Protocol for a Programme of Mixed-Methods Policy Research to Inform Primary Care’s Role in Symptomatic Early Cancer Detection in Ireland

Global burden of cancer

Cancer remains one of the leading causes of morbidity and mortality worldwide, with profound implications for healthcare systems and public health policies. Globally, cancer incidence continues to rise, driven by ageing populations, lifestyle factors, and environmental influences. In Ireland, cancer poses a particularly significant challenge, accounting for nearly 30% of registered deaths in 2022¹. Projections from the National Cancer Registry of Ireland indicate that certain cancer incidence will more than double in men and almost double in women between 2015 and 2045². These trends highlight the urgency of strengthening cancer control strategies, particularly in prevention and early detection, which are critical to improving survival rates and reducing the societal burden of cancer.

Ireland’s cancer control strategy

Ireland’s approach to cancer control has evolved over the last two decades, with the National Cancer Strategy 2017–2026 representing a cornerstone document for guiding national efforts³. This strategy outlines a comprehensive framework targeting prevention, early diagnosis, screening, treatment, survivorship, and palliative care. Its goals include reducing cancer incidence, improving survival outcomes, ensuring equitable access to timely care, and embedding research into practice.

Despite these ambitious objectives, challenges remain. Persistent issues such as acute care pressures, workforce shortages, regional disparities in care quality, and suboptimal resource allocation have limited progress in achieving consistent cancer outcomes across the country³. Furthermore, much of the focus within Ireland’s cancer policy has been on specialist and acute care, with comparatively limited emphasis on primary care’s role in cancer control³.

Role of primary care in early cancer detection

Primary care plays a pivotal role in the early detection of cancer, often serving as the first point of contact for patients with undifferentiated symptoms. In Ireland, general practitioners (GPs) are responsible for recognising early warning signs, initiating diagnostic tests, and coordinating timely referrals to specialist services⁴. Evidence suggests that optimising primary care pathways can reduce delays in diagnosis, decrease emergency presentations, and improve overall cancer outcomes^4,5.

However, significant barriers hinder the effectiveness of primary care in Ireland. These include limited direct access to diagnostic tools, variability in referral practices, and inconsistent integration of primary care into the broader cancer care network^6,7. The mixed public-private healthcare system further complicates equitable access to diagnostics and care coordination. Addressing these challenges requires targeted interventions, including clearer referral pathways, enhanced diagnostic capacity in primary care settings, and strengthened connections between primary and secondary care.

International perspectives on primary care and cancer control

Internationally, primary care has been recognised as a cornerstone of effective cancer control strategies. The International Cancer Benchmarking Partnership (ICBP) has provided valuable insights into variations in cancer outcomes across countries such as Australia, Canada, Denmark, Norway, Sweden, and the UK⁸. Key factors influencing these outcomes include the availability of direct access to diagnostic tests, structured referral pathways for non-specific symptoms, and the autonomy of primary care practitioners in decision-making⁹.

Countries with well-integrated primary care systems often demonstrate faster cancer diagnoses and better survival rates. For instance, Denmark and Sweden have implemented managed diagnostic pathways and fast-track referral systems, which have been associated with reduced diagnostic delays and improved outcomes¹⁰. Learning from such models offers valuable opportunities for Ireland to adapt evidence-based practices to its unique healthcare context. However, adapting these international strategies requires careful consideration of Ireland’s mixed healthcare system, which combines public and private service delivery.

Aim & objectives

The overarching aim of this research is to analyse and enhance primary care’s role in early cancer detection in Ireland. Specifically, the research will:

•   Analyse existing cancer control policies in Ireland to assess the effectiveness and integration of primary care in early detection efforts.

•   Compare Ireland’s approach to international models to identify transferable practices and systemic improvements.

•   Develop evidence-based recommendations to strengthen the capacity and integration of primary care within Ireland’s cancer control framework.

Study design

This study adopts a mixed-methods design, integrating qualitative approaches to examine primary care’s role in early cancer detection in Ireland. The research comprises three interlinked studies: (1) a documentary analysis of Irish cancer control policies using a systematic content analysis framework, (2) a comparative rapid review of international cancer control models, and (3) the synthesis of documentary analysis and rapid review findings for the development of evidence-based policy recommendations informed by stakeholder engagement in semi-structure interviews and roundtable discissions. The design ensures a systematic and comprehensive evaluation of current practices, international insights, and stakeholder perspectives. Reporting will adhere to the Standards for Reporting Qualitative Research (SRQR) guidelines by providing a detailed account of the study’s methodology, including participant selection, data collection procedures, analytical approach, and measures taken to ensure credibility, reflexivity, and rigor¹¹.

