GP Dr John McMenamin has had a career-long interest and involvement in cancer diagnosis and treatment. John, who practises at Wicksteed House Medical Centre in Whanganui, was previously the College representative on the national bowel cancer working group and is now GP lead for the national bowel screening programme.
He presented his thoughts on the issues affecting cancer management in primary care at the Cancer Care at a Crossroads conference at Wellington’s Te Papa earlier this year, to considerable interest.
John says new information in the last three years means we need to consider amending our approach to the diagnosis and management of cancer in primary care.
“The first thing we need to consider is the impact of ethnicity and ethnic disparities on cancer outcomes. We need to address each step on the cancer treatment pathway from a quality and equity perspective, including in primary care.
“Secondly, the treatment outcomes from cancer are affected by factors that are very relevant to primary care, and we need to have a greater focus on these – in particular the management of a person’s comorbidities or long-term conditions.
“Cancer patients can ‘disappear’ from primary care’s view once they get into a cancer pathway. We need to consciously look at how we make sure people who are in the cancer pathway still get quality primary care.”
He says there is a lot that is already working well in primary care cancer management.
“For example, most cancers are referred from primary care to specialist care in a very timely manner. This shows us people are presenting with symptoms appropriately and symptoms are being investigated by their GP promptly.”
However, he says there are a smaller percentage where there are delays.
“Some of those delays are outside our control. But there are a small number of cancers where there are inappropriate delays, and some of those delays are related to knowledge and skills in general practice. Some are system delays that relate to how a practice manages risk and in particular how it manages safety netting.”
John believes all general practices should have safety netting, which is when a person with symptoms that may indicate cancer is proactively followed up by the practice if they don’t return of their own volition.
He also advocates practices proactively managing people with a cancer diagnosis by giving them a pre-treatment health check.
“Patients who are in the cancer pathway need to have their health needs comprehensively assessed in primary care. Giving someone a health assessment at the beginning of the cancer pathway can identify health risks that will impact on their ability to sustain cancer treatments.
“If we don’t do this, some people will fall out of cancer treatment for reasons that can be easily managed in primary care but that we may not know about.
“For example, let’s say someone is living in Whanganui and going to Palmerston North for radiation treatment for breast cancer as part of their overall cancer treatment plan. They have to travel an hour a day, each way, five days a week for four weeks. This may not be possible because of funding issues, because they can’t get a driver or because they are so unwell.
“As a result, they miss a couple of days in the first week, three days in the second week and then they stop going. These would be things that could be addressed as part of a health assessment in primary care.”
John would also like to see cancer audits in practices.
“There is a lot to be learnt from reviewing cancer diagnosis. The actual number of cancer diagnoses is relatively small – a GP sees most common cancers only every one-to-two years – so this isn’t a burdensome task.
“The cancer audit would consider whether there were any preventable factors that might have impacted on delay of diagnosis or referral. Were there any issues relating to the clinical management of the patient that might have contributed to cancer? And has this person had appropriate primary care involvement in their ongoing cancer treatment?”