Domhnall MacAuley is an associate editor on CMAJ, currently at the The Cancer and Primary Care Research International Network (Ca-PRI) conference in Winnipeg
Cancer is now a major primary care research area, which is reflected in the increasing importance and impact of the Ca-PRI conference. David Weller (UK) described it as a "boutique conference", but it won’t be for much longer. Cancer has long been the preserve of specialists focused mostly on treatment, and epidemiologists analysing data principally from registries. Sick patients and sad stories tend to attract greatest sympathy, research interest, and funding. Cancer diagnostic research in primary care is difficult, the symptoms are often completely undifferentiated and it’s hard to pick up the clues in a context where most patients don’t have cancer.
Late cancer diagnosis concerns physicians and patients alike but measuring delay in diagnosis is not easy. We need to use agreed definitions and Jaim Sutton (UK) in her systematic review of studies on ovarian and colorectal cancer, identified considerable variation within in the broad categories of patient interval, primary care interval and diagnostic interval, definitions used in the Aarhus consensus statement. For future research to be meaningful, we need to use agreed definitions.
Willie Hamilton (UK) pointed out a huge knowledge gap where delay in diagnosis is concerned: there are time lines for cellular growth, and there are time lines for symptom development but we don’t know how they are connected. These differ between cancers and cancer site and, as Knut Holtedahl (Norway) reminded us, more aggressive cancers are easier to diagnose.
Greg Rubin (UK) presented data showing improvements in speed of diagnosis of cancer in primary care in the UK in response to the National Awareness and Early Diagnosis Initiative. There were some small but significant improvements in practices that used at least one of the following: significant event analysis, practice audit, risk assessment and a practice plan. This against a background of considerable systems-change. Similarly, Henry Jensen (Denmark) showed improvement with standardised cancer patient pathways. But, many patients don’t quite fit within the criteria relevant to the UK two week rule or the Danish pathway—many tend to have serious and vague symptoms that are not necessarily indicative of cancer. Greg Rubin (UK) suggested, in the subsequent discussion, that we may need to create diagnostic centres for those who don’t quite fit. And, as pointed out by a patients’ representative in the audience, it is also difficult for patients to know when to go to the doctor.
Looking at the wider aspect of preventive care, Eva Grunfeld (Toronto), in her keynote address, told us about the BETTER trial, a cluster randomised factorial controlled trial that enrolled 800 patients across Canada in primary care. The trial was conducted in good practices but there was still room for improvement. The core intervention was that patients were given a preventive prescription, and it was unique in that it addressed chronic diseases with a facilitator already in the practices. It was effective and, interestingly, it was also effective in patients who had who had mental health problem—an often hard-to-reach group. While the economic evaluation identified costs, the practices also gained incentive payments. Now that trial has been shown to be effective the team are looking at dissemination and "adaption for adoption". The programme has already been taken up in the North West Territories.
A particularly successful conference innovation was a session including ten 3-minute presentations to the full conference audience. No introduction, no moderation, just a time keeper. Great presentations across the spectrum of cancer care from sophisticated diagnostic models in developing countries to hugely contrasting diagnostic challenges with extraordinary delay in the developing world. And some fascinating insights. There is major projected shortfall in oncologists in the US as a result of increasing cancer survivorship. And, in a systematic review of cancer mobile apps, one of the authors' major tasks was excluding those apps identified in the search strategy, that were created for astrology!
Click for a link to the conference program