Healthcare practices that increase the quality of care in cancer trajectories from a general practice perspective: a scoping review

Figures & data

Table 1. Definition of quality healthcare based on a summary of a selection of the main components of definitions of quality healthcare in the reference [24].

Definition of quality healthcare
In accordance with the WHO, quality healthcare should be:
Effective: providing evidence-based healthcare services to those who need them Safe: avoiding harm to people for whom the care is intended People-centred: providing care that responds to individual preferences, needs and values Timely: reducing waiting times and sometimes harmful delays for those who both receive and give care Equitable: providing care that does not vary in quality on account of age, sex, gender, race, ethnicity, geographical location, religion, socioeconomic status, linguistic or political affiliation Integrated: providing care that is coordinated across levels and providers, and makes available the full range of healthcare services throughout the life course Efficient: maximizing the benefit of available resources and avoiding waste

Figure 1. PRISMA-ScR flowchart presenting the study selection process in the systematic scoping review.

Table 2. Study characteristics organized by study methodology and cancer trajectory phase.

Authors (year), country	Trajectory phase(s)	Participant and data characteristics	Aim of the article
Intervention studies
Grange et al. (2014), France [29]	2. First presentation and investigation of symptoms	Self-reported questionnaires from 364 GPs at baseline	To investigate the efficacy of a general practitioner awareness and training campaign compared for improving early diagnosis of melanoma
Toftegaard et al. (2016), Denmark [30]	2. First presentation and investigation of symptoms 3. Referral to secondary care	Self-reported questionnaires from 202 GPs at baseline Self-completed forms for cancer risk-assessment from 532 GPs before and 524 GPs after continuing medical education (CME)	To investigate the effect of standardized CME aimed to optimize cancer-related referrals from general practice to hospitals by reducing the GPs’ referral threshold and to increase their knowledge about cancer symptoms to identify underlying cancers at an earlier stage
Wieldraaijer et al. (2019), Netherlands [75]	4. Diagnosis 5. Treatment	Self-reported questionnaires from 170 colorectal cancer patients (72 patients before and 98 patients after the introduction)	To investigate the effect of introducing “time out consultations” (TOC) with GPs between diagnosis and active treatment, on change in number, kind, and content of consultations, and in patient-reported outcomes
Bergholdt et al. (2013a), Denmark [57]	5. Treatment 6. Follow-up	Self-reported questionnaires from 612 newly diagnosed cancer patients at baseline (intervention group n = 296, control group n = 316) and 776 GPs (intervention group n = 399, control group n = 377)	To evaluate the effects of an intervention encouraging early involvement of GPs in cancer rehabilitation assessed on satisfaction of patients with their GP in general, in relation to the cancer course, and in GPs’ self-reported satisfaction with their own contribution to their patients’ physical and psychosocial rehabilitation.
Bergholdt et al. (2013 b), Denmark [66]	5. Treatment 6. Follow-up	Self-reported questionnaires from 612 newly diagnosed cancer patients at baseline (intervention group n = 296, control group n = 316) and 752 GPs (intervention group n = 373, control group n = 379)	To evaluate effects of the intervention encouraging GPs to proactively contacting patients, on patients’ participation in rehabilitation activities, and on whether proactivity is associated with patients’ participation in rehabilitation
Bergholdt et al. (2012), Denmark [65]	5. Treatment 6. Follow-up	Self-reported questionnaires from 612 newly diagnosed cancer patients at baseline (intervention group n = 296, control group n = 316) and 752 GPs (intervention group n = 373, control group n = 379)	To investigate the effect of an intervention giving the GP an enhanced role in improving patients’ health-related quality of life and psychological distress following cancer
Boekhout et al. (2015), Canada [68]	5. Treatment 6. Follow-up	Self-reported questionnaires from 337 breast cancer patients at baseline (Intervention n = 164, Control n = 173)	To investigate the effect of implementing a shared care plan in the transition of survivorship care from specialists to primary care physicians (PCP) on health service outcomes and patient-reported outcomes
Fairweather et al. (2020), Australia [55]	5. Treatment 6. Follow-up 7. Palliative care	Self-reported questionnaires from 35 GPs and 17 hospital staff	To improve two-way communication between hospital- and community-based care providers by having two GPs from the local community attending multi-disciplinary meetings in a liaison role as a primary care representative
Stegmann et al. (2020) Netherlands [53]	5. Treatment	Self-reported questionnaires from 114 older patients with non-curable cancer at baseline (Intervention group n = 53, control group n = 61)	To assess the utility of the Outcome Prioritisation Tool (OPT), designed to aid GPs discussion with a patient about treatment goals and to empower patients
