Impact of the COVID-19 pandemic on cancer assessment in primary care: a qualitative study of GP views

Mismatch between patient expectations and practice availability

GPs reported that demand for appointments was reduced when lockdown started. Demand then slowly increased over time or even became higher than it was before the COVID-19 pandemic. Some GPs described a mismatch between patient views and expectations of primary care provision and what was available to them. There were reported misconceptions about practices being closed or GPs being too busy with COVID-19-related activities (often attributed to inaccurate reports from the media). Several GPs emphasised that primary care services remained available, even during lockdown, and that their practice was 'always open':

'I think if they had presented to us during COVID times with the symptoms, they would have been seen, but they didn’t know that we were open or that the services were available.' (GP07, F, 6–10 years)

'Well, that’s not true, we’ve not been closed at all and in fact, we’ve been working really hard because we’ve had to change quite a lot […] we’ve been open all the time and we’ve always been accessible to our patients and we’ve made it quite clear that we still want to see people particularly with possibly cancer symptoms.' (GP13, F, 11–20 years)

Patients’ increased health vigilance yet reluctance to seek help as a result of the COVID-19 pandemic

While a few reported uncertainty over whether patients’ help-seeking behaviour had changed, some GPs discussed how the COVID-19 pandemic had resulted in patients exhibiting increased health vigilance by taking more ownership and personal responsibility for their health:

'I think the threats [that] COVID presented to patients actually made them re-think, engage in some more home care and self-care to a certain degree, […] so, I think there’s been some adaptation or change in terms of [help-] seeking behaviour.' (GP22, M, 0–5 years)

However, key discussions referred to patient reluctance to seek help and reported consequences for symptom presentation and GPs' symptom assessments. Several GPs stated that patients seemed reluctant to seek help owing to the risk of catching COVID-19. GPs described how patients often made a conscious decision to delay presentation. Some questioned whether patients did not present because they were told to stay at home where possible, or were excessively worried about COVID-19 owing to available public information:

'They didn’t want to trouble us because of COVID so they waited a couple of months and then a couple of months again because it didn’t seem to be growing that much, and then you have proper cancer, basically.' (GP11, F, 11–20 years)

Some GPs gave further accounts of patients who had presented with more advanced symptoms or even tumours:

'So, patient presenting… with … malignancy-type symptoms: we’ve had a couple who were quite advanced because they’ve held off from presenting during COVID.' (GP23, F, 6–10 years)

'I see basal cell carcinomas twice as big as they would normally be, because they have been waiting for 9 months, and the waiting list is now ridiculous.' (GP11, F, 11–20 years)

'I did have a patient who’s had a neck lump for nearly5months and didn’t tell us at all […]. Yes, and this gentleman has sort of a tumour…' (GP08, M, 6–10 years)

Some GPs were concerned about delays in detecting early cancer for timely treatment. Importantly, a few believed that the usual approach to 'watch and wait' may not always be appropriate, particularly when symptoms could be owing to cancer, as the disease may already be advanced:

'The point with cancer care is you have to diagnose at a very early stage…my concern… is that we are missing… those early cancers [as] … only the investigation tells because their symptoms are so vague that you cannot pick [them] up otherwise...' (GP15, M, 11–20 years)

'You just have to be really extra vigilant really with any sort of presentation at the moment, because it may be a late presentation of something. So it probably does mean we’re investigating a lot more patients, whereas maybe [previously] we may have had a ‘wait and watch’ approach.' (GP10, M, 6–10 years)

Less able to assess subtle symptoms and signs

Most GPs discussed the pros and cons of remote versus face-to-face consultations. While most acknowledged being able to continue to provide full GP services via remote consultations, for some GPs, patients 'just need to be seen' face to face. Several GPs expressed a personal preference for face-to-face consultations. One GP described it as 'good medicine', others as a chance to have a personal touch and better understand the patient. They described how face-to-face consultations allowed them to ‘look the patient in the eye’, note more subtle signs of possible cancer, and allow patients to report additional symptoms; for example, the ‘conversation as patients leave the consulting room’:

'The classic [is] when someone… speaks to you… about their neck pain and then at the end says, oh, by the way, whilst I’m here, I’m just a bit worried about this lump in my breast… Those sort of things we perhaps aren’t getting so much [of] because we haven’t got that same interaction with them.' (GP13, F, 11–20 years)

