Exploring why European primary care physicians sometimes do not think of, or act on, a possible cancer diagnosis. A qualitative study

Senada Hajdarevic; Cecilia Högberg; Mercè Marzo-Castillejo; Vija Siliņa; Jolanta Sawicka-Powierza; Magadalena Esteva; Tuomas Koskela; Davorina Petek; Sara Contreras-Martos; Marcello Mangione; Zlata Ožvačić Adžić; Radost Asenova; Svjetlana Gašparović Babić; Mette Brekke; Krzysztof Buczkowski; Nicola Buono; Saliha Serap Çifçili; Geert-Jan Dinant; Babette Doorn; Robert D Hoffman; George Kuodza; Peter Murchie; Liina Pilv; Aida Puia; Aurimas Rapalavicius; Emmanouil Smyrnakis; Birgitta Weltermann; Michael Harris

doi:10.3399/BJGPO.2023.0029

Exploring why European primary care physicians sometimes do not think of, or act on, a possible cancer diagnosis. A qualitative study

BJGP Open. 2023 Dec 19;7(4):BJGPO.2023.0029. doi: 10.3399/BJGPO.2023.0029. Print 2023 Dec.

Authors

Senada Hajdarevic^{1

2}, Cecilia Högberg³, Mercè Marzo-Castillejo⁴, Vija Siliņa⁵, Jolanta Sawicka-Powierza⁶, Magadalena Esteva^{7

8}, Tuomas Koskela^{9

10}, Davorina Petek¹¹, Sara Contreras-Martos⁴, Marcello Mangione¹², Zlata Ožvačić Adžić^{13

14}, Radost Asenova¹⁵, Svjetlana Gašparović Babić¹⁶, Mette Brekke¹⁷, Krzysztof Buczkowski¹⁸, Nicola Buono¹⁹, Saliha Serap Çifçili²⁰, Geert-Jan Dinant²¹, Babette Doorn²¹, Robert D Hoffman^{22

23}, George Kuodza²⁴, Peter Murchie²⁵, Liina Pilv²⁶, Aida Puia²⁷, Aurimas Rapalavicius²⁸, Emmanouil Smyrnakis²⁹, Birgitta Weltermann³⁰, Michael Harris^{31

32}

Affiliations

¹ Department of Nursing, Umeå University, Umeå, Sweden [email protected].
² Department of Public Health and Clinical Medicine, Family Medicine, Umeå University, Umeå, Sweden.
³ Department of Public Health and Clinical Medicine, Education and Development Östersund, Unit of Research, Umeå University, Umeå, Sweden.
⁴ Research Support Unit Metropolitana Sud, University Institute for Primary Health Care Research IDIAPJordi Gol, Catalan Health Institute, Barcelona, Spain.
⁵ Department of Family Medicine, Riga Stradiņš University, Riga, Latvia.
⁶ Department of Family Medicine, Medical University of Białystok, Białystok, Poland.
⁷ Majorca Primary Care Department, Spain.
⁸ Balearic Islands Health Research Institute (IdISBa), Balearic Islands, Spain.
⁹ Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.
¹⁰ Center of General Practice,Tampere University Hospital, Tampere, Finland.
¹¹ Department of Family Medicine, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia.
¹² Local Health Authority Committee, Palermo City, Italy.
¹³ Department of Family Medicine, University of Zagreb, School of Medicine, Zagreb, Croatia.
¹⁴ Health Center Zagreb-Centar, Zagreb, Croatia.
¹⁵ Department Urology and General Practice, Medical University of Plovdiv, Plovdiv, Bulgaria.
¹⁶ Croatian Health Insurance Fund, Rijeka, Croatia.
¹⁷ Department of Health and Society, General Practice Research Unit, University of Oslo, Oslo, Norway.
¹⁸ Nicolaus Copernicus University, Toruń, Poland.
¹⁹ Department of General Practice, National Society of Medical Education in General Practice (SNaMID), Caserta, Italy.
²⁰ Family Medicine Department, Marmara University Medical School, Istanbul, Turkey.
²¹ Department of General Practice, Maastricht University, Maastricht, The Netherlands.
²² Department of Family Medicine, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
²³ Department of Family Medicine, Maccabi Healthcare Services, Southern District, Israel.
²⁴ Department of Family Medicine and Outpatient Care, Medical Faculty #2, Uzhhorod National University, Uzhgorod, Ukraine.
²⁵ Centre of Academic Primary Care, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK.
²⁶ Institute of Family Medicine and Public Health, University of Tartu, Tartu, Estonia.
²⁷ Department of Family Medicine, University of Medicine and Pharmacy, Cluj-Napoca, Romania.
²⁸ Family Medicine Department, Lithuanian University of Health Sciences, Kaunas, Lithuania.
²⁹ Laboratory of Primary Health Care, General Practice and Health Services Research, Aristotle University of Thessaloniki, Thessaloniki, Greece.
³⁰ Institut für Hausarztmedizin, University of Bonn, Bonn, Germany.
³¹ Institute of Primary Health Care Bern (BIHAM), University of Bern, Bern, Switzerland.
³² College of Medicine & Health, University of Exeter, Exeter, UK.

Abstract

Background: While primary care physicians (PCPs) play a key role in cancer detection, they can find cancer diagnosis challenging, and some patients have considerable delays between presentation and onward referral.

Aim: To explore European PCPs' experiences and views on cases where they considered that they had been slow to think of, or act on, a possible cancer diagnosis.

Design & setting: A multicentre European qualitative study, based on an online survey with open-ended questions, asking PCPs for their narratives about cases when they had missed a diagnosis of cancer.

Method: Using maximum variation sampling, PCPs in 23 European countries were asked to describe what happened in a case where they were slow to think of a cancer diagnosis, and for their views on why it happened. Thematic analysis was used to analyse the data.

Results: A total of 158 PCPs completed the questionnaire. The main themes were as follows: patients' descriptions did not suggest cancer; distracting factors reduced PCPs' cancer suspicions; patients' hesitancy delayed the diagnosis; system factors not facilitating timely diagnosis; PCPs felt that they had acted wrongly; and problems with communicating adequately.

Conclusion: The study identified six overarching themes that need to be addressed. Doing so should reduce morbidity and mortality in the small proportion of patients who have a significant, avoidable delay in their cancer diagnosis. The 'Swiss cheese' model of accident causation showed how the themes related to each other.

Keywords: Europe; cancer; diagnostic errors; physicians, primary care; primary health care; qualitative research.