Barriers and facilitators to colorectal cancer diagnosis in New Zealand: a qualitative study

Blackmore et al. BMC Family Practice (2020) 21:206 https://doi.org/10.1186/s12875-020-01276-w RESEARCH ARTICLE Open Access Barriers and facilitators to colorectal cancer diagnosis in New Zealand: a qualitative study Tania Blackmore1* , Kimberley Norman1, Jacquie Kidd2, Shemana Cassim1, Lynne Chepulis1, Rawiri Keenan1, Melissa Firth1, Christopher Jackson3, Tim Stokes4, David Weller5, Jon Emery6 and Ross Lawrenson1 Abstract Background: New Zealand (NZ) has high rates of colorectal cancer but low rates of early diagnosis. Due to a lack of understanding of the pre-diagnostic experience from the patient’s perspective, it is necessary to investigate potential patient and health system factors that contribute to longer diagnostic intervals. Previous qualitative studies have discussed delays using The Model of Pathways to Treatment, but this has not been explored in the NZ context. This study aimed to understand the patient experience and perception of their general practitioner (GP) through the diagnostic process in the Waikato region of NZ. In particular, we sought to investigate potential barriers and facilitators that contribute to longer diagnostic intervals. Methods: Ethical approval for this study was granted by the New Zealand Health and Disability Ethics Committee. Twenty-eight participants, diagnosed with colorectal cancer, were interviewed about their experience. Semi-structured interviews were audio recorded, transcribed verbatim and analysed thematically using The Model of Pathways to Treatment framework (intervals: appraisal, help-seeking, diagnostic). Results: Participant appraisal of symptoms was a barrier to prompt diagnosis, particularly if symptoms were normalised, intermittent, or isolated in occurrence. Successful self-management techniques also resulted in delayed help-seeking. However if symptoms worsened, disruption to work and daily routines were important facilitators to seeking a GP consultation. Participants positively appraised GPs if they showed good technical competence and were proactive in investigating symptoms. Negative GP appraisals were associated with a lack of physical examinations and misdiagnosis, and left participants feeling dehumanised during the diagnostic process. However high levels of GP interpersonal competence could override poor technical competence, resulting in an overall positive experience, even if the cancer was diagnosed at an advanced stage. Māori participants often appraised symptoms inclusive of their sociocultural environment and considered the impact of their symptoms in relation to family. Conclusions: The findings of this study highlight the importance of tailored colorectal cancer symptom communication in health campaigns, and indicate the significance of the interpersonal competence aspect of GP-patient interactions. These findings suggest that interpersonal competence be overtly displayed in all GP interactions to ensure a higher likelihood of a positive experience for the patient. Keywords: Colorectal cancer, Delays, Patient-physician relationship * Correspondence: 1 Medical Research Centre, University of Waikato, Hamilton, New Zealand Full list of author information is available at the end of the article © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Blackmore et al. BMC Family Practice (2020) 21:206 Background New Zealand (NZ) has one of the highest rates of colorectal cancer (CRC) in the world. CRC is NZs second most common cause of cancer mortality with over 1200 deaths per annum from around 3000 registered cases [1]. Māori, the indigenous population, are 30% less likely to be diagnosed with CRC but their mortality rates are only slightly lower than NZ European [2]. NZ has a low rate of early stage CRC diagnosis by international standards [3]. Those diagnosed with early stage (I and II) CRC have a better prognosis - at 90% 5-year survival -than those diagnosed with late stage disease (III or IV), at 14% 5-year survival [4]. However, the proportion of Māori and Pacific peoples who have metastatic CRC at diagnosis is much higher than for NZ European (Māori: 31.6%, Pacific: 34.9%, non-Māori/non-Pacific: 22.8%) [5]. These inequities have a considerable and disproportionate impact on poorer outcomes. Aside from bowel screening, which began gradual regional implementation from 2017 but at the point of this writing has not yet been fully implemented nationwide, improving timely diagnosis is the most important step in ensuring that CRC patients have a better chance at survival [6]. Previous research (the PIPER project) [5] has extensively examined the management of CRC in NZ post-diagnosis and highlighted the need for increased understanding of patient and health system delays prior to diagnosis. Indeed, a NZ Health and Disability Commissioner report (2004–2013) [7], has documented an over-representation of CRC among cancers with longer diagnostic intervals, with the longest times to diagnosis occurring in primary care [7]. Contributing factors to general practitioner (GP) related delay were a lack of clinical examinations and the non-specific presentation of CRC symptoms. Recent research with Māori communities has indicated continuity of care with a trusted GP is needed for general practice to engage better with Māori patients [8]. International studies have indicated that patient, physician and health system delays are key factors associated with late stage diagnosis of CRC. A qualitative study of 20 men in Australia, for example, found delays were associated with patient misinterpretation of symptoms, a failure to attribute symptoms to cancer, and subsequent delays in consulting a health care professional [9]. Other studies have also linked longer diagnostic intervals to CRC symptoms, which are commonly associated with more benign conditions such as irritable bowel syndrome or haemorrhoids, patient-GP communication about symptoms, public and GP awareness of CRC, and hospital system d (...truncated)