GPs’ acceptability and feasibility for using point-of-care tests for cancer in primary care: a qualitative interview study

Summary

GPs broadly deemed POCTs for cancer in primary care acceptable and feasible provided they were accurate, tailored for use in general practice, and externally backed with resources needed for implementation. Concerns relating to feasibility mostly pertained to the potential increased workload for time-constrained clinicians and the funding aspects of test adoption. Other considerations included the wider impact of using POCTs for patients, on the health infrastructure, and diagnostic pathways. This was particularly noted in the context of whether patients would be managed promptly in secondary care following referrals.

Rapid testing is typically used in emergency settings where prompt clinical decision making is lifesaving, or in resource-limited settings where access to diagnostic testing is otherwise restricted. We speculated that clinicians might not be convinced that ‘same-day results’ for cancer are necessary, as a short delay would be unlikely to change prognosis. However, our interviews revealed, in addition to the fast turnaround time to results, GPs identified many other perceived benefits of using POCTs for cancer, such as improved triage and more confidence in their diagnosis, especially in patients who did not qualify for urgent suspected pathways. It was noted that cancer POCTs had a potential to reduce unnecessary secondary care referrals and help stratify patients with vague symptoms.

Strong research evaluating the clinical performance of POCTs in primary care populations, alongside evidence for patient acceptability and improved outcomes, were motivators for uptake. Recommendations from NICE or local guidelines were considered important facilitators for adoption. Interestingly, some GPs reported feeling more comfortable with using POCTs if they were widely accepted among colleagues, demonstrating the function of peer influence in this context. Participants often cited the FIT test roll-out as an example of an initially resisted intervention that became more acceptable with wider use.

The narrative and language used when introducing POCTs to clinicians was thought to be important, as was providing the right knowledge and training. Awareness of cancer POCTs was generally low among participants and a potential barrier to uptake, while delayed innovation adoption in the NHS and lack of centralised roll-out with sustained funding were considered a hindrance for widespread implementation.

Strengths and limitations

The semi-structured interview design allowed us to explore aspects of acceptability based on an existing theoretical framework,¹⁹ while delving deeper into key issues critical for implementation from GPs’ perspectives. The use of the TFA for developing our topic guide ensured a comprehensive assessment of various and nuanced aspects of acceptability by prompting discussion on specific dimensions such as GP confidence in ability to use POCTs.

We adopted a flexible and iterative approach towards conducting interviews. This ensured that participants were guided through structured questions, but were encouraged to lead the conversation on issues most important to them, allowing us to capture aspects we had not previously considered. Additionally, this study provides insights for developing other cancer interventions in general practice.

Interview questions for the study were based on point-of-care testing for cancer broadly rather than using a specific POCT as an exemplar. This method effectively elicited GPs’ perspectives on the ideal characteristics of a cancer POCT, capturing evaluation and implementation issues more widely. However, clinicians’ limited knowledge about POCTs for cancer might have led to assumptions about a hypothetical test, resulting in less specific feedback.

Most study participants were experienced clinicians, with more than 15 years of practising as doctors. Therefore, our findings may not be representative of the views of junior clinicians in the workforce. GPs were predominantly from England, which could reflect a skew in perspectives more applicable to NHS England. This may be particularly important when considering differences in cancer pathway models and funding paradigms for tests between the three nations that participants were from (England, Scotland, and Wales; no responders were based in Northern Ireland).

This study focused on GPs’ perspectives, excluding other primary care clinicians. As GPs emphasised the importance of involving other clinical staff in POCT delivery, including their input may have provided alternative views on acceptability and perceived feasibility of POCTs in primary care.

