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| Journal of the New Zealand Medical Association,
08-July-2011, Vol 124 No 1338
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What do specialists and GPs
think about the introduction of colorectal cancer screening? A qualitative study
Colorectal cancer (CRC) is second only to lung cancer in
being the most common cause of cancer registration and deaths in New Zealand and
with an ageing population, the absolute number of people with CRC in New Zealand
is expected to increase.1
CRC fits most of the World Health Organization criteria for
a population screening programme.2 In 1997, the
New Zealand National Health Committee convened a working party to look at
population screening and at that time recommended that such a programme not be
considered because of inadequate resources within New Zealand, as well as the
fact that they considered that the benefit would only be a modest one and that
there was potential for harm.3 Instead, New
Zealand opted for surveillance guidelines4
which would identify those at increased risk of CRC who could then be referred
for surveillance colonoscopy.
People identified for surveillance colonoscopy have,
however, experienced long waiting periods before being tested because the
current health services cannot meet the existing
need5. Despite this current pressure on public
health services, the Ministry of Health’s Bowel Cancer Team have continued
to discuss the issue of CRC screening with health providers and the Government
is now committed to introducing a 4-year bowel screening pilot in 2011 to
determine whether a bowel screening programme should be rolled out
nationally.6
The proposed screening test is the immunochemical faecal
occult blood test (FOBT) with those testing positive going on to colonoscopy.
The aim of this paper is to explore the views of GPs and
specialists on CRC screening. To date, no other New Zealand study has questioned
health professionals in-depth on their attitudes and perceptions towards
surveillance and screening for CRC. This highlights the importance of this
research as their buy-in would have an impact on implementation and uptake of
such interventions in New Zealand.
Research done in Australia suggests that medical
practitioners are supportive of CRC screening programmes, particularly if
provided through general practice.7 Studies
have shown that GP involvement has an impact on uptake of
screening,8,9 although Federici et
al8 qualify this claim by pointing out that
whether GPs are effective in improving compliance depends upon whether they are
willing to be involved.
Beliefs about the effectiveness of the different screening
tests for CRC also play a role, with a US study finding that there are
significant concerns regarding the accuracy of the
FOBT,10 although in the Australian context,
several studies indicate increasing sympathy with FOBT over
time.11,12
As well as concerns regarding the role of GPs and the
accuracy of the FOBT, there have also been concerns expressed by medical
professionals about the increased demand on already over-stretched public health
services.7
MethodsThe data analysed in this paper were obtained from
in-depth, semi-structured interviews with 15 GPs and 11 specialists, who
included general surgeons, gastroenterologists and medical oncologists.
Participants were from the three largest cities in New Zealand: Auckland,
Wellington and Christchurch, and were selected purposively for inclusion in the
study to reflect the diversity of socioeconomic patient lists.
All participants received a $50 book voucher in
appreciation of their time. Ethical Approval for the study was granted by the
New Zealand Health and Disability Multi-region Ethics Committee.
The in-depth interviews were carried out by three
experienced interviewers and were digitally recorded and transcribed.
Participants were asked questions about their thoughts on a population-based
screening programme, the surveillance guidelines for CRC, screening, advice to
patients at different levels of risk for CRC and referrals for colonoscopic
investigation.
Each of the three interviewers had the same
semi-structured interview guide to ensure that that they all covered the same
topic areas. Questioning on the topic of FOBT was conducted in a general way and
participants were not pointed towards any particular type of test to make
comment on. This allowed for the potential for participants to raise differences
in test types.
A thematic analysis was undertaken which is a method
used extensively in qualitative research to identify, analyse and report
patterns in data.13,14 Meaning is sought in the
accounts and/or actions of participants, taking into account how the broader
social and political context impinge on these
meanings.14,15 The transcripts were all read
prior to the start of coding.
