Complexities in cancer diagnosis: An embedded qualitative intervention development study for the Think Cancer! trial on early diagnosis of cancer in primary care

Problem

Every four minutes someone in the UK dies from cancer. UK cancer mortality is worse than in many high-income countries. Diagnostic delays, including delays in primary care, partly explain this.The aim of the ‘ThinkCancer!’ intervention is to improve cancer diagnosis and therefore survival. A theoretically driven, novel, complex behavioural intervention to reduce primary care cancer diagnostic delays, it was rigorously developed, then tested in a mixed-method feasibility trial. The aim of the embedded qualitative study, reported here, was to obtain in-depth understanding of GP personal beliefs and behaviour and practice team systems and norms, on diagnosis of cancer. The originality is in combining individual GP behaviours with practice systems and culture.

Approach

This embedded study used a qualitative design to fulfil its aim of obtaining in-depth data. It was trial development work, conducted in Wales.Rigorous purposive sampling ensured a range of GPs (years since qualification, rurality, deprivation) and practices (training practice status, rurality).Twenty telephone interviews were conducted with GPs and four face-to-face focus groups with practice teams.Analysis used Framework, which facilitates analysis both by theme and case. The final stage, interpretation, involved in-depth, explanatory level analysis to identify patterns, links and associations. Interpretative analysis sessions with the wider research team allowed us to map, discuss, scrutinize and eventually finalise the emerging themes.

Findings

The findings demonstrate complex, multi-level considerations facing GPs and practice teams in the process of cancer referral. Tensions emerged between internal, individual considerations of GPs and context-dependent pressures.Detecting cancer was guided, not just by external requirements, but also by personal motivations and considerations that GPs described as part of their cancer diagnostics process: standards, integrity, emotions, relationships, reputation, autonomy, ‘gut feeling’.External influences and pressures on diagnosis processes often resulted from the primary-secondary care interface, including rejection or ‘downgrading’ of GP referrals. GPs, in response, adapted their behaviour, including delaying referral ‘until it was obvious’, increasing referral workup or developing (often informal) ways to ensure referral acceptance. Positive practice culture and helpful practice-based systems ameliorated these tensions and complexity.

Consequences

The study originality is combining individual GP behaviours with practice systems and culture, at this level of granularity. We hope that this approach will influence future research practice. These findings influenced the design of the Think Cancer! intervention, now rolled out as a RCT, with likely influence on clinical practice and policy.These research findings matter because they contribute new understandings on improving cancer diagnostic delays in primary care. They highlight a commonly overlooked problem of the dynamics and tensions shaping early cancer diagnosis in primary care. Importantly, they show how positive practice cultures and systems can ameliorate these tensions. This has implications for clinical practice and policy, highlighting the importance of whole-practice interventions.