Feasibility and acceptability of a community pharmacy referral service for suspected lung cancer symptoms

Abstract

BackgroundLung cancer survival rates in the UK are among the lowest in Europe, principally due to late-stage diagnosis. Alternative routes to earlier diagnosis of lung cancer are needed in socioeconomically deprived communities that are disproportionately affected by poor lung cancer outcomes. We assessed the feasibility and acceptability of a community-based pharmacy referral service to encourage earlier symptomatic referral for chest X-rays.MethodsSeventeen community pharmacies located in a deprived area of Wales participated between March 2019 and March 2020. Stakeholder interviews were conducted with four patients, seven pharmacy professionals and one general practitioner. Four focus groups were conducted, including one with healthcare professionals (n=6) and three with members of the public who were current and former smokers (n=13). Quantitative data regarding patient characteristics and clinical outcomes were collected from hospital records and patient referral questionnaires completed by pharmacists and analysed using descriptive statistics. Qualitative data sets were analysed thematically and triangulated.ResultsTwelve patients used the pharmacy referral service, all of whom were male. Average length of the pharmacy consultation was 13 min, with a mean 3 days to accessing chest X-rays in secondary care. Patients experienced a mean 46-day wait for results, with no lung cancer detected. Participants found the service to be acceptable and considered the pharmacy element to be broadly feasible. Perceived barriers included low awareness of the service and concerns about the role and capacity of pharmacists to deliver the service. Facilitators included perceived approachability and accessibility of pharmacists. A well-publicised, multifaceted awareness campaign was recommended.ConclusionsA community pharmacy referral service for lung symptoms was considered an acceptable alternative pathway to symptomatic diagnosis of lung cancer in deprived communities. Wider implementation of the service would require workforce capacity and training to be addressed to ensure optimum utilisation and promotion of the service.

Qualitative interview study exploring the early identification and referral of patients with suspected head and neck cancer by community pharmacists in England

“…This study, however, found that frequent purchases of the same medication were not explored fully, highlighting the potential for patients with ongoing symptoms to be missed 18. Several small-scale pilots have also found that pharmacist integration into lung cancer referral pathways is both feasible and acceptable, resulting in high-quality referrals 19 20. However, outcome data are currently very limited and barriers to successful implementation were identified to include a lack of patient awareness of such services and pharmacists’ roles, and concerns about perceived impacts on workloads.…”

Diagnosing cancer in English community pharmacies

“…Persistent cough was overwhelmingly the most common symptom reported (46%) 21. In the UK, three studies have evaluated initiatives to enable pharmacists to identify and refer people for chest radiography2223 or to a hospital clinic for further assessment 24. In total 69 pharmacies were involved, with 69 people referred for investigation, equating to 0.06-0.4 patients per pharmacy per month having a chest x ray examination.…”

“…The number of informal consultations community pharmacists deliver is increasing, and currently stands at around 20 a day, each lasting about six minutes 31. Consultations for cancer symptoms are likely to be more time consuming—for example, assessment for referral to chest radiography in pharmacy takes over twice this time 22. Even if staff in community pharmacies receive training to assess for cancer symptoms, they may not have time to deliver such consultations at scale.…”

“…If community pharmacists had lower thresholds to request testing or referral—for example, because of incentives or less time available and the experience of managing test results—this could increase risk of adverse consequences such as overdiagnosis and health service costs. However, evidence from the pilot schemes for lung cancer has indicated that pharmacists arrange tests infrequently 222324…”

Oral cancer awareness and education within the pharmacy profession

“…Development of such pathways are likely to be complex with input from multiple stakeholders but may provide an opportunity to utilise an established network of highly accessible healthcare venues to help the NHS meet its targets around early detection of cancers. Pilot studies involving direct referral of patients with symptoms of possible lungs cancer from community pharmacies have demonstrated high levels of fidelity with national referral criteria, and high levels of patient satisfaction [19][20][21] ; further research in this area involving other malignancies, including oral cancers is needed. Online risk calculators are tools that can be used to guide clinicians in decision-making around the need for (priority) referral 22 .…”