Primary care doctors are ill-prepared to deal with growing demand for cancer care

The major new The Lancet Oncology Commission, led by Greg Rubin, Professor of General Practice and Primary Care at Durham University in the UK, and until recently the first ever Clinical Lead for Cancer for the RCGP, states that with governments increasingly turning to primary care to play a larger role in health care, the grand challenge is how to equip doctors to fulfill this role effectively for cancer.

"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. However, with the growing emphasis in recent years on early diagnosis and on the patient experience during and after treatment, the vital role of primary care doctors has become clear," says Professor Rubin.

He adds, "With an aging population and a rapidly increasing number of cancer survivors, the primary care cancer workload will increase substantially over the next 10 years. Our challenge is how to prepare primary care doctors as the cornerstone in prevention, early detection, survivorship, and palliative care."

Half of all people diagnosed with cancer now live for at least 10 years after diagnosis, up from just a quarter in the 1970s. By 2030, the number of cancer survivors in the UK is predicted to double from 2 million to 4 million. In the Netherlands, the number of survivors is expected to increase by around 61% between 2010 and 2020.

People with cancer and their families want care that is accessible, close to home, continuous, and coordinated--with a seamless journey between different care settings such as primary care practices, hospitals, cancer centres, and palliative care services. Yet, surprisingly, in many countries primary care doctors have no formal role either during treatment or in the after care of people with cancer, and are often bypassed when palliative care is required.

The Commission calls for much more effective integration between primary and specialist (hospital) care. Evidence from the USA shows that long-term cancer survivors who see both primary care doctors and oncologists are more likely to receive the full array of care they need. Other research done in the UK, Canada, and Australia reports that integrated after care of cancer survivors improved patient satisfaction, with no differences in recurrence or survival, and at lower cost.

The authors point out that while demand for cancer care is predicted to increase by 40% over the next 20 years, the number of oncologists is only expected to grow by 25%. "It is too simplistic to assume that providing more oncologists is the solution," says Professor Rubin. "It is the way that health care providers work together that holds the key to meeting this need. Hospitals, primary care doctors, and other community partners need to be better coordinated for after care, survivorship, and end of life care, so that patients receive good quality care, outcomes improve, and inequalities are reduced."

The authors identify a range of measures that need to be introduced to better integrate primary and secondary care, and to ensure that primary care doctors have the necessary information and skills to fulfill their critical role in cancer care. These include: better access to diagnostic tests undepinned by comprehensive guidelines; improved education and support (information and skills); new models of shared care between primary care and oncology; greater communication with specialists and easy referral back to hospital care; and robust monitoring systems for detecting recurrence and the adverse effects of treatments.

Delay in patients visiting their primary care doctors has been identified as a cause of poor cancer outcomes. Proposed solutions include implementing public awareness campaigns, one example being a lung cancer awareness campaign in England with the strapline, "Been coughing for three weeks or more? Tell your doctor," which led to a 67% increase in people of all ages visiting their primary care doctors with a cough. The Commission emphasises that it is also vital to ensure that high quality primary care is available, affordable, trusted, and valued by the public.

Diagnosing cancer can be difficult in primary care as people can present with symptoms of cancer that can also be caused by other, much less serious, conditions. With around 90% of people with cancer first presenting with symptoms in primary care, doctors also need better technology and access to electronic decision support to help them confidently diagnose more cancers at an earlier stage and ultimately save more lives.

Improving medical education in cancer is also essential, say the authors. "Curricula at undergraduate and specialty training level need to be reviewed to ensure they are fit for purpose, and, primary care practitioners need to take the lead in ensuring that they, and the doctors and nurses of the future, are adequately prepared for managing people with cancer," says Professor Rubin. In the UK, for example, cancer has been made the first of the RCGP's "enduring priorities," for which it is developing educational resources for trainees and GPs, such as the Cancer Education Hub.

According to Professor Rubin, "Primary care doctors are expert generalists who provide continuous and comprehensive care to patients and their families, and do this in the context of the patient's social and domestic circumstances. As such they have much to offer people with cancer, and should be enabled to do so."