Key Points
-
Primary care providers have an increasingly important role in oncological services, particularly as the 'gatekeepers' to hospital-led services for the diagnosis and treatment of cancer
-
As cancer screening improves, primary care has a pivotal role in facilitating uptake, which can be enhanced using audit and feedback systems, office prompt systems and general practitioner endorsement
-
The epidemiology of cancer symptoms in primary care is becoming better understood, and risk models can be applied to identify patients requiring investigation for cancer
-
Fast-track referral routes might be a useful approach to reducing diagnostic delay in cancer, especially in health-care systems with long waiting times for out-patient diagnostic services
-
Primary care-led follow-up of breast and colorectal cancer is as effective as hospital-led care, but requires clear guidance for general practitioners, as well as good communication and access to specialists
Abstract
Primary care providers have important roles across the cancer continuum, from encouraging screening and accurate diagnosis to providing care during and after treatment for both the cancer and any comorbid conditions. Evidence shows that higher cancer screening participation rates are associated with greater involvement of primary care. Primary care providers are pivotal in reducing diagnostic delay, particularly in health systems that have long waiting times for outpatient diagnostic services. However, so-called fast-track systems designed to speed up hospital referrals are weakened by significant variation in their use by general practitioners (GPs), and affect the associated conversion and detection rates. Several randomized controlled trials have shown primary care-led follow-up care to be equivalent to hospital-led care in terms of patient wellbeing, recurrence rates and survival, and might be less costly. For primary care-led follow-up to be successful, appropriate guidelines must be incorporated, clear communication must be provided and specialist care must be accessible if required. Finally, models of long-term cancer follow-up are needed that provide holistic care and incorporate management of co-morbid conditions. We discuss all these aspects of primary care, focusing on the most common cancers managed at the GP office—breast, colorectal, prostate, lung and cervical cancers.
This is a preview of subscription content, access via your institution
Access options
Subscribe to this journal
Receive 12 print issues and online access
$209.00 per year
only $17.42 per issue
Buy this article
- Purchase on Springer Link
- Instant access to full article PDF
Prices may be subject to local taxes which are calculated during checkout
Similar content being viewed by others
References
Taplin, S. H. & Rodgers, A. B. Toward improving the quality of cancer care: addressing the interfaces of primary and oncology-related subspecialty care. J. Natl Cancer Inst. Monogr. 2010, 3–10 (2010).
Macinko, J., Starfield, B. & Shi, L. The contribution of primary care systems to health outcomes within Organization for Economic Cooperation and Development (OECD) countries, 1970–1998. Health Serv. Res. 38, 831–865 (2003).
National Public Health Partnership. Preventing Chronic Disease: a Strategic Framework [online], (2001).
Taplin, S. H., Clauser, S., Rodgers, A. B., Breslau, E. & Rayson, D. Interfaces across the cancer continuum offer opportunities to improve the process of care. J. Natl Cancer Inst. Monogr. 2010, 104–110 (2010).
Zapka, J. G., Taplin, S. H., Solberg, L. I. & Manos, M. M. A framework for improving the quality of cancer care: the case of breast and cervical cancer screening. Cancer Epidemiol. Biomarkers Prev. 12, 4–13 (2003).
Arroyave, A. M., Penaranda, E. K. & Lewis, C. L. Organizational change: a way to increase colon, breast and cervical cancer screening in primary care practices. J. Community Health 36, 281–288 (2011).
Bonfill, X., Marzo, M., Pladevall, M., Marti, J. & Emparanza, I. Strategies for increasing women participation in community breast cancer screening. Cochrane Database of Systematic Reviews, Issue 1. Art. No.: CD002943. http://dx.doi.org/10.1002/14651858.CD002943.
Ellis, P. et al. Diffusion and dissemination of evidence-based cancer control interventions. Evid. Rep. Technol. Assess. (Summ.) 79, 1–5 (2003).
Everett, T. et al. Interventions targeted at women to encourage the uptake of cervical screening. Cochrane Database of Systematic Reviews, Issue 5. Art. No.: CD002834. http://dx.doi.org/10.1002/14651858.CD002834.pub2 (2011).