Comparison with existing literature

Echoing findings from previous studies assessing the general use of non-cancer POCTs in primary care,^23–27 having well-designed tests that provide diagnostic certainty, emerged as important factors for GPs when considering the adoption in their clinical practice. Compared with these studies,^23–27 accuracy was prioritised more by GPs in our research owing to the consequences of a misdiagnosis. False-negative test results can provide false reassurance, delay cancer detection and treatment, significantly worsening patient prognosis. Conversely, a false-positive result can cause undue anxiety and lead to unnecessary invasive testing. No test achieves perfect sensitivity or specificity; however, diagnostic uncertainty, interobserver variability, and the potential for errors owing to interpretation can be considerable concerns.²⁸ GPs acknowledged this, advocating for dichotomous or numerical values for cancer POCTs to reduce uncertainty. Previously, the World Health Organization published the ASSURED criteria for the ideal POCT for use in infectious tropical diseases and sexually transmitted infections, with a particular focus on low-income countries.²⁹ This included prerequisites regarding affordability, accuracy, and user-friendliness. These features aligned with the aspects GPs in our study identified as important for a cancer POCT.

In alignment with another study on POCTs for lower respiratory tract infections, we found GPs reported similar advantages for cancer POCTs.³⁰ These included improved communication with patients, confidence in decision making, and better triaging of patients. Similar to previous research, system-level issues for implementation, such as time constraints in primary care, funding, and reimbursement models, were important aspects for consideration.^23–26 However, owing to the qualitative design of our study, we cannot determine the prioritisation order of these variables, and this may vary depending on disease context.

Many GPs believed additional staff resources could mitigate the increased workload in response to POCT uptake. This contrasts with literature suggesting that employing non-GP clinicians does not necessarily reduce GP workload.³¹ The extent to which GPs envisioned other clinical staff supporting the administration of POCTs for cancer was not clear, and some may have implicitly anticipated hiring more GPs. Further enquiry is essential for assessing how additional staff would support the roll-out of POCTs for cancer.

Inclusion of POCTs in clinical guidelines was a facilitator for GP uptake. This was interesting because research indicates GPs sometimes find it challenging to adhere to guidelines³² and lack awareness of newer recommendations.³³ GPs may instinctively prioritise clinical judgement over guidelines, which is justifiable given the important predictive value of GPs’ ’gut feelings’ in cancer diagnosis.³⁴ Future efforts should support GPs in adhering to clinical guidelines and integrate the value of clinical acumen with evidence-based practice.

Implications for practice

This study establishes the basis for introducing point-of-care cancer diagnostics in primary care by identifying GPs’ requirements and how they might be integrated. The NHS Long Term Plan aims to diagnose three in four cancers at an earlier stage by 2028. Achieving this goal will require a multifaceted approach, including optimising diagnostic pathways and integrating innovations to enhance GPs’ precision for cancer referrals. Over the past decade, urgent cancer referrals have nearly doubled,³⁵ significantly burdening diagnostic services. However, in England only 7% of these investigations resulted in a cancer diagnosis,³⁵ highlighting the potential for POCTs to improve triage and reduce referrals on urgent suspected cancer pathways.

Our findings indicated that integrating POCTs in primary care would require considerable system reform, which will need collaboration between test developers, clinicians, policymakers, and commissioners. Future evaluation studies must assess and report on aspects important to primary care clinicians such as patient benefit, risk, acceptability, and wider system feasibility, including cost-benefit analyses.

This study identified multiple factors that could impact GPs’ motivation to utilise POCTs. First, while adherence to clinical guidelines is important, clinical judgement often takes precedence. GPs are less likely to use a test if they are not convinced of its evidence, particularly regarding patient benefits and outcomes. Additionally, the introduction of a test relies on a combination of guideline recommendations, evidence, and peer opinions, demonstrating the influence of social factors.

Many GPs lack awareness and knowledge of cancer POCTs, which could hinder their adoption. This underscores the importance of providing adequate training and education if these tests are to be implemented, ensuring clinicians are confident in their use. The broader issue of slow translation and adoption of emerging innovations within the NHS was highlighted in this study. To keep pace with evolving cancer diagnostic technologies and fully leverage their advantages, it is crucial to reconsider and expedite the processes for integrating modern technologies into practice.

In conclusion, UK GPs felt POCTs can offer major benefits for cancer detection in primary care for clinicians, patients, and the wider healthcare system. However, important challenges, such as test accuracy and tailoring for general practice, must be overcome to realise these merits. Access to adequate financial and staff resources would be paramount for implementation, with careful consideration for managing the potential increased workload for clinicians. Addressing these challenges will help improve pathways to better detection and encourage the development of innovations such as multi-cancer POCTs that may be implemented in the future.