Where does primary care fit into the escalating cancer challenge?

Kelsall_Diane_01 croppedDiane Kelsall is Deputy Editor at CMAJ, and Editor of CMAJ Open. She's currently attending the 2015 Cancer and Primary Care Research International Network (Ca-PRI) conference, in Aarhus, Denmark.

 

Primary care researchers from around the world have gathered in the Danish city of Aarhus, May 20-22, 2015, to discuss the latest primary care research on cancer. In the context of the rising incidence of cancer, the big question of the conference is: where does primary care fit into this picture? At this conference, the question includes the roles of primary care clinicians, policy makers designing health care systems and primary care researchers.

Dr. Frede Olesen from the host university, Aarhus University, took participants through the complete trajectory of cancer: from prevention, screening, early diagnosis, treatment and care after treatment, and for those patients in which the disease progresses, through palliative care and care of grieving relations.

Olesen highlighted several areas where primary care research is especially valuable and needed. These included prevention (a shared agenda with public health), early diagnosis (particularly organization of care to reduce time to diagnosis) and after-treatment care (who follows patient after treatment: family physician or oncologist?) He also noted that about 80% of patients with end-stage cancer prefer to die at home and questioned how hospital-based palliative teams help patients to do this, rather than a focus on family physicians and local district nurses.

Olesen emphasized that understanding the perspective of the patient is very important at all these steps. Several tools are being used to look into this, including patient-recorded observations and patient-recorded experiences. He summarized his talk by saying that we need to relook at the effect of the "doctor drug" (i.e., the effect of the primary care physician) and perhaps redefine where and how it is used in care for patients with cancer.

Mr. Jes Sogaard, a health economist from Aalborg University, looked at the challenge of the rising incidence in cancer. The main driver of this increase is likely the aging population, and will lead to increased demands for cancer care. How much additional capacity is needed? At what cost? What should it look like? And most importantly, can our health services deliver?

He described recent work in cost modelling that showed that the demands for care will likely be proportionately less than the increased incidence in cancer, mainly because of decreased intensity of treatment in older patients. He cautioned, however, that incidence-based needs may account for less than half of the increase in treatment needs and costs, because of new treatment paradigms and technologies. Health systems may be able to cope, but restructuring will be needed to ensure that resources are being employed where needed.

Prof Greg Rubin from Durham University in the UK focused his talk on early detection of cancer in the future. Time to early detection varies considerably by jurisdiction and is affected by many factors, including health care organization and patient factors. For some cancers such as melanoma, patients may have multiple doctor visits before referral. Family physicians may inadvertently delay timely referral by investigating suspicious symptoms in primary care--where they may not have preferential access to investigations. There are for-profit companies who are offering 24-hour access to investigating for cancer. Changes in referral thresholds (such as those likely to be proposed by NICE in the UK) also affect time to early detection. Patients may not recognize their symptoms as worrisome, or if they do, may not want to "bother" the physician or may not want to find out if they do have cancer.

Because of all these factors, any interventions to improve time to early detection will need to be multifactorial. Rubin called for a shift in thinking of suspicious symptoms as a trigger for referral and investigation, rather than as a filter. An effective program will likely require some of the following: direct/rapid access to referral; proactive program for patients at high-risk of cancer; a pathway for vague symptoms; multidisciplinary diagnostic centres; increased role for non-MD primary care providers; a lower referral threshold; and the possibility of self-referral to reduce barriers for patients.

Additional talks focused on the role of primary care physicians in several critical areas. Surgeon Amtul Razzaq Carmichael looked at the importance of patients maintaining physical activity during and after treatment for breast cancer. Woman who exercise regularly before diagnosis and continue to exercise have a survival advantage. Dr. Yvonne Engels addressed the need for family physicians to be involved in anticipatory palliative care, as timely palliative care improves quality of life for patients, reduces the likelihood of depression and improves survival.

Posters, talks, symposiums and workshops also looked at research into screening, early detection, treatment, survivorship and palliation. The role of primary care in cancer may not be well defined as yet, but the Ca-PRI conference clearly shows that there is high quality primary care research being undertaken in this area and commitment by so many to improving the care of patients with cancer.

CAPRI

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