Trabjerg et al. (2020 b) Denmark [48]	5. Treatment 6. Follow-up 7. Palliative care	Self-reported questionnaires from 44 cancer patients at baseline assigned to the intervention group (breast n = 6, lung n = 17, colorectal n = 15, others n = 6), 39 GPs and 15 oncologists	To analyze video consultations (The Partnership Intervention) from a user perspective (patients, GPs and oncologists), based on three surveys of patients enrolled in the intervention group, their oncologists, and GPs
Pelayo-Alvarez et al. (2013), Spain [73]	7. Palliative care	Self-reported questionnaires from 117 patients with advanced cancer (10 different cancer types) at baseline (Intervention n = 63, Control n = 54), 84 caregivers at baseline (Intervention n = 48, Control n = 36) and 145 PCPs at baseline	To investigate the effect of an online education model for palliative care (PC) targeted to primary care physicians (PCPs) on symptom control, quality of Life (QOL), main caregiver satisfaction, PCP’s level of knowledge, and PCP’s attitude towards PC and satisfaction.
Interview and observation studies
Bergin et al. (2020), Australia [27]	1. Awareness of patients’ bodily sensations and unexplained symptoms 2. First presentation and investigation of symptoms 4. Diagnosis	43 interviews with cancer patients post diagnosis Colorectal cancer (n = 21) Breast cancer (n = 22) Supplemented with information from a patient, Primary Care Practitioner (PCP), and specialist survey	To explore how and why cancer pathways may differ by residential location for colorectal and breast cancers with different rural-urban disparity profiles
Almuammar (2020), Saudi Arabia [31]	2. First presentation and investigation of symptoms	Interviews with 20 patients with common cancer diagnosis, and 15 GPs	To investigate factors that contribute to ‘late-stage presentation’ of common cancers at cancer centers from a patient and GP perspective
Amelung et al. (2020), England [34]	2. First investigation and presentation of symptoms	Qualitative analysis of 80 video-consultations. 20 interviews with patients presenting a new or persistent problem in general practice, and 7 GP interviews representing 7 general practices	To understand doctor-patient communication around the significance of persistent or new presenting problems and its potential impact on timely cancer diagnosis
Brindle et al. (2012), England [25]	2. First presentation and investigation of symptoms	Interviews with 22 patients with early-stage lung cancer	To investigate why symptoms indicative of early-stage lung cancer were not presented to general practitioners and how early symptoms might be better elicited within primary care
Clarke et al. (2014), England [28]	2. First presentation and investigation of symptoms	Interviews with 18 mothers and 3 fathers of 18 children with a diagnosis of acute leukemia, and 9 GP’s	To investigate the prehospital presentation of pediatric leukemia and identify the disease and non-disease related factors which facilitate or impede diagnosis
Evans et al. (2019), UK [35]	2. First presentation and investigation of symptoms	Interviews with 23 cancer patients and 25 GPs	To explore patients’ and GP’s accounts of how responsibility for follow-up was perceived and shared in their experiences of cancer safety netting occurring within the past 6 months
Hultstrand et al. (2020a), Sweden [26]	2. First presentation and investigation of symptoms	Observation of 18 consultations with patients seeking care for sensations/symptoms that could indicate cancer, or had worries about cancer and the involved GP	To explore how presentations of bodily sensations were constructed and legitimized in primary care encounters within the context of Standard Cancer Patient Pathways
Hultstrand et al. (2020 b), Sweden [33]	2. First presentation and investigation of symptoms	13 interviews with GPs at 4 primary healthcare centers	To explore how GPs assign meanings and act upon patients’ symptoms in primary care encounters in the context of standardized cancer patient pathways
DiCicco-Bloom et al. (2013), USA [47]	2. First presentation and investigation of symptoms 4. Diagnosis 5. Treatment 6. Follow-up	Interviews with 11 primary care physicians (PCPs) and 10 nurse practitioners	To provide a better understanding of the nature of interactions among PCPs, patients, and oncologists throughout the cancer care continuum, to better understand the transition to survivorship
Piano et al. (2019), UK [38]	3. Referral to secondary care	Four focus groups with 29 patients who have completed diagnostic tests and received a non-malign test result within the last 6 months	To explore public attitudes towards the Faster Diagnosis Standard (FDS) within the context of recent referral experiences
Dahlhaus et al. (2014), Germany [41]	4. Diagnosis 5. Treatment 6. Follow-up	Interviews with 30 GPs	To provide a better understanding of the nature of interactions among primary care clinicians, patients, and oncologists throughout the cancer care continuum to better understand the transition to survivorship
Coindard et al. (2016), France [50]	5. Treatment	Interviews with 50 cancer patients Breast cancer (n = 20) Colorectal cancer (n = 14) Lung cancer (n = 9) Prostate cancer (n = 7)	To investigate if and why cancer patients consult their GP during the initial phase with intravenous chemotherapy, and assessment of their GP’s role in their treatment
Brandenbarg et al. (2016), Netherlands [49]	5. Treatment 6. Follow-up	Interviews with 22 cancer patients Colon cancer (n = 14) Rectum cancer (n = 8)	To clarify experiences and preferences of patients regarding the current and future role of general practitioners during treatment and follow-up care of colorectal cancer