Sabatino, S. A. et al. Interventions to increase recommendation and delivery of screening for breast, cervical, and colorectal cancers by healthcare providers: systematic reviews of provider assessment and feedback and provider incentives. Am. J. Prev. Med. 35 (Suppl.), S67–S74 (2008).
Brawarsky, P., Brooks, D. R., Mucci, L. A. & Wood, P. A. Effect of physician recommendation and patient adherence on rates of colorectal cancer testing. Cancer Detect. Prev. 28, 260–268 (2004).
Cole, S. R. et al. An advance notification letter increases participation in colorectal cancer screening. J. Med. Screen. 14, 73–75 (2007).
Irwig, L., Turnbull, D. & McMurchie, M. A randomized trial of general practitioner-written invitations to encourage attendance at screening mammography. Community Health Stud. 14, 357–364 (1990).
Lantz, P. M. et al. Breast and cervical cancer screening in a low-income managed care sample: the efficacy of physician letters and phone calls. Am. J. Public Health 85, 834–836 (1995).
O'Brien, M. A. et al. Are cancer-related decision aids effective? A systematic review and meta-analysis. J. Clin. Oncol. 27, 974–985 (2009).
Thomson O'Brien, M. A. et al. Audit and feedback versus alternative strategies: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews, Issue 2. Art. No.: CD000260. http://dx.doi.org/10.1002/14651858.CD000260 (2000).
Kupets, R. & Covens, A. Strategies for the implementation of cervical and breast cancer screening of women by primary care physicians. Gynecol. Oncol. 83, 186–197 (2001).
Shea, S., DuMouchel, W. & Bahamonde, L. A meta-analysis of 16 randomized controlled trials to evaluate computer-based clinical reminder systems for preventive care in the ambulatory setting. J. Am. Med. Inform. Assoc. 3, 399–409 (1996).
Snell, J. L. & Buck, E. L. Increasing cancer screening: a meta-analysis. Prev. Med. 25, 702–707 (1996).
Balas, E. A. et al. Improving preventive care by prompting physicians. Arch. Intern. Med. 160, 301–308 (2000).
Kinsinger, L. S., Harris, R., Qaqish, B., Strecher, V. & Kaluzny, A. Using an office system intervention to increase breast cancer screening. J. Gen. Intern. Med. 13, 507–514 (1998).
Lemelin, J., Hogg, W. & Baskerville, N. Evidence to action: a tailored multifaceted approach to changing family physician practice patterns and improving preventive care. CMAJ 164, 757–763 (2001).
Jepson, R. et al. The determinants of screening uptake and interventions for increasing uptake: a systematic review. Health Technol. Assess. 4, 1–133 (2000).
Shekelle, P. G. et al. Interventions that increase the utilization of Medicare-funded preventive services for persons age 65 and older. Evidence report/technology assessment publication no HCFA-02151. Baltimore, MD: Southern California Evidence-Based Practice Center/RAND. Report No.: HCFA Publication No.: HCFA-02151 (1999).
Binstock, M. A., Geiger, A. M., Hackett, J. R. & Yao, J. F. Pap smear outreach: a randomized controlled trial in an HMO. Am. J. Prevent. Med. 13, 425–426 (1997).
Herman, C. J., Speroff, T. & Cebul, R. D. Improving compliance with breast cancer screening in older women: results of a randomized controlled trial. Arch. Intern. Med. 155, 717–722 (1995).
Mohler, P. J. Enhancing compliance with screening mammography recommendations: a clinical trial in a primary care office. Fam. Med. 27, 117–121 (1995).
Williams, R. B., Boles, M. & Johnson, R. E. A patient-initiated system for preventive health care. A randomised trial in community-based primary care practices. Arch. Fam. Med. 7, 338–345 (1998).
Belcher, D. W. Implementing preventive services. Success and failure in an outpatient trial. Arch. Intern. Med. 150, 2533–2541 (1990).
Krogsbøll, L. T., Jørgensen, K. J., Grønhøj Larsen, C. & Gøtzsche, P. C. General health checks in adults for reducing morbidity and mortality from disease. Cochrane Database of Systematic Reviews, Issue 10. Art No.: CD009009. http://dx.doi.org/10.1002/14651858.CD009009.pub2.
