Patient and practitioner views on cancer risk discussions in primary care: a qualitative study

Understanding the causes of cancer

All participants were asked about their understanding of the causes of cancer and most recognised the influence of both genetic and environmental factors. Several patients quoted the statistic that one in two people will get cancer in their lifetime and noted that this had increased over time. Most put this down to a combination of lifestyle factors (smoking was still considered to be the leading cause) and changes in our food environment and air quality. Most practitioners had a similarly nuanced understanding of cancer causation, noting also that a decrease in cardiovascular mortality had resulted in more people living longer and, therefore, developing cancer.

In relation to the lifestyle factors in the cancer risk tool (Figure 1), several participants — both patients and practitioners — reported that they had only recently become aware of the links between obesity and cancer. Similarly, links between alcohol and certain cancers were not widely understood by patients. Practitioners were generally aware of these links, but did not discuss them routinely with patients, as described under the next theme.

Cancer risk perception and the role of chance

While recognising certain lifestyle factors as causes of cancer at a population level, both patients and practitioners highlighted the role of luck in whether a particular individual develops cancer, often relating stories of friends or family who had cancer while leading a healthy lifestyle (or smoked and drank heavily without developing cancer).

Typical cancer risk scores derived from the risk tool were discussed with participants, using illustrative examples. Practitioners were accustomed to using cardiovascular risk assessment tools, such as Q-Risk and ASSIGN, but it was noted that scores with cardiovascular risk tools were generally higher than those from the cancer risk tool. For instance, practitioners often discuss cardiovascular risk scores of 20–30% (that is, the chance of having a cardiovascular event in the next 10 years), but high scores from the cancer risk tool would typically be in the range of 5–10%. Participants were asked to reflect on these percentages:

Interviewer (INT): '... say you heard that your risk over the next 10 years was 10% would that, would that resonate, do you think that would make you sit up and think? Or if they said it’s 5% would you think “well 5 out of 100, not much to worry about”? '

M2: ' Well that would, I wouldn’t even say 10% would have been much to worry about, you’ve 90% chance you'll not get it but 10% chance, you know what I mean, it’s just a gamble isn't it, you know it really is a gamble, that’s it. '

INT: 'And do you think that kind of timeframe, you know, thinking over the next 10 years do, do folk … '

M2: ' I don’t really think that far ahead, I just take really each day by day, you know, we've got a saying “same shit, different day”. ' (M2, 50–60 years, SIMD3)

Others had a less fatalistic outlook and felt that any reduction in their cancer risk was worth working towards. Practitioners, too, had mixed views on typical percentage risk scores, with some recognising the potential for a motivational discussion based on even modest reductions in already low-risk percentages.

Previous discussions focused on smoking

All participants were asked about previous cancer risk discussions. No patients could recall ever having discussed cancer risk in relation to health behaviours, although some did mention cancer screening conversations, suggesting how easily these can be conflated.

Most practitioners had only ever discussed cancer risk with patients in relation to smoking. This was partly related to not having the training or confidence to discuss links between cancer and risk factors such as obesity, but it was also clear that some GPs felt that discussing the spectre of cancer would not be a successful motivating factor to support behaviour change:

' No it’s more in a kind of lifestyle positive way of a life affirming kind of change rather than "if you’re obese you’re going to get cancer and you die". ' (GPM3, 50–60 years, small practice, medium deprivation)

Risk advice must be delivered at an appropriate and sensitive time for the patient

For most participants, discussing cancer risk during a planned consultation (for example, a chronic disease review) felt more feasible than doing it opportunistically. Several practitioners emphasised the importance of context and timing:

' It’s all got to be contextual, you’re not going to, you know, you're not going to start bringing up, you know, somebody’s had a bad life event and they're smoking more heavily or they're eating more, you’re not going to start, you know, their mother’s just died or they're, they’ve lost their job, you’re not going to start using that tool at that point. It’s a longitudinal, the relationship is longitudinal, the opportunities will occur. ' (GPM2, 50–60 years, large practice, high deprivation)

Practitioners were conscious that discussing health behaviours with patients can be sensitive, and that tone and language used was also important. A non-judgemental approach was advocated.

Practice nurses are best placed to discuss cancer risk

In keeping with the preference for planned discussions, most participants — patients and practitioners — felt that practice nurses were best placed to have cancer risk discussions. This was related to practice nurses having longer consultations and being more accustomed to using computer-based tools in their consultations, particularly with different templates for chronic disease reviews.

Tool for motivating change or ‘tick-box’ exercise?

Most participants were enthusiastic about the tool, although there were notes of caution and patients were generally more positive about it than practitioners. Most patients felt the tool was easy to understand and that more knowledge was a good thing and could help motivate behaviour change.

Several recognised that tools such as this were not for everyone, and there is no 'one-size-fits-all' approach. Some patients reflected that using the tool in an interactive way during a consultation could help people prioritise behaviour changes that they wanted to make:

' It’s giving you options rather than telling you “You need to do this, you need to do that”. So instead of cutting out smoking you could maybe eat more fruit and veg, eat less processed foods. So it would be more helpful because it gives you a chance to maybe do things one at a time rather than trying to do everything at once and it just blows up and you are like “oh, I can’t be bothered with it”. ' (M3, 40–49 years, SIMD1)

Other patients, however, were more sceptical, believing the tool to be impersonal, reducing individuals to a set of numbers.

GPs and practice nurses were mostly positive about the tool itself. One GP (GPF2), who was an advocate of ‘lifestyle medicine’, felt the tool could be helpful in motivating behaviour change. Another praised its content and layout. The main concern about the tool, over and above the potential unintended consequences covered later, was the potential for it to become a ‘tick-box’ exercise.