Burridge et al. (2011), Australia [44]	5. Treatment 6. Follow-up 7. Palliative care	Interviews with 6 lay cancer caregivers and 19 health professionals Practicing GP (n = 6), palliative specialist (n = 5), oncologist (n = 2), caregiver representatives (n = 3), and other (n = 3)	To examine what the views of lay caregivers and health professionals reveal about the way lay caregivers’ health concerns are raised with their GP
Hall et al. (2012), UK/Scotland [54]	5. Treatment 6. Follow-up	Interviews in year 2002: 39 colorectal cancer (CRC) patients Interviews in year 2009: 30 CRC patients	To explore experiences and support needs of people with CRC To identify opportunities for supportive primary care interventions with potential to benefit people with CRC
Browne et al. (2011), Scotland [42]	5. Treatment 6. Follow-up	Interviews with 24 newly diagnosed colorectal cancer patients (15 female/9 males age range 34–84 years)	To explore colorectal cancer patients’ experiences of psychosocial problems and their management in primary and specialist care
Adams et al. (2011), England [36]	6. Follow-up	Interviews with 38 patients with 12 different cancer types Six focus groups with primary care teams from 6 practices (31 GPs, 1 GP trainee, 1 medical student, 13 practice nurses, 2 district nurses, and 23 other healthcare professionals)	To implement the Quality and Outcomes Framework (QOF) cancer care review, and to investigate: patients’ experiences of primary care over the first 3 years following a cancer diagnosis, patients’ views on optimal care, and views of primary care professionals regarding cancer care
Bowmann et al. 2010, USA [67]	6. Follow-up	Interviews with 215 older long-term cancer survivors Breast cancer (49.8%) Colorectal cancer (24.7%) Prostate cancer (25.6%)	To investigate cancer survivors’ reports of primary care physicians (PCP) involvement in; discussing cancer history, whether the PCP initiated discussions, and whether discussions led to tests/procedures
Geelen et al. (2014), Netherlands [62]	6. Follow-up	Interviews with 35 primary care professionals (11 GPs)	To explore how a proactive and holistic approach in cancer survivorship care fit in with ‘habitus’ and everyday practice of GPs
Margariti et al. (2020), England [58]	6. Follow-up	Semi-structured telephone interviews with 20 GPs	To examine the preparedness, concerns, and experiences of GPs in relation to their role in providing follow-up care to prostate cancer survivors
Murchie et al. (2010), Scotland [39]	6. Follow-up	Interviews with 18 patients with cutaneous melanoma, purposely sampled from the intervention group in an RCT study assessing the effect of GP-led melanoma follow-up	To explore patient’s practical experiences and feelings about receiving structured melanoma follow-up from their GP
van Leeuwen et al. (2018), Netherlands [60]	6. Follow-up	Interviews with 10 GPs participating in a project where GPs were responsible for complete survivorship care including recurrence detections and rehabilitation	To evaluate the experiences of GPs with monthly oncology meetings in a GP-practice to support GP-led survivorship care of colon cancer patients
Waterland et al. (2020), Australia [64]	6. Follow-up 7. Palliative care	Interviews with 23 GPs	To report GPs’ experiences of providing nutrition and exercise advice to their patients, and to identify perceived barriers and enablers to further implementation of exercise and nutrition advice throughout the cancer journey from a GP perspective
Beernaert et al. (2014), Belgium [46]	7. Palliative care	Interviews with 18 patients: Cancer (n = 6), COPD (n = 3), Heart failure (n = 3), Dementia (n = 6) Six focus groups with family physicians (n = 20) and community nurses (n = 12)	To explore the barriers to and facilitators of the early identification by family physicians of the palliative care needs
Couchman et al. (2020), England [74]	7. Palliative care	Interviews with 15 cancer patients	To explore patients’ views and experiences of: The role of the family physician (FP) in providing palliative care to adult patients with cancer, and the facilitators and barriers to the FP’s ability to fulfil this perceived role
van Gurp et al. (2016), Netherlands [59]	7. Palliative care	Observation of 129 teleconsultations with 18 palliative care patients (n = 16 cancer patients, 17 informal caregivers, 15 primary care physicians (PCPs) and 12 specialist palliative care team clinicians (SPCT) Interviews with 9 patients, 9 informal caregivers, 14 PCPs and 1 homecare nurse	To explore whether and how teleconsultation supports the integration of primary care, specialist palliative care, and patient perspectives and services How patients and (in)formal caregivers experience collaboration in a teleconsultation approach
Other peer-reviewed studies
Fraulob et al. (2020) England [32]	2. First presentation and investigation of symptoms 3. Referral to secondary care 4. Diagnosis 5. Treatment 6. Follow-up	84 specific comments about general practice in a qualitative survey feedback from brain cancer patients	To understand patients’ experiences of general practice care in more detail by identifying the range of issues described in comments and to use these analyses to suggest ways in which care and support may be improved.