Reid, G. S. et al. Cervical screening in Perth and Kinross since introduction of the new contract. BMJ 303, 447–450 (1991).
Grady, K. E., Lemkau, J. P., Lee, N. R. & Caddell, C. Enhancing mammography referral in primary care. Prevent. Med. 26, 791–800 (1997).
Hillman, A. L. et al. Physician financial incentives and feedback: failure to increase cancer screening in Medicaid managed care. Am. J. Public Health 88, 1699–1701 (1998).
Doran, T. et al. Effect of financial incentives on incentivised and non-incentivised clinical activities: longitudinal analysis of data from the UK Quality and Outcomes Framework. BMJ 342, d3590 (2011).
Clementz, G. L., Aldag, J. C., Gladfelter, T. T., Barclay, A. M. & Brooks, H. F. A randomized study of cancer screening in a family practice setting using a recall model. J. Fam. Pract. 30, 537–541 (1990).
Bowman, J., Sanson-Fisher, R., Boyle, C., Pope, S. & Redman, S. A randomised controlled trial of strategies to prompt attendance for a Pap smear. J. Med. Screen. 2, 211–218 (1995).
Atri, J. et al. Improving uptake of breast screening in multiethnic populations: a randomised controlled trial using practice reception staff to contact non-attenders. BMJ 315, 1356–1359 (1997).
Ward, J. E., Boyle, K., Redman, S. & Sanson-Fisher, R. W. Increasing women's compliance with opportunistic cervical cancer screening: a randomized trial. Am. J. Prevent. Med. 7, 285–291 (1991).
Hewitson, P., Ward, A. M., Heneghan, C., Halloran, S. P. & Mant, D. Primary care endorsement letter and a patient leaflet to improve participation in colorectal cancer screening: results of a factorial randomised trial. Br. J. Cancer 105, 475–480 (2011).
Zajac, I. T. et al. Endorsement by the primary care practitioner consistently improves participation in screening for colorectal cancer: a longitudinal analysis. J. Med. Screen. 17, 19–24 (2010).
Wishart, G. C. et al. Screen-detected vs symptomatic breast cancer: is improved survival due to stage migration alone? Br. J. Cancer 98, 1741–1744 (2008).
Hamilton, W. Five misconceptions in cancer diagnosis. Br. J. Gen. Pract. 59, 441–445 (2009).
Zarchy, T. M. & Ershoff, D. Which clinical variables predict an abnormal double-contrast barium enema result? Ann. Intern. Med. 114, 137–141 (1991).
Jellema, P. et al. Value of symptoms and additional diagnostic tests for colorectal cancer in primary care: systematic review and meta-analysis. BMJ 340, c1269 (2010).
Hamilton, W. The CAPER studies: five case-control studies aimed at identifying and quantifying the risk of cancer in symptomatic primary care patients. Br. J. Cancer 101 (Suppl. 2), S80–S86 (2009).
Hamilton, W. et al. The importance of anaemia in diagnosing colorectal cancer: a case-control study using electronic primary care records. Br. J. Cancer 98, 323–327 (2008).
Hamilton, W. et al. The risk of colorectal cancer with symptoms at different ages and between the sexes: a case-control study. BMC Med. 7, 17 (2009).
Hamilton, W., Peters, T. J., Bankhead, C. & Sharp, D. Risk of ovarian cancer in women with symptoms in primary care: population based case-control study. BMJ 339, b2998 (2009).
Hamilton, W., Peters, T. J., Round, A. & Sharp, D. What are the clinical features of lung cancer before the diagnosis is made? A population based case-control study. Thorax 60, 1059–1065 (2005).
Hamilton, W., Round, A., Sharp, D. & Peters, T. J. Clinical features of colorectal cancer before diagnosis: a population-based case-control study. Br. J. Cancer 93, 399–405 (2005).
Hamilton, W., Sharp, D. J., Peters, T. J. & Round, A. P. Clinical features of prostate cancer before diagnosis: a population-based, case-control study. Br. J. Gen. Pract. 56, 756–762 (2006).