The data collected were sorted into datasets, which are
extracts from all the data divided into topics of particular analytical
interest. The data in each dataset were read and re-read and coded for features
of specific interest. The coded segments of the transcripts were sorted into
overarching themes and sub-themes and then refined.
ResultsThe majority of specialists and GPs thought that in theory a
population-based CRC screening programme was a good idea, yet they saw this as
being idealistic. They perceived such a programme to be unrealistic primarily
due to lack of resources and they also had concerns about what they perceived to
be the low sensitivity and specificity of the FOBT. Another concern held by the
GPs in relation to both the above mentioned themes was the possibility of
engendering anxiety in their patients.
Resourcing a screening programme—Lack
of resources include a concern by both groups about the shortage of
colonoscopists in the public system to cope with a population screening
programme, and a concern by the GPs regarding the lack of financial compensation
when they are likely to have to bear the responsibility of promoting and
monitoring the screening programme.
If a population-based screening programme was to be
introduced, specialists perceived that it was the GP’s job, as the
ambulance at the bottom of the cliff, to communicate risk of CRC to patients and
recommend screening. Specialists saw themselves as just there to deal to people
at the bottom of the cliff:
GPs actually, I think, are
where all screening programmes— the hub of all screening programmes in
reality, effective screening programmes— are managed. That’s what
they do. It’s their job. I’m the ambulance at the bottom of the
cliff. GPs basically are to stop them falling over the cliff, and that’s
what screening’s about. So it has to be run through GP programmes. GPs
will run the databases, their electronic data systems should talk to the
government systems, patients should be sent out reminders that they have their
thing, just like you do with breast cancer, cervical cancer screening. All those
things, the tools are there. They’re already using them. (Sp4)
The GPs agreed that they were the best source to deliver
information on screening to their patients; however, they were concerned about
the lack of resources to carry out this role as there were not the financial
resources to do so:
For anything to be rolled
out effectively, General Practice has to be involved, but for General Practice
to be involved, there has to be financial recognition of that. It will not work
if it’s rolled out just through public health. (GP4)
I don’t know how that
would work. Because, no, unless the screening’s done away from General
Practice, you know, if we would be asked to coordinate it and invite patients
for it and to look at the results that come back and make decisions on who needs
what, then obviously that’s an expense to us that we wouldn’t do
unless someone is paying us. (GP7)
But notwithstanding financial issues, GPs were concerned
about bringing up the topic of screening for other reasons, including a
reluctance to increase patient anxiety:
I have to sit down and talk
to people about the risks of not having the screening as opposed to screening
and their anxiety. (GP1)
On the whole, women come out
of there, we’ve scared them shitless, we’ve subjected them to all
this, our agenda of screening, we’ve frightened them, then they come back
there and told that they’re all right, and they feel so grateful. They
feel so relieved that they forget that it was us bloody doctors who’ve put
them through it all in the first place. (GP5)
Screening was also a difficult concept for some GPs to
explain to patients especially when they were not convinced of the benefits of
screening:
So you’ve got to be
very clear that if you’re going to make somebody worried or going to
concern them about something, you are doing it with the best interests at heart
and that they are going to get some benefit from this. And if you’re just
going to worry them, well we’ve got a whole worried population in all
sorts of ways. (GP1)
Both groups argued that there would be insufficient
resources to deal with the many anticipated follow-up colonoscopies:
Oh great idea, great idea
(screening programme), but a lot of work for someone, who has to tease through
what’s the best screening to offer, and I would, I would be hugely
concerned if it was offered before we could deliver the next step. That would
worry me a lot. So it’s a lot of gear and it needs to be rolled out very
slowly.... well it, you can’t throw money at it, that’s out at the