Context

Ireland’s healthcare system is characterised by a mixed public-private model, with primary care largely delivered by General Practitioners (GPs) who act as gatekeepers for patient access to specialist care^10,12. Cancer is a leading cause of morbidity and mortality in Ireland, with projected incidence rates expected to more than double in men and almost double in women between 2015 and 2045¹³. Although survival rates have improved over the past decade, disparities persist in diagnostic access and cancer outcomes, particularly in rural and underserved areas^14,15. Addressing these challenges requires strengthening the integration of primary care into the cancer control pathway, as emphasised in the National Cancer Strategy 2017–2026.

This research will focus exclusively on primary care’s role in symptomatic detection of cancer, excluding areas such as asymptomatic screening, cancer treatment, survivorship, and palliative care.

Study 1: Documentary analysis of Irish cancer control policies

Aim: To systematically evaluate Irish policy documents and strategies supporting early cancer detection in primary care, with a focus on implementation effectiveness and gaps in service delivery.

Methods: The study will follow Bowen’s framework for qualitative document analysis¹⁶. Relevant documents, including policy papers, government reports, and guidelines, will be identified through systematic searches of electronic databases (e.g., PubMed, Scopus, Web of Science), grey literature sources (e.g., Health Service Executive reports, National Cancer Strategy documents) and snow balling techniques.

Search Strategy: Search terms will include: “Primary Care”, “Early Cancer Detection”, “Health Policy”, “Ireland”, “General Practice”, and “Cancer Diagnosis”. Searches will include documents published in English from the year 2000 onwards.

Inclusion and Exclusion Criteria: The review will include documents explicitly addressing primary care’s role in cancer detection in Ireland and exclude those solely focussed on secondary or tertiary care.

Data Extraction & Analysis: A standardised data extraction template will be used to capture document details, focus areas, and key findings (refer to extended data- Table 1). Qualitative content analysis will be conducted to identify themes and sub-themes related to policy strengths, implementation barriers, and gaps in service delivery.

Data Synthesis: The synthesis will integrate findings from various sources to construct a comprehensive overview of primary care’s current role in cancer detection in Ireland. It will focus on summarising key themes, identifying policy gaps, and highlighting areas requiring further investigation or immediate action. This phase aims to consolidate domestic data to set an understanding for subsequent studies, particularly before comparing with international models.

Study 2: Comparative analysis of international cancer control models

Aim: To identify best practices from international models of early cancer detection in primary care and evaluate their applicability to Ireland’s healthcare system.

Methods: A rapid review methodology will be employed, following the guidance of the Cochrane Rapid Review Methods Group (RRMG)^17,18.

Search Strategy: Searches will be conducted in PubMed, Scopus, Web of Science, and Google Scholar, with additional grey literature sourced from global health organisations and government publications. The search will include terms such as "Primary Care", "Early Detection", “Cancer Screening”, "Health Policy", "Best Practices", "International Models", and "Healthcare Systems". The strategy will be designed to identify models that have shown efficacy in diverse healthcare systems. Given the rapid review nature, the search will be limited to the most recent and relevant publications, primarily focusing on documents published within the last ten years. Included documents will be those that detail primary care interventions, policies, or practices proven effective in cancer control and are applicable to mixed healthcare systems like Ireland's.

Data Extraction and Analysis: A standardised data extraction template will capture details on model descriptions, effectiveness measures, and contextual factors. Thematic analysis will identify common features and variations in effective practices, including referral pathways, diagnostic access, and system integration.

Data Synthesis: The synthesis phase will integrate findings from the rapid review to offer a comparative perspective that highlights actionable insights and innovative practices that could be considered for implementation in Ireland.

Study 3: Development of policy recommendations

Aim: To synthesise findings from the first two studies and develop evidence-informed, actionable policy recommendations to strengthen early cancer detection in primary care in Ireland.

Methods: This study will integrate findings from the previous studies with new qualitative data obtained through expert interviews and policy roundtable discussions. These discussions will involve a broad spectrum of stakeholders, including healthcare professionals, policymakers, and patient advocates. The methodology is informed by the approach used in the study "Addressing Cancer Care Disparities Across the Cancer Care Continuum"¹⁹, which employed multi-stakeholder roundtable discussions and comprehensive environmental scans to ensure a holistic policy development process.

