Comment
*Carin A Uyl-de Groot, Werner B F Brouwer,
Jan M de Maeseneer, Jaap Verweij
Institute for Medical Technology Assessment, and Institute of
Health Policy and Management, Erasmus University Rotterdam,
PO Box 1738, 3000 DR Rotterdam, Netherlands (CAU-dG, WBFB);
Department of Family Medicine and Primary Health Care, Ghent
University, University Hospital, Gent, Belgium (JMdM); and
Erasmus MC, Rotterdam, Netherlands (JV)
uyl@bmg.eur.nl
CAU-dG reports grants from Boehringer Ingelheim, GSK, Janssen-Cilag, Astellas,
Roche, Therakos, Amgen, Gilead, Merck, Sanofi, Bayer, the Dutch government,
and the European Union outside the submitted work. WBFB reports grants from
AstraZeneca, GlaxoSmithKline, Janssen, MSD, Novartis, Pfizer, the Dutch
Government, and the European Union outside the submitted work. JV reports
personal fees from Sarcoma Alliance through Research and Collaboration, GSK,
Lilly, Eisai, Sanofi, Bayer, Boehringer Ingelheim, Synthon, Abbvie, Merck-Serono,
XBiotech, Cancer Research UK, and Sotio outside the submitted work. JMdM
declares no competing interests.
1 Rubin G, Berendsen A, Crawford SM, et al. The expanding role of primary
care in cancer control. Lancet Oncol 2015; 16: 1231–72.
Chinese perspective of the role of primary care in cancer control
In The Lancet Oncology Commission,1 Greg Rubin and
colleagues describe the expanding role of primary care in
cancer control. I agree with the authors that primary care
has an increasingly important role for patients throughout
their journey. The Commission gives valuable perspectives
for further development of primary cancer care.
According to China’s Aging Society and the Pension
Insurance Development Report in 2014,2 the proportion
of the population in China aged 65 years or older rose
from 9·4% in 2012 to 9·7% in 2013. Cancer is one of
many diseases of the elderly, and the number of patients
with cancer will continue to increase. Indeed in 2014, the
National Central Cancer Registry reported cancer incidence
had reached 250·28 per 100 000 people and mortality was
156·83 per 100 000 people in mainland China.3
Because of improved treatment options, cancer has
become a chronic disease that is nonetheless difficult to
cure and that requires long-term management. Many
patients with cancer seek medical assistance first in local
hospitals; thus, the development of medical facilities at
the city, county, and community levels is important in
China. Therefore, primary care physicians (PCPs) would
be an important part of cancer control. At present, the
work of community health care is best done in Shanghai,
China, where such health-care services were built at
a scale of one per 10 000–20 000 people. By relieving
outpatient examination fees for community hospitals
www.thelancet.com/oncology Vol 16 September 2015
2 Uyl-de Groot CA, de Vries EGE, Verweij J, Sullivan R. Dispelling the myths
around cancer care delivery: it’s not all about costs. J Cancer Policy 2014;
2: 22–29.
3 The Health Foundation. Summit report: leading the way to shared decision
making. February 2012. http://www.health.org.uk/sites/default/files/
LeadingTheWayToSharedDecisionMaking.pdf (accessed Sept 2, 2015).
4 de Maeseneer JM, van Driel ML, Green LA, van Weel C. The need for research
in primary care. Lancet 2003; 362: 1314–19.
5 de Maeseneer JM, Boeckxstaens P. Multimorbidity, goal-oriented care, and
equity. Br J Gen Pract 2012; 62: e522–24.
6 de Maeseneer J, Roberts RG, Demarzo M, et al. Tackling NCDs: a different
approach is needed. Lancet 2012, 379; 1860–61.
7 EXPH (EXpert Panel on effective ways of investing in Health). Definition of
a frame of reference in relation to primary care with a special emphasis on
financing systems and referral systems. Brussels: European Commission,
2014. http://ec.europa.eu/health/expert_panel/opinions/docs/004_
definitionprimarycare_en.pdf (accessed Aug 28, 2015).
8 Luengo-Fernandez R, Leal J, Gray A, Sullivan R. Economic burden of cancer
across the European Union: a population-based cost analysis. Lancet Oncol
2013; 14: 1165–74.
9 Raphael C, Ahrens J, Fowler N. Financing end-of-life care in the USA.
R Soc Med 2001; 94: 458–61.
and controlling medical service fees for inpatients and
outpatients of these hospitals, and by implementing
programmes such as the Shanghai community health
mutual help programme, more than 80% of patients
Brooks/Brown/Science Photo Library
with common or chronic diseases go to community
hospitals as their first point of contact. There has
also been substantial progress in the construction of
community health-care systems in other areas of China,
and such systems will continue to evolve in the future.
The role of community care in cancer control includes See The Lancet Oncology
Commission page 1231
prevention, screening, diagnosis, treatment, survivorship
care, and palliative care. In the past 10 years, several
public health programmes of cancer screening, early
diagnosis, and treatment were led by China’s National
Health and Family Planning Commission. In rural areas,
these projects for breast and cervical cancers were all
done in local maternal and child care service centres.