'I think, if you have got somebody in the room with you, it’s far easier to eyeball people and say, you’re well, you’re ill.' (GP12, F, 11–20 years)

Some GPs talked about the usefulness of ‘gut feeling’ during face-to-face contact with a patient, which is known to be an important factor when managing cancer uncertainty:

'[I]n terms of assessing people on the phone, it’s just not quite the same as seeing somebody facetoface and, sort of, thinking “you’re ill, you’ve got something going on, I’m not sure what.” And yeah, you sort of lose another way of assessing people. Of course, it’s not perfect, but you do get the impression when somebody walks in as to…that they’ve got something going on that you’ve got to get to the bottom of.' (GP09, M, ≥21 years)

'You miss when somebody walks in the room you think “this is something serious” sometimes, that is what you don’t have on the telephone. So you need to have those people in or visit them to make sure you still can make those sort of judgments.' (GP14, F, ≥21 years)

Several GPs gave examples of when a face-to-face consultation was still required, such as persistent or ongoing symptoms, and physical symptoms that raised a suspicion of cancer. This was particularly the case for bowel symptoms and patients with abdominal pain, when a physical examination was required:

'If you think they have some form of malignancy, you still have to bring them to the surgery, make the assessment, and then do the onward referral to the secondary care.' (GP08, M, 6–10 years)

'Most of the people we’ve seen facetoface, even in the COVID times, have [had] abdominal pain […] Even if you say it’s not serious, most people want to put…or I personally want to put my hand on the tummy to just make sure there are no signs of an acute abdomen or something...' (GP18, M, 11–20 years)

'I think if you’ve got even the slightest concern about a carcinogenic process, you need to see them facetoface. I don’t think you can really avoid it. So normally after a telephone consultation or a telephone call, if their symptoms are persisting you want to see them facetoface.' (GP17, M, ≥21 years)

GPs also spoke about challenges with using video consultations, including the time it took to set them up and limited patient access to reliable internet connection or to a smartphone, and how this affected certain patient groups who may be at higher risk of cancer.

Less able to manage cancer uncertainty

Half the GPs described their role managing risk, believing that not being able to have face-to-face consultations resulted in taking more risks and potentially missing signs that could indicate cancer. At times, this increased risk was reported to cause anxiety among GPs:

'Relying less on what we see, and just trusting more what we hear […] It’s come with its own level of anxiety as well, if you’re ever anxious of making the wrong decision, this last6months has been the time.' (GP22, M, 0–5 years)

'I think, there’s undoubtedly a greater degree of risk, be it perceived or be it real, with doing more remote consulting.' (GP12, F, 11–20 years)

A couple of GPs highlighted the importance of safety netting to mitigate the increased risk:

'I think the changes have forced us to carry a bit more of the weight of responsibility and uncertainty than we used to. But as a GP, that’s what you do, you’re faced with uncertainty all the time… (GP21, M, 6–10 years)

'We’ve all been a bit more uncomfortable with the perceived increase[d] risk, and you’re having to do more safety netting, you’re having to do more advice on when to return and all of those things, and who to seek help from. So, I think, it is more risky.' (GP12, F, 11–20 years)

Re-purposing diagnostic resources, using the FIT as an exemplar

Some GPs highlighted that guidance around referrals was constantly changing. For example, in 2017, the National Institute for Health and Care Excellence (NICE) diagnostics guidance DG30 recommended that FITs should be requested routinely for all patients with non-specific gastrointestinal or vague symptoms, as a positive FIT demonstrated faecal haemoglobin and recommendation for an urgent referral and colonoscopy. During May and June 2020, many clinical commissioning groups (CCGs) began to recommend extending use of FIT to patients meeting the NICE suspected cancer guideline NG12 owing to limited access to colonoscopies. Several but not all the interviewees were aware of this new requirement for a FIT result before referring a patient via the 2-week wait (2WW) urgent pathway:

'[C]olonoscopies and gastroscopies were stopped during COVID… [then] you had to do a FIT test. Even if you were trying to refer to a2-week wait you required a FIT test, and only if that was positive, then they would go ahead and do a colonoscopy.' (GP05, M, ≥21 years)

Some GPs also discussed using FITs more often, sometimes resulting in shortages. Some believed that FIT had an extra use as patients did not need to be seen face to face, consistent with reducing COVID-19 risk:

'I think it’s a valuable tool. It’s so easy to do for patients. It’s non-invasive. It’s done pretty remotely. They can send it in, and they can do it in the privacy of their own home. So it’s not even bringing patients in to expose them to our healthcare assistants.' (GP05, M, ≥21 years)

'Again, you know, when it’s sometimes even difficult to see patients face to face, arranging for them to do a FIT test could be very helpful.' (GP01, M, ≥21 years)

Some GPs commented on the utility of FIT as a diagnostic test, suggesting that it has good performance data, is useful for 'debatable' cases, and could reassure both healthcare professionals and patients:

'Our threshold for using a FIT test has dropped and, even for those grey-area patients… we’re probably more likely to do a FIT test [now] than we were pre-COVID, because it… provides very useful, hopefully reassuring, information.' (GP01, M, ≥21 years)

While some GPs stated that they had started to order tests before seeing the patient, another believed that testing should not be used as a substitute for other types of assessment:

'[W]hat I personally do is, people with abdominal symptoms who contact me, I tend to take the history over the phone. And again, it’s about trying to limit contact with them too, because of COVID, some people I will send to test first, because […] I know they’re going need a FIT. Then sometimes even without examining them, I will speak to them over the phone, take a thorough history and if they’re fulfilling the criteria for it and not meeting the2-week wait threshold, which excludes FIT, then I’ll send them for screening blood tests and the FIT at the same time, and then follow them up afterwards. So, some people you need to examine, but some people you don’t before you send them to test.' (GP12, F, 11–20 years)

'I think it’s a bad principle to do tests on somebody who you haven’t fully… assessed. Doing tests is part of your assessment but when I qualified we were taught 70%is in the story, 20%is in the examination and 10%in the test […] I’m definitely ordering fewer tests because […] I’m less likely to order a test if I haven’t actually seen somebody face to face. I don’t see a test as a substitute for seeing them.' (GP03, M, ≥21 years)

Interconnectedness between NHS primary and secondary care: changes in secondary care impact primary care

GPs talked about both positive and negative ways in which changes in secondary care had impacted primary care. They reported positive impacts of the COVID-19 pandemic on diagnosing patients, including using advice from secondary care or meeting with specialists to discuss diagnostic multidisciplinary team (MDT) decisions for their patients:

'We’ve used a lot of advice and guidance with the hospital system, and that’s actually worked really well …Previously advice and guidance was fairly useless, in that it would take a couple of months to get any response back, whereas now [within] 48hoursyou get a message back.' (GP09, M, ≥21 years)

However, most GPs believed that cancer diagnoses had been delayed as a result of COVID-19 and described delays in secondary care investigations, particularly for routine and outpatient services. For instance, there were reports of cancelled or postponed endoscopies and imaging tests:

'We used to be able to book routine CT abdo pelvis [but] the routines are still not being done. So that has introduced delays and every so often you get a nasty shock with one of those, or your vague suspicion would be confirmed.' (GP21, M, 6–10 years)

GPs also described how patients waiting for secondary care appointments continued to seek support from primary care to prevent their condition from deteriorating. One GP talked about the need to contact patients when appointments due to a suspicion of cancer were cancelled:

'And quite a lot of them coming back to us with problems which are kind of worsening in the meantime, and we’ll be trying to firefight and trying to establish which of those people actually have deteriorated and need to be sort of pushed up the line.' (GP13, F, 11–20 years)

'[we were] given a list of patients whose scans were cancelled because you booked them as a routine, and then you have to go back and talk to them about how they’re feeling now.' (GP07, F, 6–10 years)

Some GPs were concerned that patients could be fearful about attending hospital appointments owing to concerns about COVID-19 risk:

'And I had …occasional situations where… somebody seemed unwell, where you might want them in the hospital, where you might want to refer them, and they said, “no, not going anywhere near that hospital, because I’ll get corona.”' (GP20, F, 11–20 years)

One GP stated that cancer treatment was also being delayed, while a few others described the increased use of telephone or remote appointments in secondary care. There were particular concerns about how secondary care would be able to manage large waiting lists and an increasing backlog, in terms of how long this would take and whether there were enough resources to do so:

'The dermatology department has got a 42-weekwait at the moment…they’ve always been short of clinicians anyway, but the waiting list is massive.' (GP19, F, ≥21 years)