Box 3.

Themes and illustrative quotes demonstrating the effect of frailty, cognitive impairment, and comorbidities

Theme	Subtheme	Illustrative quotes
Frailty	Healthcare professionals are informally assessing frailty	A GP stated:
		‘I’ve never used any specific scale to assess anyone’s frailty. I don’t know what the evidence is behind that frailty score.’ 50
	Healthcare professionals are less likely to investigate or refer patients they deem to be frail	A GP stated:
		‘We need to consider … the psychological and organic weaknesses that mean, possibly justifiably, that we shouldn’t do as much as we would with a younger person.’ 56
		A GP stated:
		‘This woman in her 80s had a breast mass … she [had] poor life expectancy, she was already on home oxygen, heart failure, all those comorbid conditions, we could see her lungs failing, and I don’t think we need to do anything about [the breast mass] .’71
	Assumptions about frailty may prevent investigation	A GP stated:
		‘There may be a degree [of] assumption going on “I don’t think Mrs Bloggs is well enough” and I wonder whether there is a better way …’ 50
Cognitive impairment	Healthcare professionals are less likely to investigate or refer older patients they deem to be cognitively impaired	A GP stated:
		‘Well, I don’t push the investigation or anything … For me, it’s really a complete hindrance to send people for investigations to seek out cancerous pathology.’ 56
	Older patients with cognitive impairment may be distressed by examinations or investigations	An older patient with dementia who had undergone tests for colorectal cancer stated:
		‘That woman who ran around and hurt me. Well, she didn’t know what she were doing. “No!” I kept saying to her. I said “It’s not right!” Two people hit at me.’
		The study reported that there were also signs of distress during the interview, ’contorting her face’ and ‘wringing her hands with worry’, which showed the pain and distress of undergoing intimate clinical investigations.63
	The presence of cognitive impairment can affect communication with healthcare professionals	A 79-year-old with colorectal cancer stated it was his wife who had noticed the patient’s symptoms:
		‘I have Alzheimer’s disease and my wife noticed the change in bowel habits. I had no other signs or symptoms.’ 67
	Despite cognitive impairment, patients may be fit and investigation could be warranted	A GP stated:
		‘Even if they’re very cognitively impaired, we can still share plenty of things, and often they find that it’s worthwhile to continue to fight.’ 56
Comorbidities	Investigation and referral of symptoms possibly owing to cancer were delayed because of comorbidities	The carer of a 78-year-old man recalled how the GP attributed his signs of illness to pain from a knee replacement:
		‘We said, you know, he’s really finding it hard to mobilise and you know, loss of appetite and depression. And, [the GP] instead of looking for another reason, it was, “oh well, he’s in pain. You know, if you sort the pain out, we’ll sort the other bits out”.’ 55
		A 72-year-old woman with ovarian cancer and longstanding back pain reported:
		‘I first visited my doctor about my symptoms … I was not examined. I was told the pain was coming from my back (I had a back problem for years).’ 67
		‘I’ve got COPD [chronic obstructive pulmonary disease] but I never coughed up blood before. I thought it will clear up but after two weeks it didn’t so I thought I had better get it checked.’ 53
	Annual check-ups for comorbidities resulted in opportunities for earlier diagnosis	‘The cancer was only found on annual chest check for COPD.’ 67
		A patient (aged between 85 and 89 years) with lung cancer stated:
		‘I go six monthly to the nurse in the clinic and I mentioned to her I was spitting blood and she said “well make an appointment with the doctor” …’ 53