Noteboom et al. (2020), Netherlands [51]	4. Diagnosis 5. Treatment	Patients with a new diagnosis of metastatic gastrointestinal or lung cancer, or having changes in treatment perspective Self-reported questionnaires from patients (n = 12), GPs (n = 18), specialist (n = 8) Semi-structured interviews: 9 patients and 5 GPs	To explore uptake and first experiences with a Time Out Consultation (TOC) concerning experienced added value for Shared Decision Making (SDM) according to patients, family physicians and specialists
Trabjerg et al. (2020a), Denmark [52]	5. Treatment 6. Follow-up 7. Palliative care	Recordings of 12 video consultations with 12 cancer patients (colorectal n = 2, lung n = 6, gynecological n = 1, breast n = 1, pancreatic n = 2), 8 oncologists, and 11 GPs	To explore the consultation structure, health concerns, and patient-centeredness when two doctors are attending consultations through video with a patient with cancer at the offices of oncologists or GPs
Collie et al. (2014), Canada [56]	6. Follow-up	Survey of 54 cancer survivors (Head-and-neck and breast cancer), 22 family physicians, and 9 nurses Interviews with cancer survivors and healthcare professionals Head-and-neck cancer (n = 4), Breast cancer (n = 8) Family physicians (n = 3), Specialist nurses (n = 9)	To assess the value of survivorship care plans for cancer survivors
Nababan et al. (2020), Australia [63]	6. Follow-up	Questionnaires: 75 lung cancer patients Interviews: 47 lung cancer patients	To assess patients’ experience of GP involvement following lung cancer diagnosis, and patients’ view on communication between hospital cancer specialists and GPs
Rio et al. (2017), Australia [70]	6. Follow-up	73 patients with endometrial cancer Survey (n = 31 patients) In-depth phone surveys (n = 5 patients) Review of medical records in pre-model cohort group (n = 20) GPs of the 73 patients (n = 72 GPs) Survey: 37 GPs	To develop a GP model of follow-up care after surgical treatment with early endometrial cancer that provide comprehensive clinical handover to GP and was acceptable for both patients and GPs
Hackett et al. (2018), UK [72]	7. Palliative care	5 focus groups with 27 health professionals (6 GPs) Survey of 24 general practice managers or GP leads Observations of multidisciplinary GSF-meetings in 3 general practices (n = 32 health professionals) 8 interviews with healthcare professionals (3 GPs)	To improve understanding of variations in practice using the Gold Standards Framework (GSF: A description of a number of evidence-based principles of practice as a guide for the care of palliative patients and their families) through exploring the perspectives and experiences of members of primary healthcare teams involved in the care of patients with advanced cancer
Finucane et al. (2020), Scotland [71]	Review: 7. Palliative care Interview: 7. Palliative care	Review of 1034 patient journals of deceased patients Cancer patients (n = 361) Organ failure (n = 265) Frailty and/or dementia (n = 408) Interviews with GPs in 17 practices (n = 17), and in one practice two nurses was interviewed	To estimate the proportion of people with an advanced progressive illness who had a Key information summary (KIS) by the time of death and when the KIS was started To identify which elements of anticipatory care planning were most frequently recorded in the KIS To explore general practice staff perceptions of the KIS
Non-peer-reviewed case reports
Larsen et al. (2014), Denmark [43]	2. First presentation and investigation of symptoms 4. Diagnosis 5. Treatment 6. Follow-up 7. Palliative care	50 very ill patients, mostly cancer patients One general practice	To describe experiences of a proactive approach of care towards very ill patients throughout their cancer trajectory
Albinus (2013), Denmark [40]	3. Referral to secondary care 4. Diagnosis 5. Treatment 6. Follow-up 7. Palliative care	Newly diagnosed cancer patients and patients referred with cancer suspicion A general practice (consisting of 3 GPs)	To describe experiences from a general practice with having close contact with patients during the entire cancer trajectory, from referral to secondary care until death or recovery.
NHS (2019), Great Britain [61]	6. Follow-up	Group consultations arranged by one general practice nurse: One group with gynecological cancer patients and similar cancer patients (similar not specified) One group with prostate cancer patients	To describe experiences with a group consultation model for cancer patients in general practice after completion of an accredited education program on group consultations
Hoffmann (2015), Denmark [69]	6. Follow-up 7. Palliative care	General practitioners (GPs) and the departments of urology in Central Denmark Region, with GPs having 0–2 primarily curative treated prostate patients without recurrence and prostate cancer patients with disseminated cancer	To describe experiences from a shared care-project between urology department in hospital and general practice of patients with prostate cancer. When it is possible hospital follow-ups for prostate cancer patients is moved to general practice.
Non-peer-reviewed reports
Danish Cancer Society (2017), Denmark [37]	2. First presentation and investigation of symptoms 3. Referral to secondary care 5. Treatment	A survey of 5,389 cancer patients	To clarify patient perspectives on the cancer trajectory from first symptoms and contact to the healthcare system, and onwards to completed treatment in secondary care
Danish Cancer Society (2019), Denmark [45]	6. Follow-up 7. Palliative care	A survey of 3,153 cancer patients	To clarify needs and experiences of cancer patients ∼2.5 years after their cancer diagnosis

