4.3 Comparison with existing literature
The need for extra time to conduct a risk calculation and communicate
this effectively, listening, informing, explaining and discussing
further investigations with the patient, as found in this study, are
known to add complexity and costs to the patient
consultation.10 Additional time is a scarce resource
in the face of increasing practitioner workload, which will affect
implementation of innovations like this. Integration of the risk
assessment tool within the general practice IT system, with links to
existing patient data, and training on how to use the tool were seen as
essential to addressing issues of time and complexity of use.
Patients feeling worried or anxious about being referred for cancer
investigations was perceived as another barrier to the use of the tool,
although this does not correspond with a recent systematic review of
randomised controlled trials of cancer risk assessment tools in primary
care, which found no increase in cancer worry.17 This
contradiction in the evidence could be due to the fact that, the current
study is qualitative and based on the views of participants,
particularly service users who had not yet experienced the process of
using the tool with a clinician but were expressing what they felt could
happen, if the cancer risk information including referral, is not
properly communicated to them.9,18 On the other hand,
the participants in studies included in the systematic review of trials
might have benefited from interventions including clinician input, which
could have reduced their anxiety levels. Nevertheless, the fact that
these views were expressed in this study suggests that some patients
could indeed experience worry and anxiety, if the patient care, from
investigations through to diagnosis and treatment of cancer is not
properly planned and carried out to meet the needs of individual
patients.
Another barrier identified by participants was over-referral, although
some practitioners felt this was unlikely to be a problem because they
felt they could use risk assessment tools alongside their professional
judgement, only referring patients who needed this. This is supported by
current guidance that Cancer Decision Support tools should prompt
primary care practitioners to think about the possibility of cancer, and
then decide on referral based on their clinical
judgment.19 Despite this, the potential for increased
rates of referral of people without cancer (false positives) remains a
concern, with potential costs needing to be weighed against late
referral.
Practitioners in a simulation study conducted in Australia appeared not
to trust some risk outputs of the QCancer tool,20 and
this accords with scepticism expressed by some clinicians in this study.
Practitioners might be sceptical because they perceive the evidence that
QCancer or other cancer risk assessment tools improve outcomes is
limited. Intervention characteristics can be an important potential
facilitator or barrier,10 particularly when evidence
of effectiveness in practice is lacking.21
Previous studies have found barriers that needed to be considered for
successful implementation of cancer risk assessment tools in primary
care including: lack of trust on the part of some GPs in the risk
calculation, especially when it conflicted with clinical judgement;
variable interpretation of symptoms leading to variations in risk
assessment, and the difficulty experienced by some GPs in communicating
numerical risk to patients.20 Participants in this
study felt that the tools might conflict with existing guidelines, a
finding in line with the construct of compatibility,10i.e. whether an intervention fits with existing workflows.
Dikomitis and colleagues found that training and guidance were needed in
using cancer risk assessment tools in routine
practice22 because of difficulties experienced by
practitioners in employing the tools. Similarly, practitioners in this
study expressed concerns relating to difficulties in understanding,
accessing and using the cancer risk assessment tool, and called for
integration of the tool in general practice IT systems and training of
practitioners on accessing and using the tool. Hence, lack of
integration of the tools in the practice IT system and lack of or
inadequate training were perceived as barriers to implementation of the
tool. Indeed, to meet the needs of patients, clinicians need to be
supported with their learning needs such as sources of
information,23,24 about decision aids like cancer risk
assessment tools.
Another barrier identified was the perception that patients with
symptoms suggestive of cancer would need to be referred for further
investigations irrespective of their quantified risk. Indeed, it has
been suggested that when using Cancer Decision Support tools,
practitioners who suspect a possible cancer diagnosis can refer a
patient even if their quantified risk is low or does not meet the
referral NICE guidelines.19 Furthermore, Macmillan
Cancer Support who have integrated the QCancer and Risk Assessment Tool
(RAT) and have called them the electronic Cancer Decision Support (eCDS)
tools, have suggested that these tools can complement existing NICE
guidelines by flagging an alert on the computer screen about the
possibility of cancer. Following this flagging on the computer, the
clinician can then decide whether to refer a patient, based on NICE
guidelines.19
With reference to facilitators, participants in this study felt that the
use of the cancer risk assessment tool could support decision-making
especially with patients whose cancer symptoms were unclear, or when
cancer was a differential diagnosis, helping to speed up the assessment,
diagnosis and treatment of cancer. The findings from this study support
findings from a previous study on GPs’ experiences of using diagnostic
tools, which found that the RAT helped GPs with lung and colorectal
cancer symptom recognition and confirmed their decision about whether to
refer.25 In another study, embedding electronic
decision-support tools was found to have educational benefits, with GPs
reportedly learning about cancer symptoms when using cancer risk
assessment tools.22,25 Green and colleagues also found
that embedding clinical decision support tools in clinical practice was
more likely to be achieved when they were used to support, rather than
supersede, the clinical judgement of practitioners,25corresponding with the views expressed by practitioners in this current
study.
Another facilitator to the use of the tools found in this study, that
the use of the cancer risk assessment tool could help to identify, raise
awareness of and promote positive health behaviours in patients,
supports findings from recent systematic review of randomised controlled
trials of cancer risk assessment tools in primary care, which suggested
that health promotion messages within tools may have positive effects on
behaviour change.17
The cancer risk assessment tools meant for people presenting with
symptoms are based on an individual patient’s risk factors and symptoms;
this helps to personalise care. Since the risk generated is for an
individual patient, the referral and further investigations as well as
the subsequent diagnosis and treatment or cancer care will be specific
to that individual, taking into consideration their individual
attributes and symptoms. Personalised or person-centred care is about
taking into consideration the desires or values, social circumstances
and lifestyles of people, while working with people as individuals to
develop appropriate solutions.13,26
4.4
Implications for practice and further research
For a successful implementation, barriers to the use of the cancer risk
assessment tool need to be addressed. This will include ensuring that
the tool is integrated in the general practice IT systems and training
practitioners on how to access and use the tool during the patient
consultations. It is of note that Macmillan Cancer Support and Cancer
Research UK have worked with the major primary care IT providers (EMIS,
SystmOne and Vision+) in integrating the eCDS tools in general practice
systems, although this integration will need to be enforced as expressed
by participants in this study.
Practitioners are likely to refer patients with symptoms suggestive of
cancer whatever their quantified risk if these fall within NICE cancer
referral guidelines, suggesting that risk assessment tools should be
used flexibly to fit with clinical practice.
Quantitative research is needed to examine the effects of the use of the
cancer risk assessment tool (QCancer) on rates of referral,
investigations and diagnoses, whether positive or negative for cancer.
Further research is also needed to quantitatively evaluate whether the
cancer risk assessment tool improves patient outcomes compared with
current practice.