moment, and it, if for example, if you did fund a screening policy that
identified those people with faecal occult bloods who are positive, you’d
then want to offer them a colonoscopy. We need more colonoscopists. (Sp11)
Both GPs and specialists identified the increasingly long
waiting list in the public system for people requiring colonoscopies at present,
which would be compounded after the introduction of a screening programme:
Well considering they
can’t, can’t get timely colonoscopy done for symptomatic patients,
surely the whole idea of it really just makes me feel absolutely awful. The idea
of having this raised expectation that this is all going to be set up for them,
and there’s going to be a huge focus on this. Either it won’t fly
because they just haven’t got the resources to put it in, or they’re
going to take resources away from somewhere else. That’s a huge concern,
and I can’t see that happening. And so if you have a situation where you
can’t actually do anything about the positive faecal occult bloods or have
to wait for months... (GP6)
In response to their concerns about resourcing, specialists
and GPs argued that it would be more beneficial to have a targeted screening
programme aimed only at those at increased risk or rather than a recall system,
provide a one-off colonoscopy to people at the age of 50:
In fact that could be a
strategy for the country obviously, having a one-off screen at 50. I know people
get bowel cancer at 25 and so on and so on, but on a population base it’s
unlikely, or very rare. (Sp3)
So it’s probably
better addressed in the first instance to the at-risk group, just because of the
logistics of trying to redress the system. (Sp10)
Colonoscopy was seen as the gold-standard test of choice for
CRC screening, especially by specialists:
Well faecal occult bloods
are positive ... So that’s not accurate, um and there are false negatives,
um which means if they come back negative, that person will decide he
doesn’t need screening by the gold standard, which is colonoscopy. So
you’ve missed a whole chance and you’ve lost... (Sp5)
This specialist argued that colonoscopy was a preferred
choice of screening tool to the FOBT because of the greater specificity it
provided.
Test sensitivity and specificity—As
mentioned previously, the screening test proposed in New Zealand is the
immunochemical FOBT with individuals testing positive going on for colonoscopic
investigation. The immunochemical FOBT has a higher sensitivity and specificity
than the guaiac FOBT.
Participants were asked about FOBT screening in general, not
specifically on their thoughts on guaiac and immunochemical FOBTs. Most GPs did
not differentiate between the two and talked about FOBT tests in general having
a low specificity and sensitivity:
I don’t generally do
faecal occult bloods. It’s a waste of time. If they’re negative,
you’re still going to have to investigate them cause of the 50% false
negative rate. So there’s little point in stuffing around doing that if
they’ve just got to have a colonoscopy. (GP6)
Few specialists, too, differentiated between the different
types of FOBT:
(FOBT) generates some,
generates more colonoscopies than truly needed, so it’s, you know,
it’s not specific. (SP6)
One specialist acknowledged that there were different types
of FOBT but was unsure about which one would be used in the proposed screening
programme, implying that neither was optimal:
So I suspect that faecal
occult blood testing in one form or another, be it guaiac or be it
immuno-histo-chemistry, the issue’s unresolved there. I think that’s
probably the way we’re going to go, but I suspect that with a bit of luck
in 10, 20 years time we’ll actually do testing for mutagens within the
stool and we’ll be able to detect it better that way. (SP4)
Similar to the discussion on screening with patients, GPs
were concerned about the heightened anxiety false positives would engender in
their patients which reinforced in their minds the lack of merit in doing an
FOBT:
I mean inevitably you get a
lot of false positive screening tests that subsequently turn out to be negative
on colonoscopy, so yes, it can create a lot of anxiety. (GP7)
Some GPs argued that FOBTs did not feature in their
decision-making about referral for screening but “if the person has got
risk factors, they need the screening whether or not the faecal occult
blood’s positive or not” (GP11). Many GPs instead indicated that
they would currently refer patients for CT colonography as a first step instead
of FOBT as they perceived the sensitivity and specificity of that test to be
superior to FOBT:
CT colonogram, yeah,
I’ve certainly made a lot of use of that test since it became available.