Hippisley-Cox, J. & Coupland, C. Identifying patients with suspected lung cancer in primary care: derivation and validation of an algorithm. Br. J. Gen. Pract. 61, e715–e723 (2011).
Hippisley-Cox, J. & Coupland, C. Identifying patients with suspected colorectal cancer in primary care: derivation and validation of an algorithm. Br. J. Gen. Pract. 62, e29–e37 (2012).
Hippisley-Cox, J. & Coupland, C. Symptoms and risk factors to identify women with suspected cancer in primary care: derivation and validation of an algorithm. Br. J. Gen. Pract. 63, e11–e21 (2013).
Hippisley-Cox, J. & Coupland, C. Symptoms and risk factors to identify men with suspected cancer in primary care: derivation and validation of an algorithm. Br. J. Gen. Pract. 63, e1–e10 (2013).
Emery, J. Assessment of cancer risk in men and women. Br. J. Gen. Pract. 63, 4–5 (2013).
Collins, G. S. & Altman, D. G. Identifying patients with undetected colorectal cancer: an independent validation of QCancer (Colorectal). Br. J. Cancer 107, 260–265 (2012).
Astin, M., Griffin, T., Neal, R. D., Rose, P. & Hamilton, W. The diagnostic value of symptoms for colorectal cancer in primary care: a systematic review. Br. J. Gen. Pract. 61, e231–e243 (2011).
Olde Bekkink, M. et al. Diagnostic accuracy systematic review of rectal bleeding in combination with other symptoms, signs and tests in relation to colorectal cancer. Br. J. Cancer 102, 48–58 (2010).
Shapley, M., Mansell, G., Jordan, J. L. & Jordan, K. P. Positive predictive values of ≥5% in primary care for cancer: systematic review. Br. J. Gen. Pract. 60, e366–e377 (2010).
McCowan, C., Donnan, P. T., Dewar, J., Thompson, A. & Fahey, T. Identifying suspected breast cancer: development and validation of a clinical prediction rule. Br. J. Gen. Pract. 61, e205–e214 (2011).
Barton, M. B., Elmore, J. G. & Fletcher, S. W. Breast symptoms among women enrolled in a health maintenance organization: frequency, evaluation, and outcome. Ann. Intern. Med. 130, 651–657 (1999).
Bywaters, J. The incidence and management of female breast disease in a general practice. J. R. Coll. Gen. Pract. 27, 353–357 (1977).
Eberl, M. M., Phillips, R. L. Jr, Lamberts, H., Okkes, I. & Mahoney, M. C. Characterizing breast symptoms in family practice. Ann. Fam. Med. 6, 528–533 (2008).
Jones, R., Latinovic, R., Charlton, J. & Gulliford, M. C. Alarm symptoms in early diagnosis of cancer in primary care: cohort study using General Practice Research Database. BMJ 334, 1040 (2007).
Young, J. M., Muscatello, D. J. & Ward, J. E. Are men with lower urinary tract symptoms at increased risk of prostate cancer? A systematic review and critique of the available evidence. BJU Int. 85, 1037–1048 (2000).
Bruyninckx, R., Buntinx, F., Aertgeerts, B. & Van Casteren, V. The diagnostic value of macroscopic haematuria for the diagnosis of urological cancer in general practice. Br. J. Gen. Pract. 53, 31–35 (2003).
UK Department of Health, Health Service Circulars. HSC2000/013 Referral guidelines for suspected cancer [online], (2000).
Meechan, D. et al. Variation in use of the 2-week referral pathway for suspected cancer: a cross-sectional analysis. Br. J. Gen. Pract. 62, e590–e597 (2012).
Lewis, R. et al. A systematic review of cancer waiting time audits. Qual. Saf. Heath Care 14, 62–66 (2005).
Thorne, K., Hutchings, H. A. & Elwyn, G. The effects of the two-week rule on NHS colorectal cancer diagnostic services: a systematic literature review. BMC Health Serv. Res. 6, 43 (2006).
