Open Access Open Badges Study protocol

How do surgeons decide to refer patients for adjuvant cancer treatment? Protocol for a qualitative study

Robin Urquhart1*, Cynthia Kendell1, Joan Sargeant23, Gordon Buduhan4, Paul Johnson4, Daniel Rayson5, Eva Grunfeld67 and Geoffrey A Porter148

Author Affiliations

1 Cancer Outcomes Research Program, Cancer Care Nova Scotia, Halifax, Nova Scotia, Canada

2 Division of Medical Education, Dalhousie University, Halifax, Nova Scotia, Canada

3 Continuing Medical Education, Dalhousie University, Halifax, Nova Scotia, Canada

4 Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada

5 Division of Medical Oncology, Dalhousie University, Halifax, Nova Scotia, Canada

6 Ontario Institute for Cancer Research, Toronto, Ontario, Canada

7 Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada

8 Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada

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Implementation Science 2012, 7:102  doi:10.1186/1748-5908-7-102

Published: 25 October 2012



Non-small cell lung cancer, breast cancer, and colorectal cancer are commonly diagnosed cancers in Canada. Patients diagnosed with early-stage non-small cell lung, breast, or colorectal cancer represent potentially curable populations. For these patients, surgery is the primary mode of treatment, with (neo)adjuvant therapies (e.g., chemotherapy, radiotherapy) recommended according to disease stage. Data from our research in Nova Scotia, as well as others’, demonstrate that a substantial proportion of non-small cell lung cancer and colorectal cancer patients, for whom practice guidelines recommend (neo)adjuvant therapy, are not referred for an oncologist consultation. Conversely, surveillance data and clinical experience suggest that breast cancer patients have much higher referral rates. Since surgery is the primary treatment, the surgeon plays a major role in referring patients to oncologists. Thus, an improved understanding of how surgeons make decisions related to oncology services is important to developing strategies to optimize referral rates. Few studies have examined decision making for (neo)adjuvant therapy from the perspective of the cancer surgeon. This study will use qualitative methods to examine decision-making processes related to referral to oncology services for individuals diagnosed with potentially curable non-small cell lung, breast, or colorectal cancer.


A qualitative study will be conducted, guided by the principles of grounded theory. The study design is informed by our ongoing research, as well as a model of access to health services. The method of data collection will be in-depth, semi structured interviews. We will attempt to recruit all lung, breast, and/or colorectal cancer surgeons in Nova Scotia (n ≈ 42), with the aim of interviewing a minimum of 34 surgeons. Interviews will be audiotaped and transcribed verbatim. Data will be collected and analyzed concurrently, with two investigators independently coding and analyzing the data. Analysis will involve an inductive, grounded approach using constant comparative analysis.


The primary outcomes will be (1) identification of the patient, surgeon, institutional, and health-system factors that influence surgeons’ decisions to refer non-small cell lung, breast, and colorectal cancer patients to oncology services when consideration for (neo)adjuvant therapy is recommended and (2) identification of potential strategies that could optimize referral to oncology for appropriate individuals.

Cancer; Surgeon; Referral rates; Qualitative methods; Grounded theory