How Can Primary Care Practitioners Transform Cancer Care?
In 2015, more than 8 million deaths worldwide were attributed to cancer. Of these deaths, nearly two-thirds occurred in low and middle income countries (LMIC).
Financially and personally distressing, a cancer diagnosis is devastating to both to families and individuals in any country. Cancer research is progressing at a rate faster than ever before, yet many of the benefits of early detection, better treatment, and mitigation of known risk factors are limited to high-income countries. In fact, as rates of mortality from common cancers begin to decline in high-income countries, mortality rates for the same cancers are increasing in low-income countries. In LMICs, overburdened health systems rarely have the resources to detect and treat tumors and cancer survival for patients in the developing world remains low. According to a World Health Organization report released in early February, primary health care can play a pivotal role in improving outcomes for cancer patients. As high income countries struggle to reduce the exorbitant costs related to cancer care, and developing health systems attempt to balance the need to effectively treat both infectious and non-communicable diseases, the foundational role of primary care cannot be overlooked.
Education: engaging with communities to improve health literacy
Primary care is often the first point of entry into the health system for cancer patients: nearly 85% of eventual cancer diagnoses first present symptomatically in a primary care setting. Equitable access to basic health services is essential for timely detection and diagnosis of symptoms. When clinicians are able to identify cancer early on, patient quality of life and chance of survivorship are far higher than in late-stage diagnoses. Unfortunately, for many patients in LMICs, this critical period is frequently missed. LMICs often lack the resources to carry out large-scale population screening. When cancers are eventually identified, more often than not they have already progressed significantly.
In addition to serving as the first point of contact for the health system, primary care practitioners are also in a unique position to proactively reduce the barriers to cancer screening and care. Distilling stigma, discussing risk factors with patients and promoting health literacy are critical to fostering a sense of agency among patients. Empowering patients to practice self-care normalizes health-promoting behaviors and can lead to improved health outcomes. A Malaysian pilot study found that when community nurses conducted monthly community health education talks and distributed informational packets about symptoms and self-examination, incidence of late-stage breast cancer diagnosis decreased from 77% to 37% over a four year period.
Improving health literacy gives patients back the feeling of personal autonomy that is so often lost with a traumatic disease diagnosis. Increasing community education by mobilizing local health workers is a cost-effective strategy to address the growing cancer burden in low-resource settings.
Treatment: overcoming costs and increasing access
The developing world accounts for 80% of disability adjusted life years lost to cancer, yet only receives 5% of total cancer dollars spent worldwide. Many argue that cancer treatment in LMICs is unfeasible due to expense and limited resources. Yet cost effective interventions in LMICs is possible. Primary care providers play an important role in the mitigation is lifestyle factors that increase cancer risk and, as evidenced by the great successes in AIDS treatment programs around the world, complex case management in low-income and middle-income countries is indeed possible.
A partnership between Partners in Health, the Dana-Farber Cancer Institute, Harvard Medical School, and Brigham and Women's Hospital is demonstrating the potential of comprehensive cancer treatment in rural settings. Working in Rwanda, Malawi and Haiti, this partnership uses remote specialist consultation to support local health workers as they deliver chemotherapy regimens to catchment areas between 800,000 and 1 million individuals. The success of these programs demonstrates that the need for on-site, specialized oncologists to deliver comprehensive cancer treatment can be overcome. Primary care workers who are embedded in their communities are well-positioned to work hand-in-hand with oncologists to deliver treatment over long periods of time. As these programs work to scale-up their successes, drawing on the existing primary care workforce in rural areas will be essential to improving the scope of treatment.
Cancer control in low and middle income countries is an achievable reality. Amid an ever-changing global health landscape, effective action is needed now to ensure that developing health systems are able to handle the growing burden of cancer in their communities. As programs, such as those mentioned above, work to scale-up their successes, investing in already existing primary care workforces will improve the scope of care while reducing the financial burden of specialist care. For both chronic and communicable diseases, primary care practitioners must be at the forefront of patient care.