Barraclough, K. Diagnosis: shifting the ROC curve. Br. J. Gen. Pract. 62, 452–453 (2012).
Tørring, M. L. et al. Time to diagnosis and mortality in colorectal cancer: a cohort study in primary care. Br. J. Cancer 104, 934–940 (2011).
Vedsted, P. & Olesen, F. Are the serious problems in cancer survival partly rooted in gatekeeper principles? An ecologic study. Br. J. Gen. Pract. 61, e508–e512 (2011).
Mansell, G., Shapley, M., Jordan, J. L. & Jordan, K. Interventions to reduce primary care delay in cancer referral: a systematic review. Br. J. Gen. Pract. 61, e821–e835 (2011).
Cockburn, J., Pit, S., Zorbas, H. & Redman, S. Investigating breast symptoms in primary care: enhancing concordance with current best advice. Cancer Detect. Prevent. 25, 407–413 (2001).
Jiwa, M. et al. Implementing referral guidelines: lessons from a negative outcome cluster randomised factorial trial in general practice. BMC Fam. Pract. 7, 65 (2006).
Logan, E. C., Yates, J. M., Stewart, R. M., Fielding, K. & Kendrick, D. Investigation and management of iron deficiency anaemia in general practice: a cluster randomised controlled trial of a simple management prompt. Postgrad. Med. J. 78, 533–537 (2002).
Wolters, R., Wensing, M., Van Weel, C. & Grol, R. The effect of a distance-learning programme on patient self-management of lower urinary tract symptoms (LUTS) in general practice: a randomised controlled trial. Eur. Urol. 46, 95–101 (2004).
Khan, N. F. Implementation of a diagnostic tool for symptomatic colorectal cancer in primary care: a feasibility study. Prim. Health Care Res. Dev. 10, 54–64 (2009).
Lewis, R. A. et al. Follow-up of cancer in primary care versus secondary care: systematic review. Br. J. Gen. Pract. 59, e234–e247 (2009).
Montgomery, D. A., Krupa, K. & Cooke, T. G. Alternative methods of follow up in breast cancer: a systematic review of the literature. Br. J. Cancer 96, 1625–1632 (2007).
Grunfeld, E. et al. Routine follow up of breast cancer in primary care: randomised trial. BMJ 313, 665–669 (1996).
Grunfeld, E. et al. Follow-up of breast cancer in primary care vs specialist care: results of an economic evaluation. Br. J. Cancer 79, 1227–1233 (1999).
Grunfeld, E. et al. Randomized trial of long-term follow-up for early-stage breast cancer: a comparison of family physician versus speciality care. J. Clin. Oncol. 24, 848–855 (2006).
Wattchow, D. A. et al. General practice vs surgical-based follow-up for patients with colon cancer: randomised controlled trial. Br. J. Cancer 94, 1116–1121 (2006).
Aubin, M. et al. Interventions to improve continuity of care in the follow-up of patients with cancer. Cochrane Database of Systematic Reviews, Issue 7. Art. No.: CD007672. http://dx.doi.org/10.1002/14651858.CD007672.pub2.
Jefford, M. et al. Tailored chemotherapy information faxed to general practitioners improves confidence in managing adverse effects and satisfaction with shared care: results from a randomised controlled trial. J. Clin. Oncol. 26, 2272–2277 (2008).
Nielsen, J. D., Palshof, T., Mainz, J., Jensen, A. B. & Olesen, F. Randomised controlled trial of a shared care programme for newly referred cancer patients: bridging the gap between general practice and hospital. Qual. Saf. Health Care 12, 263–272 (2003).
Gysels, M., Richardson, A. & Higginson, I. J. Does the patient-held record improve continuity and related outcomes in cancer care: a systematic review. Health Expect. 10, 75–91 (2007).
Williams, J. G. et al. Pragmatic randomised trial to evaluate the use of patient held records for the continuing care of patients with cancer. Qual. Health Care 10, 159–165 (2001).
McCabe, M. S. et al. American Society of Clinical Oncology statement: achieving high-quality cancer survivorship care. J. Clin. Oncol. 31, 631–640 (2013).
