Clinicians' Views of Patient-initiated Follow-up in Head and Neck Cancer: a Qualitative Study to Inform the PETNECK2 Trial.

AIMS: Current follow-up for head and neck cancer (HNC) is ineffective, expensive and fails to address patients' needs. The PETNECK2 trial will compare a new model of patient-initiated follow-up (PIFU) with routine scheduled follow-up. This article reports UK clinicians' views about HNC follow-up and PIFU, to inform the trial design. MATERIALS AND METHODS: Online focus groups with surgeons (ear, nose and throat/maxillofacial), oncologists, clinical nurse specialists and allied health professionals. Clinicians were recruited from professional bodies, mailing lists and personal contacts. Focus groups explored views on current follow-up and acceptability of the proposed PIFU intervention and randomised controlled trial design (presented by the study co-chief investigator), preferences, margins of equipoise, potential organisational barriers and thoughts about the content and format of PIFU. Data were interpreted using inductive thematic analysis. RESULTS: Eight focus groups with 34 clinicians were conducted. Clinicians highlighted already known limitations with HNC follow-up - lack of flexibility to address the wide-ranging needs of HNC patients, expense and lack of evidence - and agreed that follow-up needs to change. They were enthusiastic about the PETNECK2 trial to develop and evaluate PIFU but had concerns that PIFU may not suit disengaged patients and may aggravate patient anxiety/fear of recurrence and delay detection of recurrence. Anticipated issues with implementation included ensuring a reliable route back to clinic and workload burden on nurses and allied health professionals. CONCLUSIONS: Clinicians supported the evaluation of PIFU but voiced concerns about barriers to help-seeking. An emphasis on patient engagement, psychosocial issues, symptom reporting and reliable, quick routes back to clinic will be important. Certain patient groups may be less suited to PIFU, which will be evaluated in the trial. Early, meaningful, ongoing engagement with clinical teams and managers around the trial rationale and recruitment process will be important to discourage selective recruitment and address risk-averse behaviour and potential workload burden.

PRIORITISATION IN THE UNITED KINGDON NATIONAL HEALTH SERVICE DURING A NATIONAL EMERGENCY: A QUALITATIVE CASE STUDY OF SURGICAL TEAMS' EXPERIENCES OF COLORECTAL CANCER SURGERY IN THE ACUTE EARLY STAGES OF THE COVID-19 PANDEMIC

Introduction The onset of the COVID-19 pandemic in early 2020 triggered reorganisation of hospital departments around the world as resources were configured to prioritise critical care. In spring 2020, NHS England issued national guidance proposing acceptable time intervals for postponing different types of surgical procedures for patients with cancer and other conditions. The 'Consider-19' study sought to investigate prioritisation decisions in practice, with in-depth examination of colorectal cancer surgery as a case-study, given recommendations that these procedures could be delayed by up to 12 weeks. Methods Twenty-seven semi-structured interviews were conducted with healthcare professionals between June - November 2020. A key informant sampling approach was used, followed by snowballing to achieve maximum regional variation across the UK. Data were analysed thematically using the constant comparison approach. Results Interviewees reported a spectrum of perceived disruption to colorectal cancer surgery services in the early phase of the pandemic, with some services reporting greater scarcity of resources than others. Nonetheless, all reported a need to prioritise patients based on local judgments. Prioritisation was framed by many as unfamiliar territory, requiring significant deliberation and emotional effort. Whilst national guidance provided a framework for prioritising, it was largely left to local teams to devise processes for prioritising within surgical specialities and then between different specialities, resulting in much local variation in practice. Discussion The pandemic necessitated a significant change in practice as surgeons, in a tense and uncertain situation, found themselves having to navigate clinically, emotionally, and ethically- charged decisions about how best to use limited surgical resources. Whilst unavoidable, many felt uncomfortable with the task and the consequences for their patients. The findings point to a need to better support surgeons tasked with prioritising patients and raise questions about who should be involved in this activity.