Suchergebnisse

Early cancer diagnosis is a clinical and research priority of the UK government. Earlier cancer diagnosis should enable identification of cancers at an earlier stage, leading to improved outcomes.1 This must be balanced with the potential physical and psychological harms of over-investigation and over-diagnosis. The 'two-week wait' (2WW) referral pathway represents the most common route to cancer diagnosis. However, only 39% of cancer diagnoses were made via 2WW pathways in 2017, while significant proportions of diagnoses are made via other outpatient clinics (32%) or emergency presentation (19%), representing potentially missed diagnostic opportunities.2 Approximately 50% of cancer patients present with non-specific but concerning symptoms of cancer (NSCS).3 Compared to 'alarm symptoms' these have low predictive values for cancer and are less indicative of site-specific disease; consequently, they are not reflected in 2WW referral criteria.3 These patients frequently are referred later for specialist investigation and have more advanced disease.4 A principal goal for the new NHS Rapid Diagnostic Centres (RDCs) is to provide a pathway for patients with NSCS to detect cancer earlier, where treatment outcomes are more favourable.1 NHS England aims to provide full population coverage with RDCs by 2024.5

<b><i>Background:</i></b> Improving understanding of the genetic basis of disease susceptibility enables us to estimate individuals' risk of developing cancer and offer them disease prevention, including screening, stratified to reflect that risk. Little attention has so far been given to the implementation of stratified screening. This article reviews the issues that would arise in delivering such tailored approaches to prevention in practice. <b><i>Results:</i></b> Issues analysed include the organisational context within which implementation of stratified prevention would occur, how the offer of screening would be made, making sure consent is adequately informed, how individuals' risk would be assessed, the age at which risk estimation should occur, and the potential use of genetic data for other purposes. The review also considers how management might differ depending on individuals' risk, how their results would be communicated and their follow-up arranged, and the different issues raised by modification of an existing screening programme, such as that for breast cancer, and the establishment of a new one, for example for prostate cancer. <b><i>Conclusion:</i></b> Stratified screening based on genetic testing is a radically new approach to prevention. Various organisational issues would need to be considered before it could be introduced, and a number of questions require further research.

The nature of cancer control is changing, with an increasing emphasis, fuelled by public and political demand, on prevention, early diagnosis, and patient experience during and after treatment. At the same time, primary care is increasingly promoted, by governments and health funders worldwide, as the preferred setting for most health care for reasons of increasing need, to stabilise health-care costs, and to accommodate patient preference for care close to home. It is timely, then, to consider how this expanding role for primary care can work for cancer control, which has long been dominated by highly technical interventions centred on treatment, and in which the contribution of primary care has been largely perceived as marginal. In this Commission, expert opinion from primary care and public health professionals with academic and clinical cancer expertise—from epidemiologists, psychologists, policy makers, and cancer specialists—has contributed to a detailed consideration of the evidence for cancer control provided in primary care and community care settings. Ranging from primary prevention to end-of-life care, the scope for new models of care is explored, and the actions needed to effect change are outlined. The strengths of primary care—its continuous, coordinated, and comprehensive care for individuals and families—are particularly evident in prevention and diagnosis, in shared follow-up and survivorship care, and in end-of-life care. A strong theme of integration of care runs throughout, and its elements (clinical, vertical, and functional) and the tools needed for integrated working are described in detail. All of this change, as it evolves, will need to be underpinned by new research and by continuing and shared multiprofessional development.