Grunfeld, E. et al. Evaluating survivorship care plans: results of a randomized, clinical trial of patients with breast cancer. J. Clin. Oncol. 29, 4755–4762 (2011).
Jefford, M., Schofield, P. & Emery, J. Improving survivorship care. J. Clin. Oncol. 30, 1391–1392 (2012).
Khan, N., Ward, A., Watson, E., Austoker, J. & Rose, P. Long-term survivors of adult cancers and uptake of primary health services: a systematic review. Eur. J. Cancer 44, 195–204 (2008).
Earle, C. C., Burnstein, H. J., Winer, E. P. & Weeks, J. C. Quality of non-breast cancer health maintenance among elderly breast cancer survivors. J. Clin. Oncol. 21, 1447–1451 (2003).
Bellizzi, K. M., Rowland, J. H., Jeffery, D. D. & McNeel, T. Health behaviors of cancer survivors: examining opportunities for cancer control intervention. J. Clin. Oncol. 23, 8884–8893 (2005).
Earle, C. C. & Neville, B. A. Under use of necessary care among cancer survivors. Cancer 101, 1712–1719 (2004).
Lewis, R. A. et al. Patients' and healthcare professionals' views of cancer follow-up: systematic review. Br. J. Gen. Pract. e248–e259 (2009).
Aubin, M. et al. Family physician involvement in cancer care follow-up: the experience of a cohort of patients with lung cancer. Ann. Fam. Med. 8, 526–532 (2010).
Baravelli, C. et al. The views of bowel cancer survivors and health care professionals regarding survivorship care plans and post treatment follow up. J. Cancer Surviv. 3, 99–108 (2009).
Brennan, M. E., Butow, P., Marven, M., Spillane, A. J. & Boyle, F. M. Survivorship care after breast cancer treatment--experiences and preferences of Australian women. Breast 20, 271–277 (2011).
Hudson, S. V. et al. Adult cancer survivors discuss follow-up in primary care: 'not what I want, but maybe what I need'. Ann. Fam. Med. 10, 418–427 (2012).
Rutherford, A. & Burge, B. General practitioners and hospitals. Continuity of care. Aust. Fam. Physician 30, 1101–1107 (2001).
Department of Health, NHS Improvement. Survivorship: Living with and Beyond Cancer [online], (2009).
Watson, E. K. et al. Personalised cancer follow-up: risk stratification, needs assessment or both? Br. J. Cancer 106, 1–5 (2012).
Emery, J. et al. The role of primary and community-based healthcare professionals in early detection and follow-up in cancer care: a rapid review of best practice models. Sax Institute [online], (2013).
Author information
Authors and Affiliations
Contributions
J. D. Emery, K. Shaw, B. Williams, and L. J. Trevena researched the data for the article. All authors contributed to the discussion of the article's content, wrote the manuscript and edited it before submission.
Corresponding author
Ethics declarations
Competing interests
The authors declare no competing financial interests.
Rights and permissions
About this article
Cite this article
Emery, J., Shaw, K., Williams, B. et al. The role of primary care in early detection and follow-up of cancer. Nat Rev Clin Oncol 11, 38–48 (2014). https://doi.org/10.1038/nrclinonc.2013.212
Published:
Issue Date:
DOI: https://doi.org/10.1038/nrclinonc.2013.212
This article is cited by
-
Primary care practitioners' priorities for improving the timeliness of cancer diagnosis in primary care: a European cluster-based analysis
BMC Health Services Research (2023)
-
Reduced Survival Outcome After Receiving a New Cancer Diagnosis in the Emergency Department: Findings from a Hospital Network in Rural Eastern North Carolina
Journal of Racial and Ethnic Health Disparities (2023)
-
Impact of COVID-19 on hospital screening, diagnosis and treatment activities among prostate and colorectal cancer patients in Canada
International Journal of Health Economics and Management (2023)
-
Feasibility of a community-based cancer awareness initiative: views of those delivering and managing the intervention
Journal of Public Health (2023)
-
Cost-effectiveness of general practitioner- versus surgeon-led colon cancer survivorship care: an economic evaluation alongside a randomised controlled trial
Journal of Cancer Survivorship (2023)