there are issues to do with availability of your usual primary care physician and palliative care teams."

Will all of these plans eventually be cost-effective?

"I think that it is cost-effective," Dr Rubin replied. "There is some evidence of the cost neutrality for shared care or transfer of care from secondary care for breast cancer follow-up, but that's a relatively limited example."

Resources may need to be moved around ― rather than increased ― to facilitate a more integrated model, he added.

Sean Duffy, national clinical director for cancer at National Health Service (NHS) England and senior lecturer consultant in obstetrics and gynecology at the University of Leeds, welcomed the new report.

He told Medscape Medical News: "More people are surviving cancer than ever before, but we know we can and must do better."

For example, NHS England is working with general practitioners and primary care providers on improvements in cancer care with the goal of increasing survival.

"Early diagnosis is one of the most important factors in improving cancer survival ― it is critical that patients spot symptoms early and GPs make sure they are sent for diagnostic tests quickly," he said.

Dr Rubin has financial ties with Medx and Eli Lilly. Three coauthors report ties with various pharmaceutical companie.

Lancet Oncol. 2015:16:1231-72. Abstract

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