Making Decisions About Cancer Screening When the Guidelines Are Unclear or Conflicting
Data Collection and Analysis
Data collection and analysis occurred iteratively.12-14 After every focus group 3 investigators reviewed transcripts independently to identify the central issues that emerged. Over several meetings they compared and combined their independent analyses. Emerging themes were explored and expanded in subsequent focus groups. Although saturation15 had been achieved by the 8th focus group, we completed the final 2 groups to ensure regional representation. The second step in the analysis involved determining the similarities, differences, and potential connections among key words, phrases, and concepts within and among each focus group transcript. Finally, the themes and subcategories of all focus groups were compared and contrasted, and the quotes that most accurately illustrated the themes were identified.
Trustworthiness and Validation
All groups were audiotaped and transcribed verbatim, and extensive field notes were made during the focus groups and throughout the analysis. Validation of the data was achieved by conducting member-checking interviews16 with 15 information-rich participants from the focus groups after completion of the initial analysis. We then refined the themes.
Results
The physicians’ demographics Table 1 reflect the Canadian family physician population.17 Three major themes emerged from the analysis as determinants of cancer screening with unclear or controversial guidelines: patient factors, physician factors, and physician-patient relationship factors Table 2.
Patient Factors
Patient factors included expectations, anxieties, family history, peers, and media influences. Many of the physician participants commented that patient expectations and demands for screening were major determinants of their decision to screen when guidelines were unclear. Although they expressed discomfort with this behavior, physicians acknowledged being frequently swayed by patient demands. One said, “I think that if the patient comes into my office and he wants something, that influences me a hell of a lot.” (QC rural)
The physicians also suggested that patients’ anxieties about cancer were important. The higher the perceived anxiety, the more likely they were to order the relevant cancer screening test, even if the recommendations were unclear. A participant said, “If a patient came in with a particular anxiety and would be allayed by [screening]…I would go ahead and recommend it.” (BC rural)
The presence of any positive family history appeared to influence the physicians’ screening decisions, even if it was not a recognized risk factor in the cancer screening guideline. Physicians also felt that the media is an important influence on patients’ requests for screening. One of the physicians said, “I think the media really influences a lot of patients, and unfortunately it doesn’t always give them the correct information.” (ON urban)
Physician Factors
Physician factors included the perception of guidelines, clinical practice experience, the influence of colleagues, the distinction between the screening styles of specialists and family physicians, and the time and financial costs involved in performing the screening maneuver. The 2 most important determinants appeared to be the physicians’ perceptions of guidelines and their clinical experience.
The physicians’ perception of guidelines had 5 components Table 2. First, many physicians saw guidelines as just guidelines and not as directives. This was most evident when the guideline was viewed as unclear or conflicting. Second, many indicated that unclear guidelines are not guidelines at all and that their task was to individualize the screening decisions to patients and their situations. A participant said, “If they’re unclear, then you have to use your judgment in terms of the patient, your patient population, their follow-up ability, what their risk factors, age, etcetera, are.” (AB rural)
The third perception of guidelines was confusion due to the multiplicity and changing nature of guidelines. One physician said, “As far as breast cancer goes, it appears…things are still…in flux…changing all the time.” (ON urban)
The physicians’ degree of trust in the source of the guideline was the fourth component. A participant said, “If you get a guideline from a consensus group where…a group of specialists get together…including some family docs…certainly I would take that with more…clout.” (AB rural)
The fifth component was the perceived effectiveness of a particular screening maneuver. One physician said, “In the…years that we’ve been [screening] we have found cancers at the stage A and B…that have been easily looked after…. We have not had 1 patient pass away.” (AB rural)
Physicians viewed their clinical experience as influencing their cancer screening decisions, and many felt that they were much more likely to order screening tests early in their careers. A participant said, “In terms of screening there’s a tendency, especially when you’re young and keen and scared, that you’re gonna miss something.” (AB urban)
Physicians were concerned about missing a diagnosis of cancer. If they actually had such an experience, it subsequently lowered their threshold for cancer screening for some time afterward. One physician said, “Suppose you missed a case of colorectal cancer, and someone else finds it; then you tend to run gun shy for a long time and perhaps overinvestigate and over-refer for a time.” (BC rural)