And as a screening tool, well it’s supposed to be, it’s supposed to
have a high, you know, a very high sensitivity and specificity for diagnosing
bowel cancer. And it’s quite good at picking up polyps as well. Of course
if you pick up a polyp, those people have got to then go on and have a
colonoscopy. (GP7)
There was a lot of support by GPs for CT colonography
whether or not their patients were drawn from low or high socioeconomic areas.
It was seen as less invasive and risky than colonoscopy with no likelihood of
perforation, more reliable in picking up abnormalities than FOBT and, in
addition, would pick up other abnormalities which both FOBT and colonoscopy
would miss.
The specialists, on the other hand, did not see this as an
advantage and as well as being concerned about the risk of radiation, argued
that the increased cost to the screening programme through picking up other
abnormalities was not warranted.
CT colonography obviously
offers a possibility, but the issues with that, I think, is the CT, is the
radiological dose, if you’re giving to a huge, you know, whole population,
and one of the things that could end up making a screening programme really
expensive is the picking up of other things that you didn’t expect that
you then feel obliged to follow, so like adrenal tumours or the like. I mean
some people could see that as a good trade off, they’re picking up things
that you might not otherwise, but it adds quite a cost to your screening
programme. (SP1)
The holistic nature of general practice and the relationship
of trust between patient and GP meant that the concerns of GPs regarding the
merits of particular tests were not echoed by those of the specialists. This may
have implications in the implementation of a CRC screening programme in New
Zealand.
DiscussionThe study findings generally support those international
studies which indicate that GPs are supportive of
screening7; have
concerns about the accuracy of FOBT,10 may not
be convinced that capacity exists to introduce the
programme7 and have concerns about screening
engendering worry for patients which is a concern also supported in the
literature in relation to mammographic
screening.18 But, significant effort is likely
to be required to ‘sell’ a screening programme to New Zealand GPs
and specialists that has as its point of entry the FOBT.
GPs, especially, perceived the sensitivity and specificity
of FOBT to be low but it is most likely that these perceptions were based on the
guaiac FOBT which until recently has been the standard test used in New Zealand.
The proposed screening programme in New Zealand would make use of the newer
immunochemical FOBT which has a higher sensitivity and specificity for detecting
left-sided CRC and also does not require the dietary restrictions called for by
older tests.16
The fact that participants were not questioned directly on
the different types of FOBT is a potential limitation of the study, but their
responses do also highlight the need for up-to-date information on contemporary
forms of FOBT. It may also be the case, as has been found elsewhere, that GPs
become more confident about the use of FOBT over
time11,12
The GP advocates for and acts in the best interests of their
patients.17 Family GPs, because of the ongoing
relationship with their patients and their families, develop a relationship of
trust and it is more likely that their advice on risk and need for screening
would hold more weight than information from an unknown other.
In order for GPs to have some confidence in advocating
screening to patients, they obviously need to be convinced that the process is
worthwhile. The issue of the role of GPs in the implementation of a screening
programme for CRC and the potential increase in their workload and
responsibilities as a result, needs to be addressed.
The concerns of both GPs and specialists surrounding
resourcing in relation to the physical availability of colonoscopic services
also need to be addressed. This is particularly important in the case of the GPs
as it became clear from the other participants (members of the public) in the
wider research project of which this is a part, that they still very much
respect the advice of their family doctor. In giving this advice, GPs are
cognisant of not wanting to unnecessarily engender patient anxiety and because
of their ongoing relationship, are concerned to do the best for their patients.
If GPs are to have confidence in promoting the programme,
then they need to be convinced that it will work for their patients.
Competing interests: None.
Author information: Gillian Abel, Senior
Lecturer; Lee Thompson, Senior Lecturer; Department of Public Health and General
Practice, University of Otago, Christchurch
Correspondence: Gillian Abel, Department of
Public Health and General Practice, University of Otago – Christchurch, PO
Box 4345, Christchurch, New Zealand. Fax: +64 (0)3 3643614; email: gillian.abel@otago.ac.nz
References:
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