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      Primary care for cancers at diagnosis and follow-up: a narrative review

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          Abstract

          This paper is concerned about the family physician’s role in early cancer diagnosis and follow-up with his/hers patients who have just been diagnosed with cancer; treatment modalities for cancer; and family physician continuous roles for patients who are under definitive cancer treatment, experiencing side-effects of cancer treatment; some of the effective means to reduce these side-effects during cancer treatment and management of oncologic emergencies. Having some knowledge on the current cancer therapies would undoubtedly help family physicians to follow up patients with cancer more confidently, to appreciate their side-effects, symptomatic treatment, recognize the limit of primary care and be even useful for counseling and consultation with patients or their family members with a family history of cancer. Systematic searches with terms comprised “cancer”, “malignancy”, “primary care”, “general practice”, “cancer AND diagnosis” and “cancer AND follow-up” were done in the major databases such as Pubmed, ScienceDirect and Ovid. We employed selective searches with the above terms and their combination in some of the major journal such as The Lancet Oncology, The Lancet, New England Journal of Medicine, etc. These were followed by snowballing the relevant articles from the citation of references in those selected papers. The goal of this narrative review is not to provide exhaustive documentation of sound evidence for practice of primary care for cancer patients at diagnosis and follow-up. It mainly aims to provide specific evidence-based information and suggestions that are thought to be relevant for primary care professionals and policymakers.

          Most cited references53

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          Safety, activity, and immune correlates of anti-PD-1 antibody in cancer.

          Blockade of programmed death 1 (PD-1), an inhibitory receptor expressed by T cells, can overcome immune resistance. We assessed the antitumor activity and safety of BMS-936558, an antibody that specifically blocks PD-1. We enrolled patients with advanced melanoma, non-small-cell lung cancer, castration-resistant prostate cancer, or renal-cell or colorectal cancer to receive anti-PD-1 antibody at a dose of 0.1 to 10.0 mg per kilogram of body weight every 2 weeks. Response was assessed after each 8-week treatment cycle. Patients received up to 12 cycles until disease progression or a complete response occurred. A total of 296 patients received treatment through February 24, 2012. Grade 3 or 4 drug-related adverse events occurred in 14% of patients; there were three deaths from pulmonary toxicity. No maximum tolerated dose was defined. Adverse events consistent with immune-related causes were observed. Among 236 patients in whom response could be evaluated, objective responses (complete or partial responses) were observed in those with non-small-cell lung cancer, melanoma, or renal-cell cancer. Cumulative response rates (all doses) were 18% among patients with non-small-cell lung cancer (14 of 76 patients), 28% among patients with melanoma (26 of 94 patients), and 27% among patients with renal-cell cancer (9 of 33 patients). Responses were durable; 20 of 31 responses lasted 1 year or more in patients with 1 year or more of follow-up. To assess the role of intratumoral PD-1 ligand (PD-L1) expression in the modulation of the PD-1-PD-L1 pathway, immunohistochemical analysis was performed on pretreatment tumor specimens obtained from 42 patients. Of 17 patients with PD-L1-negative tumors, none had an objective response; 9 of 25 patients (36%) with PD-L1-positive tumors had an objective response (P=0.006). Anti-PD-1 antibody produced objective responses in approximately one in four to one in five patients with non-small-cell lung cancer, melanoma, or renal-cell cancer; the adverse-event profile does not appear to preclude its use. Preliminary data suggest a relationship between PD-L1 expression on tumor cells and objective response. (Funded by Bristol-Myers Squibb and others; ClinicalTrials.gov number, NCT00730639.).
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            Cancer diagnosis in primary care.

            Around a quarter of those in the developed world die of cancer. Most cancers present to primary care with symptoms, even when there is a screening test for the particular cancer. However, the symptoms of cancer are also symptoms of benign disease, and the GP has to judge whether cancer is a possible explanation. Very little research examined this process until relatively recently. This review paper examines the process of primary care diagnosis, especially the selection of patients for rapid investigation. It concentrates on the four commonest UK cancers: breast, lung, colon, and prostate as these have been the subject of most recent studies.
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              Five misconceptions in cancer diagnosis.

              Much investment has been put into facilities for early cancer diagnosis. It is difficult to know how successful this investment has been. New facilities for rapid investigation in the UK have not reduced mortality, and may cause delays in diagnosis of patients with low-risk, or atypical, symptoms. In part, the failure of new facilities to translate into mortality benefits can be explained by five misconceptions. These are described, along with suggested research and organisational remedies. The first misconception is that cancer is diagnosed in hospitals. Consequently, secondary care data have been used to drive primary care decisions. Second, GPs are thought to be poor at cancer diagnosis, yet the type of education on offer to improve this may not be what is needed. Third, symptomatic cancer diagnosis has been downgraded in importance with the introduction of screening, yet screening identifies only a small minority of cancers. Fourth, pressure is put on GPs to make referrals for those with an individual high risk of cancer - disenfranchising those with 'low-risk but not no-risk' symptoms. Finally, considerable nihilism exists about the value of early diagnosis, despite considerable observational evidence that earlier diagnosis of symptomatic cancer is beneficial.
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                Author and article information

                Journal
                FMCH
                Family Medicine and Community Health
                FMCH
                Family Medicine and Community Health & American Chinese Medical Education Association (USA )
                xxx-xxx
                2305-6983
                March 2013
                February 2014
                : 1
                : 1
                : 56-67
                Affiliations
                [1] 1Department of Family Medicine, Universiti Putra Malaysia, Malaysia
                [2] 2Klinik Kesihatan Simpang Kuala, Alor Setar, Kedah, Malaysia
                Author notes
                CORRESPONDING AUTHOR: Chew Boon How Department of Family Medicine, Faculty of Medicine & Health Sciences, Universiti Putra Malaysia, 43400 Serdang, Selangor, Malaysia chewboonhow@ 123456yahoo.com
                Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
                Article
                fmch20130109
                10.15212/FMCH.2013.0109
                99f10b65-b281-4e0f-8087-5d855e7d77ee
                Copyright © 2013 Family Medicine and Community Health

                This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 Unported License (CC BY-NC 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. See https://creativecommons.org/licenses/by-nc/4.0/.

                History
                Categories
                Review

                General medicine,Medicine,Geriatric medicine,Occupational & Environmental medicine,Internal medicine,Health & Social care
                General practice,Cancers,Survivors,Office visits,Diagnosis,Primary care

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