The motivation for this research was the publication in 1995 of the Calman-Hine report. This provided a strategic framework for the delivery of cancer care by creating a network of cancer care centres in England and Wales to enable patients to receive a uniformly high standard of care. The report acknowledged the fact that although the evidence on optimal cancer care used to prepare the report was based on two key sources (i) medical literature and (ii) audit data provided by UK cancer registries, they did not lend themselves to controlled experiments as most information came from retrospective analyses; hence they were subject to a number of possible flaws and biases. Yet the report recommended some key structural changes to be implemented. The focus of the research described in this thesis was centred on the recommendation of a multidisciplinary team (MDT) review of patients prior to a treatment decision, both in general cancer units as well as in specialised cancer centres. Given the mandate to implement these recommendations, the research questions addressed were “can the current configuration support this recommendation?”, “what evidence was there to support the effectiveness of the MDT?” and “was there a model of care to support the service delivery of cancer care?” A literature review established that there was no existing template upon which MDT services could be set up. This research therefore set out to develop an MDT model to support operational delivery of care in the setting of a cancer centre. The clinical specialty in which this research was undertaken was that of lung cancer. The research successfully developed a conceptual model. However, in the process, a number of operational and practical constraints were identified within the revised service configuration designed to deliver high quality cancer care through the incorporation of the MDT service, and this ultimately limited the extent to which the model could be deployed in the particular clinical setting. Nevertheless, the modelling process did enable a range of core issues to be identified, enabling design solutions to be formulated and tested, thereby confirming the effectiveness of the MDT model. In particular, the adoption of a soft modelling approach was shown to be beneficial in addressing operational problems. By engaging clinical and other end-users right from the start in the modelling process, the models did become operationally accepted, allowing resistance to change to be overcome and the solution to be integrated into the business process. MDT services are now well established, both in cancer units and cancer centres and published data on their effectiveness in the treatment of lung cancer, although not conclusive; demonstrate an increase in resection rates. However, assessing the long-term impact of MDTs on lung cancer outcomes remains a topic for future research.

The work described in this thesis concerns the use and quality of primary care service use by people living beyond a diagnosis of breast, colorectal and prostate cancer and long-term risks associated with cancer. Firstly, the thesis provides a background for this work, with a definition of long-term survivors as those living at least five years past cancer, and the role of primary care in the care of this population. The second section describes use of the General Practice Research Database amongst a cohort of cancer survivors compared to a control population. Breast and colorectal cancer survivors consult more frequently than controls up to 10 years post-diagnosis, while prostate survivors continue to see their GP up to 3 times more for at least 15 years. Most survivors receive adequate preventative care and chronic disease monitoring, excepting mammography for long-term breast cancer survivors. Cancer survivors receive more prescriptions for pain relief, anti-depressants and erectile dysfunction, suggesting higher rates of pain, depression and sexual dysfunction. Breast cancer survivors have an elevated risk of incident heart failure, coronary artery disease and hypothyroidism, while colorectal survivors experience increased risk of dementia and diabetes. All three groups of cancer survivors had higher risks of osteoporosis and second cancers, all-cause, non-cancer and cancer mortality compared to controls. The third section describes a qualitative study of the primary care usage and unmet needs of 40 long-term survivors of breast, colorectal and prostate cancer. Most respondents did not need active GP involvement. Others had ongoing information and psychological service needs. Some felt that their GPs did not have the right expertise for cancer related issues or were too busy, while others had concerns about continuity of GP care. Overall, this thesis provides a background on how the increasing numbers of cancer survivors use and experience primary care in the UK, areas of good practice, and areas where care can be improved in the future.

This study addresses the importance of studies of human psychoneuroimmunology in understanding the role of psychological factors in cancer. Research trends in psychosocial aspects of cancer are reviewed, exploring the role of distress and the support group as an intervention which potentially reduces distress through enhancing interpersonal relationships, emotional adjustment and communication with health professionals, in these ways helping the patient to cope with the symptoms of treatment. In South Africa, most hospitals which treat cancer patients medically do not simultaneously have support groups for the newly diagnosed patient to join in order to discuss immediate fears and acquire more knowledge about their particular disease. Following an experimental cancer support group involving patients who had recently undergone a bone marrow transplant (some considerable time after their first cancer diagnosis) in Cape Town's Groote Schuur Hospital, the researcher, as one of the participants in the fortnightly meetings convened to dicuss psychosocial issues related to each patient's experience of the cancer and transplant process, transferred the themes, concepts and questions that arose in that scenario, to a cancer clinic in Pretoria where recently diagnosed patients were asked to volunteer to participate in such a group. It was felt that these patients would derive some benefit early in their treatment programme. Psychosocial concerns are left to the individual patient to seek therapy should it be required. Presently, it is reported in the body of knowledge about cancer, that interventions aimed at alleviating the psychosocial distress of cancer patients highlight hypnosis, guided imagery and relaxation therapy. It is contended that a more appropriate intervention for the majority of people with cancer in South Africa would entail a fellow-patient support group meeting on a regular basis. / Psychology / (M.A. (Psychology)

This study addresses the importance of studies of human psychoneuroimmunology in understanding the role of psychological factors in cancer. Research trends in psychosocial aspects of cancer are reviewed, exploring the role of distress and the support group as an intervention which potentially reduces distress through enhancing interpersonal relationships, emotional adjustment and communication with health professionals, in these ways helping the patient to cope with the symptoms of treatment. In South Africa, most hospitals which treat cancer patients medically do not simultaneously have support groups for the newly diagnosed patient to join in order to discuss immediate fears and acquire more knowledge about their particular disease. Following an experimental cancer support group involving patients who had recently undergone a bone marrow transplant (some considerable time after their first cancer diagnosis) in Cape Town's Groote Schuur Hospital, the researcher, as one of the participants in the fortnightly meetings convened to dicuss psychosocial issues related to each patient's experience of the cancer and transplant process, transferred the themes, concepts and questions that arose in that scenario, to a cancer clinic in Pretoria where recently diagnosed patients were asked to volunteer to participate in such a group. It was felt that these patients would derive some benefit early in their treatment programme. Psychosocial concerns are left to the individual patient to seek therapy should it be required. Presently, it is reported in the body of knowledge about cancer, that interventions aimed at alleviating the psychosocial distress of cancer patients highlight hypnosis, guided imagery and relaxation therapy. It is contended that a more appropriate intervention for the majority of people with cancer in South Africa would entail a fellow-patient support group meeting on a regular basis. / Psychology / (M.A. (Psychology)