title: Decision-making by surgeons about referral for adjuvant therapy for patients with non-small-cell lung, breast or colorectal cancer: a qualitative study.
abstract: BACKGROUND
  Because surgeons are the main gatekeepers to oncology services, understanding how they make decisions related to referral for adjuvant therapies is important to optimize referral rates and use of oncology services for patients with potentially curable disease. We examined decision-making by surgeons related to referral to oncology services for patients having undergone curative-intent surgery for non-small-cell lung, breast or colorectal cancer.
  
  
  METHODS
  We conducted a qualitative study, whose design was guided by the principles of grounded theory. Semi-structured interviews were held with 29 surgeons who performed non-small-cell lung, breast or colorectal cancer surgery in the province of Nova Scotia. Data were collected and analyzed concurrently. Analysis involved an inductive, grounded approach using constant comparative analysis. Data collection and analysis continued until theoretical saturation was reached.
  
  
  RESULTS
  Seven factors influenced the surgeons' decision-making related to referral to oncology services: indications and contraindications for therapy; patients' beliefs and preferences; a belief that oncologists are the experts; knowledge of local standards of care; consultation with oncology colleagues; navigating patient logistics (e.g., lodging, caregiving responsibilities, insurance coverage); and system resources and capacity.
  
  
  CONCLUSIONS
  Our study's findings provide a novel understanding of how surgeons make decisions about oncology referral and point to potential areas for intervention to promote referral to oncology services for patients for whom adjuvant therapy is recommended.
authors: Department of Surgery (Urquhart, Johnson, Porter), Department of Community Health and Epidemiology (Urquhart, Johnson, Porter), Division of Medical Education (Sargeant) and Division of Medical Oncology (Rayson), Dalhousie University, Halifax, NS; Cancer Outcomes Research Program (Urquhart, Kendell, Porter), Capital District Health Authority/Dalhousie University, Halifax, NS; Department of Surgery (Buduhan), University of Manitoba, Winnipeg, Man.; Ontario Institute for Cancer Research (Grunfeld), Toronto, Ont.; Department of Family and Community Medicine (Grunfeld), University of Toronto, Toronto, Ont.
authors: Robin
authors: R
authors: Urquhart
authors: Department of Surgery (Urquhart, Johnson, Porter), Department of Community Health and Epidemiology (Urquhart, Johnson, Porter), Division of Medical Education (Sargeant) and Division of Medical Oncology (Rayson), Dalhousie University, Halifax, NS; Cancer Outcomes Research Program (Urquhart, Kendell, Porter), Capital District Health Authority/Dalhousie University, Halifax, NS; Department of Surgery (Buduhan), University of Manitoba, Winnipeg, Man.; Ontario Institute for Cancer Research (Grunfeld), Toronto, Ont.; Department of Family and Community Medicine (Grunfeld), University of Toronto, Toronto, Ont.
authors: Cynthia
authors: C
authors: Kendell
authors: Department of Surgery (Urquhart, Johnson, Porter), Department of Community Health and Epidemiology (Urquhart, Johnson, Porter), Division of Medical Education (Sargeant) and Division of Medical Oncology (Rayson), Dalhousie University, Halifax, NS; Cancer Outcomes Research Program (Urquhart, Kendell, Porter), Capital District Health Authority/Dalhousie University, Halifax, NS; Department of Surgery (Buduhan), University of Manitoba, Winnipeg, Man.; Ontario Institute for Cancer Research (Grunfeld), Toronto, Ont.; Department of Family and Community Medicine (Grunfeld), University of Toronto, Toronto, Ont.
authors: Gordon
authors: G
authors: Buduhan
authors: Department of Surgery (Urquhart, Johnson, Porter), Department of Community Health and Epidemiology (Urquhart, Johnson, Porter), Division of Medical Education (Sargeant) and Division of Medical Oncology (Rayson), Dalhousie University, Halifax, NS; Cancer Outcomes Research Program (Urquhart, Kendell, Porter), Capital District Health Authority/Dalhousie University, Halifax, NS; Department of Surgery (Buduhan), University of Manitoba, Winnipeg, Man.; Ontario Institute for Cancer Research (Grunfeld), Toronto, Ont.; Department of Family and Community Medicine (Grunfeld), University of Toronto, Toronto, Ont.
authors: Daniel
authors: D
authors: Rayson
authors: Department of Surgery (Urquhart, Johnson, Porter), Department of Community Health and Epidemiology (Urquhart, Johnson, Porter), Division of Medical Education (Sargeant) and Division of Medical Oncology (Rayson), Dalhousie University, Halifax, NS; Cancer Outcomes Research Program (Urquhart, Kendell, Porter), Capital District Health Authority/Dalhousie University, Halifax, NS; Department of Surgery (Buduhan), University of Manitoba, Winnipeg, Man.; Ontario Institute for Cancer Research (Grunfeld), Toronto, Ont.; Department of Family and Community Medicine (Grunfeld), University of Toronto, Toronto, Ont.
authors: Joan
authors: J
authors: Sargeant
authors: Department of Surgery (Urquhart, Johnson, Porter), Department of Community Health and Epidemiology (Urquhart, Johnson, Porter), Division of Medical Education (Sargeant) and Division of Medical Oncology (Rayson), Dalhousie University, Halifax, NS; Cancer Outcomes Research Program (Urquhart, Kendell, Porter), Capital District Health Authority/Dalhousie University, Halifax, NS; Department of Surgery (Buduhan), University of Manitoba, Winnipeg, Man.; Ontario Institute for Cancer Research (Grunfeld), Toronto, Ont.; Department of Family and Community Medicine (Grunfeld), University of Toronto, Toronto, Ont.
authors: Paul
authors: P
authors: Johnson
authors: Department of Surgery (Urquhart, Johnson, Porter), Department of Community Health and Epidemiology (Urquhart, Johnson, Porter), Division of Medical Education (Sargeant) and Division of Medical Oncology (Rayson), Dalhousie University, Halifax, NS; Cancer Outcomes Research Program (Urquhart, Kendell, Porter), Capital District Health Authority/Dalhousie University, Halifax, NS; Department of Surgery (Buduhan), University of Manitoba, Winnipeg, Man.; Ontario Institute for Cancer Research (Grunfeld), Toronto, Ont.; Department of Family and Community Medicine (Grunfeld), University of Toronto, Toronto, Ont.
authors: Eva
authors: E
authors: Grunfeld
authors: Department of Surgery (Urquhart, Johnson, Porter), Department of Community Health and Epidemiology (Urquhart, Johnson, Porter), Division of Medical Education (Sargeant) and Division of Medical Oncology (Rayson), Dalhousie University, Halifax, NS; Cancer Outcomes Research Program (Urquhart, Kendell, Porter), Capital District Health Authority/Dalhousie University, Halifax, NS; Department of Surgery (Buduhan), University of Manitoba, Winnipeg, Man.; Ontario Institute for Cancer Research (Grunfeld), Toronto, Ont.; Department of Family and Community Medicine (Grunfeld), University of Toronto, Toronto, Ont.
authors: Geoffrey A
authors: GA
authors: Porter