Mariken Stegmann

Introduction  An  estimated 14.1 million new cases of cancer were reported worldwide in 2012, and this  incidence is increasing, with cancer now being the second leading cause of death  worldwide. 1,2  The three most common types of cancer are lung, breast and colorectal  cancer. 2  Cancer care is complex and involves a range of healthcare providers both inside  and outside hospitals, 3  and patients find it important that these providers exchange  relevant information appropriately to ensure smooth continuity of care. 4,5  In countries  where general practitioners (GPs) provide that continuity of care and function as  gatekeepers, communication between primary and secondary care is particularly relevant  and especially for patients in complex situations such as cancer. 6–8  In the Netherlands and  other countries with a similar system, all patients do have a GP and they often see their GP  also during specialist treatment, not only for other health problems but also for  explanation and for emotional support.  Formal communication between different healthcare providers in these countries is mostly  by written correspondence, which is often sent digitally. When a GP refers a patient to a  hospital specialist, they must write a “referral letter” that mentions the reason for referral.  Then, when the hospital specialist has seen a patient, a “specialist letter” should be  returned to the GP detailing the findings, treatment and follow‐up plans. Because of the  coordinating role of the GP, this letter should be sent within 5 days and sooner if needed to  ensure continuity of care. 9 However, primary and secondary care each have their own needs and expectations, which  can lead to communication difficulties. 10–14  Moreover, each party typically reports the  quality of correspondence as being low from the other party, with disagreement cited  about the precise issues. 11,14  Referral letters are often said to lack relevant clinical  information or a specific request, 14,15  whereas specialist letters are reported to lack  information about what the GP needs to know, 16,17  and can arrive late after a  consultation. 12,16  According to both patients and physicians, inadequate communication  between healthcare providers can lead to suboptimal quality, poor coordination,  discontinuity and suboptimal quality of care. 18,19 The aim of this qualitative study was to explore the information that is shared in referral  letters and specialist letters between primary and secondary care during the process of  diagnosis and initial treatment of patients with lung, breast or colorectal cancer. Methods  Design and setting  In this study, we performed a qualitative analysis of correspondence because of the  explanatory nature of the research question. The medical records of patients diagnosed  with lung, breast and colorectal cancer in the north of the Netherlands in 2014 or 2015  were assessed. These tumours were chosen because they are the most common types 2  and  because both oncology specialists and GPs are frequently consulted about them during  treatment. 6,20  To provide a comprehensive overview and confirmation of our findings, we  performed data triangulation (i.e., cross verification with other sources) was performed 21 through semi‐structured interviews with GPs and oncology healthcare providers. The  6 67 Qualitative mixed-methods analysis of correspondence