How can a feasibility trial to test an early diagnosis complex intervention, be delivered during a global pandemic? The rapid adaptation of ThinkCancer!
Early diagnosis of cancer usually leads to better survival and therefore it is important for primary care to act quickly when potential cancer symptoms are presented. ThinkCancer! is an educational and quality improvement workshop-based intervention, originally designed to be delivered in-person at GP surgeries. Due to the outbreak of the COVID-19 pandemic and the subsequent fall in urgent cancer referrals the problem has increased in urgency and the intervention and trial were adapted for remote delivery.
A randomised controlled feasibility trial to assess usual feasibility criteria (recruitment, retention, fidelity, data collection and outcome measures), alongside a health economic and mixed methods process evaluation was designed for delivery to a sample of primary care teams across Wales. Iterative adaptation of the intervention was expected. Recruitment began in Autumn 2019 by email invitation to all practices in Wales, with no exclusion criteria in place, aiming to recruit 23-30 practices at 2:1 intervention to control ratio. The intervention was developed from a multimethod research programme, and includes educational sessions for both clinical and non-clinical staff, appointment of a practice safety netting champion and the bespoke design and implementation of a practice safety netting plan. The delivery methods of the workshops changed dramatically to allow for MS Teams or Zoom platform use, though the content initially required little adaptation.
To date we have received 45 expressions of interest (12% of all GP practices in Wales), randomising 30 practices with 21 to intervention, surpassing progression criteria. Practices report a keen desire to take part in recognition of the importance of the subject. Intervention delivery is challenging due to time constraints and pressure on primary care. Loss of protected educational time and increased workload due to staff shortages and additional demands on time due to Covid-19 are barriers to delivering workshops. Delivering the workshop in 3 smaller units of time has improved uptake, with 8 practices completed so far. Post workshop feedback has already led to adaptations to presentation materials and positive comments around learning and confidence. Remote delivery of the workshop is proving challenging at times where Information Technology issues occur or groups are less engaged. The reach of the intervention has been improved by allowing recordings of the sessions to circulated to team members not able to join live sessions.
Meeting progression criteria, observed intervention acceptability and participant feedback is already driving the design of a future definitive phase 3 trial. Forced Covid-19 adaptations have led to an intervention that can be more easily delivered at scale and at less cost. A successful main trial could lead to the nationwide adoption of ThinkCancer!, improving cancer outcomes through accurate early referral and reducing diagnostic delay with effective consultation and GP practice system level safety netting.