What influences GPs' use of pelvic examination? A qualitative investigation in primary care.

BACKGROUND: Omission of pelvic examination (PE) has been associated with diagnostic delay in women diagnosed with gynaecological cancer. However, PEs are often not carried out by GPs. AIM: To determine the perceptions of GPs about the role of PEs, the barriers to and facilitators of PEs, and GPs' experience of PEs in practice. DESIGN AND SETTING: Qualitative semi-structured interview study conducted in one health board in Scotland (mixed urban and rural) with an approximate population of 500 000. METHOD: Interviews were conducted face-to-face or by telephone between March and June 2019. Framework analysis used the COM-B behaviour change model concepts of capability, opportunity, and motivation. RESULTS: Data was compatible with all three domains of the COM-B framework. Capability related to training in and maintenance of skills. These went beyond carrying out the examination to interpreting it reliably. Opportunity related to the clinical environment and the provision of chaperones for intimate examination. Interviewees described a range of motivations towards or against PEs that were unrelated to either capability or opportunity. These all related to providing high-quality care, but this was defined in different ways: 'doing what is best for the individual', 'doctors examine', and 'GPs as pragmatists'. CONCLUSION: GPs' reasons for carrying out, or not carrying out, PEs in women with symptoms potentially indicating cancer are complex. The COM-B framework provides a way of understanding this complexity. Interventions to increase the use of PEs, and critics of its non-use, need to consider these multiple factors.

Can-Pain-a digital intervention to optimise cancer pain control in the community: development and feasibility testing.

PURPOSE: To develop a novel digital intervention to optimise cancer pain control in the community. This paper describes intervention development, content/rationale and initial feasibility testing. METHODS: Determinants of suboptimal cancer pain management were characterised through two systematic reviews; patient, caregiver and healthcare professional (HCP) interviews (n = 39); and two HCP focus groups (n = 12). Intervention mapping was used to translate results into theory-based content, creating the app "Can-Pain". Patients with/without a linked caregiver, their general practitioners and community palliative care nurses were recruited to feasibility test Can-Pain over 4 weeks. RESULTS: Patients on strong opioids described challenges balancing pain levels with opioid intake, side effects and activities and communicating about pain management problems with HCPs. Can-Pain addresses these challenges through educational resources, contemporaneous short-acting opioid tracking and weekly patient-reported outcome monitoring. Novel aspects of Can-Pain include the use of contemporaneous breakthrough analgesic reports as a surrogate measure of pain control and measuring the level at which pain becomes bothersome to the individual. Patients were unwell due to advanced cancer, making recruitment to feasibility testing difficult. Two patients and one caregiver used Can-Pain for 4 weeks, sharing weekly reports with four HCPs. Can-Pain highlighted unrecognised problems, promoted shared understanding about symptoms between patients and HCPs and supported shared decision-making. CONCLUSIONS: Preliminary testing suggests that Can-Pain is feasible and could promote patient-centred pain management. We will conduct further small-scale evaluations to inform a future randomised, stepped-wedge trial. TRIAL REGISTRATION: Qualitative research: ClinicalTrials.gov , reference NCT02341846 Feasibility study: NIHR CPMS database ID 34172.

The use, quality and effectiveness of pelvic examination in primary care for the detection of gynaecological cancer: a systematic review.

BACKGROUND: Urgent suspected cancer referral guidelines recommend that women with gynaecological cancer symptoms should have a pelvic examination (PE) prior to referral. We do not know to what extent GPs comply, their competency at PE, or if PE shortens the diagnostic interval. OBJECTIVES: We conducted a systematic review of the use, quality and effectiveness of PE in primary care for women with suspected gynaecological cancer. METHOD: PRISMA guidelines were followed. Three databases were searched using four terms: PE, primary care, competency and gynaecological cancer. Citation lists of all identified papers were screened independently for eligibility by two reviewers. Data extraction was performed in duplicate and independently. Paper quality was assessed using the relevant Critical Appraisal Skills Programme checklist. Emergent themes and contrasting issues were explored in a narrative ecological synthesis. MAIN FINDINGS: Twenty papers met the inclusion criteria. 52% or less of women with suspicious symptoms had a PE. No papers directly explored GPs' competence at performing PE. Pre-referral PE was associated with reduced diagnostic delay and earlier stage diagnosis. Ecological synthesis demonstrated a complex interplay between patient and practitioner factors and the environment in which examination is performed. Presenting symptoms are commonly misattributed by patients and practitioners resulting in misdiagnosis and lack of PE. CONCLUSION: We do not know if pre-referral PE leads to better outcomes for patients. PE is often not performed for women with gynaecological cancer symptoms, and evidence that it may result in earlier stage of diagnosis is weak. More research is needed.

Distinguishing variation in referral accuracy from referral threshold: analysis of a national dataset of referrals for suspected cancer.

OBJECTIVES: To distinguish between variation in referral threshold and variation in accurate selection of patients for referral in fast-track referrals for possible cancer. To examine factors associated with threshold and accuracy and model the effects of changing thresholds. DESIGN: Analysis of national data on cancer referrals from general practices in England over a 5-year period. We developed a new method to estimate specificity of referral to complement existing sensitivity. We used bivariate meta-analysis to produce summary measures and described practices in relation to these. SETTING: 5479 general practitioner (GP) practices with data relating to more than 50 cancer cases diagnosed over the 5 years. OUTCOMES: Number of practices whose 95% confidence regions for sensitivity and specificity indicated that they were outliers in terms of either referral threshold or decision accuracy. RESULTS: 2019 practices (36.8%) were outliers in relation to referral threshold compared with 1205 practices (22%) in relation to decision accuracy. Practice age profile, cancer incidence and deprivation showed a modest association with decision accuracy but not with thresholds. If all practices shared the referral behaviour of those in the highest quintile of age-standardised referral rate, there would be a 3.3% increase in cancers detected through fast-track pathways at the cost of a 36.9% increase in urgent referrals. CONCLUSION: This new method permits variation in referral to be described more precisely and quality improvement activities to be targeted. Changing referral thresholds without increasing accuracy will result in modest effects on detection rates and a large increase in demand on diagnostic services.

Can patient-reported measurements of pain be used to improve cancer pain management? A systematic review and meta-analysis.

PURPOSE: Cancer pain is a distressing and complex experience. It is feasible that the systematic collection and feedback of patient-reported outcome measurements (PROMs) relating to pain could enhance cancer pain management. We aimed to conduct a systematic review of interventions in which patient-reported pain data were collected and fed back to patients and/or professionals in order to improve cancer pain control. METHODS: MEDLINE, EMBASE and CINAHL databases were searched for randomised and non-randomised controlled trials in which patient-reported data were collected and fed back with the intention of improving pain management by adult patients or professionals. We conducted a narrative synthesis. We also conducted a meta-analysis of studies reporting pain intensity. RESULTS: 29 reports from 22 trials of 20 interventions were included. PROM measures were used to alert physicians to poorly controlled pain, to target pain education and to link treatment to management algorithms. Few interventions were underpinned by explicit behavioural theories. Interventions were inconsistently applied or infrequently led to changes in treatment. Narrative synthesis suggested that feedback of PROM data tended to increase discussions between patients and professionals about pain and/or symptoms overall. Meta-analysis of 12 studies showed a reduction in average pain intensity in intervention group participants compared with controls (mean difference=-0.59 (95% CI -0.87 to -0.30)). CONCLUSIONS: Interventions that assess and feedback cancer pain data to patients and/or professionals have so far led to modest reductions in cancer pain intensity. Suggestions are given to inform and enhance future PROM feedback interventions.