Programme no. 237-OP
Public Health
Could it be colorectal cancer? General Practitioners' use of Faecal Occult Blood Tests and navigation towards decision on referral - a qualitative study.
Cecilia Högberg*1, Eva Samuelsson2, Mikael Lilja3, Eva Fhärm4
1Department of Public Health and Clinical Medicine, Unit of Clinical Research Centre - Östersund,Umeå University,Umeå,Sweden, 2Department of Public Health and Clinical Medicine, Unit of Clinical Research Centre - Östersund,Umeå University,Umeå,Sweden, 3Department of Public Health and Clinical Medicine, Unit of Clinical Research Centre - Östersund,Umeå University,Umeå,Sweden, 4Department of Public Health and Clinical Medicine, Family Medicine,Umeå University,Umeå,Sweden
* = Presenting author
Objectives: To explore what makes GPs suspect crc and their practice concerning investigation and referral.
Background: Abdominal complaints are common reasons to contact General Practitioners (GPs), and mostly caused by benign conditions. It can be a challenge to sort out the patients with suspected colorectal cancer (crc) needing investigation in secondary care. A diagnostic aid frequently used in Sweden and other countries is Faecal Occult Blood Test (FOBT). There are however no guidelines for the use of FOBTs, and it is uncertain how test results are interpreted in everyday clinical practice. Studies have shown that negative tests are associated with a risk of delayed diagnosis, and that many patients with positive tests are not investigated further. The reasons for this are unclear.
Results: Eleven GPs were interviewed. The analysis resulted in five categories:

1. Careful listening to the patient’s history required: Listening attentively was emphasized as essential, but with a risk of being misled by the patient’s own explanations.

2. Tests can be of help - FOBTs can help or complicate: Anaemia was generally considered an important factor. FOBTs were used by all the interviewed, but in varying degrees, and interpretation and consequences of the results varied.

3. To refer or not to refer - safety margins necessary: Uncertainty was described as often present in everyday work. Common vague symptoms could be crc and justified referral with safety margins.

4. Growing more confident - yet humble: With increasing experience the GPs described becoming more confident in decisions but also more humble and less prestigious.

5. The patient’s advocate: The GPs adapted to a constantly changing reality, striving to keep the patient’s best in focus.

Material/Methods: Semi-structured individual interviews were made with strategically selected GPs in the county of Jämtland, Sweden, and analysed with qualitative content analysis. All interviews were performed, audiotaped, and transcribed verbatim by CH. CH and at least one other author separately coded each interview. Consensus on saturation, codes, categories, and further analysis was reached through group discussions.
Conclusion: In deciding which patients to refer careful listening to the patient’s history is found essential, and FOBTs are frequently used as support. There is an awareness of the limitations of FOBTs but a considerable variation in ways to handle the test results. The diagnostic process can be described as navigating uncertain waters with safety margins.
Points for discussion: Transferability to other settings?

Experiences from other countries?

Further research in this area?