Many patients with cancer-related symptoms initially
go to local county or community hospitals, before
being referred to large cancer centres or comprehensive
hospitals to receive a final diagnosis and treatment. But
management of complications, rehabilitation, supportive
care, and follow-up are still provided in county or
community hospitals. Most patients with end-stage
cancer receive palliative care in these hospitals too, and
Chinese traditional medicine also plays an important part
in reducing side-effects and improving quality of life.
1227
 Comment
A series of measures have been undertaken to promote
the development of primary care in China. The Chinese
Society of General Practice was founded in 1993—a first
step towards the recognition of general medical practice
in China. The basic framework of the primary care
medical education system was constructed in 2000 and
a fairly comprehensive general medical education system
was in place by 2010 to meet the needs of health reform
and of community health services.
China’s national medical insurance system, covering
the whole country, was established in 2008 and is
broadly divided into three types: basic medical insurance
for urban employees, basic medical insurance for urban
residents, and rural cooperative medical insurance
for farmers. Other people who live in rural areas are
entitled to the same basic medical insurance as urban
employees. To further improve the medical insurance
system and reduce the economic burden for people who
have serious diseases such as cancer, the catastrophic
medical insurance system was set up in 2012 and is
now available in more than 90% of cities and counties
as of June, 2015. Therefore, patients who have serious
diseases can be reimbursed for more than 50% of the
additional cost after the original reimbursement. All
of these insurance systems are accepted at all levels of
hospitals to ensure the referral channels are unimpeded.
The Key Tasks of Health Reform in 2015 of the State Council
report4 stressed that the Chinese Government would need
Paying for the expanding role of primary care in cancer control
Advances in cancer detection and treatment pose a
challenge to traditional cancer services focused on the
acute delivery of specialist care. In The Lancet Oncology
Commission,1 Greg Rubin and colleagues set out an
Tek Image/Science Photo Library
exhaustive charter for the role of primary care services,
and the primary care physician (PCP). The authors
suggest 18 action points for a greater role for the PCP
from detection to palliation.
Effective PCP involvement in cancer care will depend
See The Lancet Oncology on the identification of appropriate PCP roles and the
Commission page 1231
development of skills, which the Commission does
address, and also on the provision of the right financial
incentives, which the Commission mentions only
briefly. At a fundamental level, how PCPs are paid affects
the type and volume of care they provide. Australia, as
1228
to continue to support construction of the community
health-service system and enhance the comprehensive
ability of community health services. Furthermore, to
improve the medical capacity of PCPs, standardised
training of junior doctors would need to be fully
implemented, and about 50 000 new junior physicians
will receive such training in 2015. With an increased
emphasis on cancer control services in community
hospitals, the diagnosis and treatment of patients should
be improved. The key findings of The Lancet Oncology
Commission1 provide valuable information to help to
improve the health-care system in China.
Yuankai Shi
National Cancer Center; Department of Medical Oncology, Cancer
Hospital, Chinese Academy of Medical Sciences and Peking Union
Medical College; and Beijing Key Laboratory of Clinical Study on
Anticancer Molecular Targeted Drugs, Beijing 100021, China
syuankai@cicams.ac.cn
I declare no competing interests.
1 Rubin G, Berendsen A, Crawford SM, et al. The expanding role of primary
care in cancer control. Lancet Oncol 2015; 16: 1231–72.
2 Aging Society and the Pension Insurance Development report. 2014.
http://www.cnki.net/KCMS/detail/detail.aspx?QueryID=0&CurRec=1&recid
=&filename=JJZK2015Z1017&dbname=CJFDLAST2015&dbcode=CJFQ&pr
=&urlid=&yx=&v=MjY1MDBGckNVUkwrZmJ1WnRGeXpnVTc3Qkx5ZlJaYkc
0SDlTbXJvOUVZNFI4ZVgxTHV4WVM3RGgxVDNxVHJXTTE= (accessed
Feb 23, 2015; in Chinese).
3 Chen W, Zheng R, Zeng H, Zhang S, He J. Annual report on status of cancer
in China, 2011. Chin J Cancer Res 2015; 27: 2–12
4 The Key Tasks of Health Reform in 2015 of the State Council. April 26,
2015. http://www.gov.cn/zhengce/content/2015-05/09/content_9716.
htm (accessed May 5, 2015).
in the UK and several other European countries, has a
strong primary care system with a gatekeeping role.
Unlike the UK, Australian PCPs are funded on a fee-for-
service basis, and patients are not registered to specific
PCPs or primary care organisations.2 Incentive payments
for PCPs have been targeted to specific interventions
such as cervical screening.3 But if each specific cancer-
related behaviour outlined in the Commission were
to attract its own payment, the funding system would
soon become overwhelmingly complex.
In general, a reliance on fee-for-service provides an
incentive for PCPs to increase the volume of care and to
generate revenue, rather than to provide continuity and
integration of patient care. This is becoming an increasing
challenge with the growing incidence of complex and
www.thelancet.com/oncology Vol 16 September 2015