Table 3. Identified healthcare practices that increase the quality of care, their corresponding cancer trajectory phases, and components of quality healthcare.

Healthcare practices that increase quality of care	Cancer trajectory phases	Components of quality healthcare
Listen carefully to the full story	1. Awareness of patients’ bodily sensations and unexplained symptoms 2. First presentation and investigation of symptoms 3. Referral to secondary care 4. Diagnosis 5. Treatment 6. Follow-up 7. Palliation	Efficient quality of care Equitable quality of care People-centered quality of care Timely quality of care
Use action plans and time-out-consultations	1. Awareness of patients’ bodily sensations and unexplained symptoms 2. First presentation and investigation of symptoms 3. Referral to secondary care 4. Diagnosis 5. Treatment 6. Follow-up 7. Palliation	Efficient quality of care Integrated quality of care People-centered quality of care Safe quality of care Timely quality of care
Plan and provide proactive care	4. Diagnosis 5. Treatment 6. Follow-up	Effective quality of care Efficient quality of care Integrated quality care People-centered quality of care Safe quality of care Timely quality of care
Act as an interpreter of diagnosis, treatment options, and its consequences for the patient	4. Diagnosis 5. Treatment 6. Follow-up	Effective quality of care Efficient quality of care People-centered quality of care Safe quality of care
Coordinate care with specialists, patients, and caregivers with mutual respect	4. Diagnosis 5. Treatment 6. Follow-up	Effective quality of care Efficient quality of care Integrated quality of care People-centered quality of care Timely quality of care

Table A.1. Example of search in Medline using a combination of three search blocks.

Search block	Search terms
1	Cancer* OR neoplasm*
2	Patient pathway* OR continuity of patient care OR shared care OR co-manag* OR patient care manag* OR collaborative care OR care coordinat* OR continuum OR proactive care OR relationship centered care OR patient-focused care OR patient-centered nursing OR patient-centered communication OR shared decision* OR physician-patient relation* OR nurse-patient relation* OR attitude of health personnel OR attitude of patient* OR communication OR professional competence* OR patient experience* OR caregiver experience*
3	General practice OR general practice staff OR general practitioner* OR primary care physician* OR patient care team OR family physician OR primary care practitioner* OR family practice*

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