Participants: Participants will be recruited from a pre-identified pool of healthcare professionals, policy experts, patient advocates, and other relevant stakeholders. A purposive sampling strategy will be employed to ensure that a wide range of perspectives are represented, particularly those with direct experience or expertise in primary care and cancer control. The target sample size for the interviews is expected to be between 15 and 20 participants, sufficient to reach thematic saturation as per the guidance of Guest, Bunce, and Johnson²⁰. The policy roundtable will include approximately 10 to 15 participants to ensure a manageable yet diverse discussion.

Data Collection: Semi-structured interviews will be conducted to gather insights related to primary care and early diagnosis of cancer. Additionally, a facilitated policy roundtable session will be organised, where stakeholders will collaboratively review and refine preliminary policy recommendations.

Data Analysis and Synthesis: The qualitative data collected through expert interviews and policy roundtable discussions will undergo thematic analysis, following the approach outlined by Braun and Clarke²¹. The process will begin with the transcription of interview and discussion content, ensuring accuracy and fidelity to participants’ input. An initial coding framework will be developed, informed by key findings from the earlier documentary analysis and rapid review. This framework will provide a structured basis for systematically coding the data while remaining flexible to accommodate emergent themes.

The coding process will be iterative, with the framework refined as the analysis progresses to ensure that all relevant insights are captured comprehensively. Thematic analysis will focus on identifying patterns and recurring issues, as well as uncovering challenges and opportunities related to primary care’s role in early cancer detection. This process will aim to illuminate practical barriers, system-level inefficiencies, and areas where primary care integration into cancer control strategies can be strengthened.

The synthesis process will integrate insights derived from the thematic analysis with the findings from the earlier studies. By systematically comparing qualitative themes with the results of the documentary analysis and rapid review, areas of convergence and divergence will be explored in detail. This comparative approach will enable a deeper understanding of the broader policy landscape and help contextualise the qualitative findings within the existing evidence base.

The final synthesis will focus on developing evidence-informed policy recommendations, grounded in the combined data from all three studies²². These recommendations will be designed to address identified gaps, align with national cancer control objectives, and support the implementation of actionable strategies to enhance the role of primary care in early cancer detection (refer to extended data: Table 2).

Stakeholder engagement

We will schedule regular interactions with healthcare providers, policymakers, patient advocacy groups, and research communities. These stakeholders will play a pivotal role in shaping the research process, providing diverse perspectives, and ensuring that the study addresses relevant and practical issues in cancer care.

Public and Patient Involvement

The PRiCAN PPIE group will be involved in the design, conduct, analyse, and dissemination of the research.

Strengths and limitations

The study is methodologically robust, using qualitative data sources to deliver a detailed understanding of primary care’s role in cancer detection. By addressing both structural barriers and clinical challenges, the research framework offers the potential for actionable insights that are grounded in both policy and practice.

However, certain limitations must be acknowledged. The effectiveness of the proposed policy recommendations will depend significantly on stakeholder engagement during the expert interviews and roundtable discussions. Limited participation, lack of diversity among stakeholders, or insufficient representation of key groups (e.g., rural GPs or marginalised populations) could constrain the comprehensiveness of the findings. To mitigate this, the study has incorporated purposive sampling to ensure diversity in perspectives.

Another limitation is the potential lack of generalisability of findings to healthcare systems outside Ireland, given the country’s unique public-private model. Nonetheless, the inclusion of international comparative analysis will provide insights into practices that could be tailored to other contexts, particularly in settings with mixed healthcare funding structures. Lastly, the limited availability of high-quality, directly relevant literature, particularly in the Irish context, may challenge the evidence base of the documentary analysis and rapid review phases.

Implications for policy and practice

The findings of this study are anticipated to have significant implications for healthcare policy, clinical practice, and cancer control strategies.

From a policy perspective, the study seeks to address critical gaps in primary care integration into cancer detection pathways. These include strengthening referral systems, improving GP access to diagnostic tools, and fostering collaboration between primary and secondary care. Evidence-informed recommendations generated from this study can support the alignment of primary care with the goals of the National Cancer Strategy 2017–2026, enhancing early diagnosis efforts and contributing to improved patient outcomes.

In clinical practice, the study is expected to highlight opportunities for improving the diagnostic capacity of primary care providers. This includes enhancing GP training and education, streamlining referral protocols, and reducing diagnostic delays. Such improvements could directly impact patient outcomes by promoting earlier cancer detection and timely treatment. Additionally, the study will identify areas where targeted professional development initiatives can help GPs refine their diagnostic and management skills for cancer patients.

Beyond cancer detection, this protocol provides a structured framework for evaluating healthcare policies, which can be applied to other areas of health research. Its integration of qualitative methods with stakeholder engagement ensures that findings remain contextually relevant, while the inclusion of international evidence highlights scalable solutions that could inform broader health policy.