Collecting information in advance could help

Several GPs mentioned the possibility of gathering information for the tool in advance of the consultation, to save practitioner time and allow patients to consider priorities (if any) for health behaviour change. Practice nurses agreed that this approach could work for some patients, recognising the shift towards doing things online:

' We are trying to get the patients to use the online website more and make appointments, ordering their prescriptions so that would be ideal. ' (PNF2, 50–60 years, medium practice, medium deprivation)

Patient and practitioners agreed this could also be done in the waiting room before appointments.

Beware unintended consequences

Participants were asked about potential unintended consequences of using a cancer risk tool in consultations. Practitioners raised more concerns than patients. Several GPs, for example, mentioned the possibility of generating anxiety, although this was less of a concern for the practice nurses in the study. Some patients also felt that there was the potential to increase worry, but this would depend on how the consultation was handled; if discussed sensitively, this would not be an issue.

A few GPs worried that using the tool would distract from the patient’s agenda and was not very person-centred; a concern shared by this patient:

' I also think that sometimes what we do is we introduce tools for people who can’t have the conversation rather than teach people how to have the conversation. So should some of this money be spent in teaching GPs how to talk to patients or giving them enough space and time to talk to patients rather than having a " come and look at my computer " . ' (F3, 50–60 years, SIMD7)

Finally, a point made by several practitioners was that the tool could potentially widen health inequalities, as those most likely to benefit would be least likely to engage:

' The inverse care law and the people that’s going to come and people that might change are the ones who are the, in the least need of change, the ones who are in the most need of change who, you know, but there’s nothing we can do about that in terms of, it’s a fact, we’ve just got to work round it. ' (GPM2, 50–60 years, large practice, high deprivation)

Barriers to behaviour change

Numerous barriers to behaviour change were discussed, with most being individual-level barriers shaped by socioeconomic circumstances. Several patients discussed the importance of individual willpower and motivation to make changes. For two patients, this motivation came from a sudden event such as a heart attack, which was a wake-up call to live a healthier lifestyle.

Some participants noted the importance of addressing underlying drivers of unhealthy behaviours, viewed by many as coping mechanisms. The addictive nature of many unhealthy behaviours was also raised, in relation to smoking, alcohol, and overeating:

' Food is an addiction the same as heroin is an addiction but with food addiction, you need to take food to live. You can stop heroin because you don’t need heroin to live but you need food to live. So a food addiction to me is the worst addiction that people can have and it’s not so easy to stop and a lot of people just see it as a lifestyle choice. It’s not. ' (F1, 50–60 years, SIMD1)

Another factor was lack of time for physical activity, particularly for people working long hours, antisocial shift patterns, or doing several jobs to make ends meet. Language barriers (to accessing services) were also mentioned, along with cultural differences in health behaviours (for example, diet, smoking).

Need to address wider determinants of unhealthy behaviours

The most frequently cited determinant of unhealthy behaviours was poverty. It was noted that living in poverty affected a person’s ability to eat healthily and be physically active, and increased the likelihood of using smoking or alcohol as coping mechanisms. Some practitioners felt that people living in more deprived areas were less future-oriented — 'they live for the day ' (PNF1) — so were less likely to invest in their future health. In the quote below, this practice nurse, in an economically deprived area, pointed out that discussing fruit and vegetables would feel inappropriate in the context of more pressing demands such as mental health or addiction crises:

' Sometimes it’s overwhelming. Really all I'm trying to do is to stop the alcohol or the … or the self-harming or the, it’s really, fruit and veg are way down the list. Sometimes you just think, you know, I'm not even mentioning that because it’s just insulting really, this person’s not got time for fruit or a vegetable. ' (PNF4, 50–60 years, small practice, high deprivation)

Commercial determinants of health were also discussed by patients and practitioners as having shaped environments to make people more sedentary and provide easier access to unhealthy energy-dense food and drink.

Helpful approaches to support behaviour change

Suggestions to improve support for health behaviour change ranged from the micro (individual) to the meso (community, institutional) to the macro (environmental, infrastructural) levels, although most focused on the role of primary care.

At the micro level, participants emphasised the importance of a person-centred approach in consultations:

' We’ve got a bit into the … the house of care thing for diabetes, which is quite a nice model for actually trying to engage patients with what actually matters to them. And the whole thing that there is no point in telling someone to stop smoking if they actually want to die, you know, if you, you actually do need to try to engage with what people actually in practice can or want to do. ' (GPF1, 50–60 years, large practice, low deprivation)

At the meso level, patients described how various community resources had helped them to make health behaviour changes. Examples included smoking cessation support from pharmacies; support with changes to diet and exercise from groups, such as Slimming World or Weight Watchers; and support to reduce alcohol consumption from third-sector groups such as Alcoholics Anonymous. Many patients also said how helpful friends and family had been.

It was noted that many patients in deprived areas have other more pressing demands, so support with issues such as housing or benefits was considered a pre-requisite for engagement with health behaviour change. Community links practitioners made a big difference in this regard. One practice nurse said how helpful it was to have a welfare rights worker at the practice who could address financial concerns that were preventing engagement with health behaviour change.

Other factors that could support behaviour change at the practice level included more time in consultations; training (for GPs and nurses) in motivational interviewing and other approaches to supporting behaviour change; and better feedback from services that patients are referred to. Fruit and vegetable stalls in health centres were praised by one of the practice nurses.

Finally, at the macro level, action on the wider determinants of health behaviour was discussed. Most fundamentally, government intervention to tackle poverty was cited. Practitioners recognised that their actions to support health behaviour change were just one part of a multi-level approach, including advertising and changing social norms through positive role-modelling.