Research
Volume 50, Issue 6, June 2021

Managing patients receiving new and unfamiliar cancer treatments: A qualitative study of general practitioners’ experience

Eleanor Lynch    Jennifer McIntosh    Bogda Koczwara    Jane Crowe    Jon Emery   
doi: 10.31128/AJGP-05-20-5417   |    Download article
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Background and objectives

As systemic cancer treatments increase in complexity, general practitioners (GPs) need access to reliable information to support patients on new and often unfamiliar treatments. The authors explored the experience of GPs in supporting patients receiving anticancer therapy, and the barriers and facilitators to the implementation of a new resource designed to support GPs in this role.

Methods

Semi-structured qualitative interviews were conducted with 15 GPs and oncology clinicians. Thematic analysis of interviews used inductive coding.

Results

Themes identified were GPs not feeling part of the team when looking after patients on cancer treatment, the role a new set of eviQ information resources could play in supporting GPs and barriers and facilitators to the implementation of these resources.

Discussion

GPs value reliable, published cancer treatment information, but it does not remove the need for individualised patient correspondence or the inclusion of the GP in the treating team.

 

Cancer diagnoses in Australia are steadily increasing, and systemic treatments are evolving and increasing in complexity.1,2 General practitioners’ (GPs’) ability to promptly recognise potentially serious side effects of treatment, especially those unique to newer therapies, can be crucial to patient safety.3

GPs are likely to encounter patients on an ever-expanding range of systemic cancer treatments, and while recent studies have looked at the important role that GPs have in cancer survivorship care,4–6 there has been less focus on the GP’s role during active cancer treatment, such as the management of comorbidities, being the first port of call for a treatment side effect or being the ‘coordinator of care’.

A major challenge faced by GPs in the care of patients on cancer treatment is a lack of useful, timely communication from the patient’s oncologist.7,8 For GPs to safely care for these patients in the community, they require information on treatment type, including prognosis, follow-up plan and potential side effects of treatment, as well as suggested management.8 The new eviQ resources have been proposed as one way of helping to meet this information need.

A number of online resources exist to support health professionals in the care of patients on cancer treatment. The most comprehensive Australian resource, eviQ, is an Australian Government cancer treatment resource that is freely available online to health professionals and the public.9

While most material published by eviQ is written for cancer professionals and patients, it has recently published a set of resources designed to support GPs in the management of patients who are prescribed any of four different types of systemic cancer treatment, including newer molecular targeted therapies and immunotherapy.10

However, little is known about whether GPs are even aware of eviQ, whether they will use the resources once they are aware or how the resources will translate into clinical use.

The aim of this study was to examine how supported GPs felt when managing patients on systemic cancer treatment, using the recently published eviQ information as an example of a resource that could potentially support them in this role.

Methods

A phenomenological approach using an interpretivist paradigm was chosen, as it enabled a more in-depth exploration of participants’ responses to interview questions and to the GP-focused resources, and allowed researchers to answer the research question, even with a small sample size.11

Sample, recruitment and variables

The study was conducted at the University of Melbourne in Parkville, Victoria. Some participants were interviewed in person at their place of work if this was local, or via telephone in the case of some regional participants.

The study recruited 15 GPs, oncology nurses and medical oncologists practising in Victoria between March and November of 2019 (Table 1), through informal professional networks and snowball sampling to obtain participants of different sexes, ages, locations of practice and experiences looking after patients on cancer treatment.

Table 1. Characteristics of the sample
Age range (years) Sex
(male/female)
Clinician subtype Practice location Years in oncology practice or general practice
General practitioners
20–30 Female Registrar Inner regional Second-year general practice training
30–40 Female Registrar Major city Second-year general practice training
50–60 Male Fellow Major city 25
50–60 Female Fellow Major city 32
60–70 Female Fellow Major city 39
50–60 Female Fellow Inner regional 28
30–40 Male Registrar Inner regional First-year general practice training
20–30 Male Registrar Inner regional First-year general practice training
30–40 Female Fellow Inner regional 7
Oncology nurses
40–50 Female N/A Major city 20
50–60 Female N/A Major city 23
Medical oncologists
50–60 Female N/A Major city 25
30–40 Female N/A Major city 6
50–60 Male N/A Major city 19
40–50 Male N/A Major city 15
N/A, not applicable

Purposive sampling was used to ensure key groups of participants with a mix of relevant experience were recruited.11

Sampling ceased when similar responses were being noted in GPs being interviewed, indicating data saturation.12 The Accessibility and Remoteness Index of Australia was used to classify locations of practice of participants according to remoteness.13

Our primary objective was to explore GPs’ reactions to the GP-focused resources to determine if they could fill an information gap, but we interviewed a smaller sample of oncology clinicians to identify any system barriers that may influence dissemination and implementation of the resources from an oncology perspective.

Ethical approval was obtained from the Melbourne Human Ethics Advisory Group, Department of General Practice (approval number 1953790.1). All participants provided written consent for participation in the study.

Interviews

Participants were approached initially by email, then followed up by EL to arrange a face-to-face meeting or telephone interview.

Participants were presented with the factsheets at the interview, either using laminated versions of the factsheets, or if participating in a telephone interview, a digital version was emailed to the participant to review during the interview.

Semi-structured interviews were conducted by EL and audio-recorded, then transcribed and uploaded onto NVivo 12.14

The interview guide was informed by consensus of involved researchers, using open-ended questions. Two of the senior researchers were part of the stakeholder group that developed the eviQ resources; therefore, these researchers were not involved in conducting the interviews or analysing the results.

Using the interview guide, participants were asked to reflect on the resources and comment on how easy they would be to use, anything they would change and whether any sections were likely to be more or less useful than others.

Semi-structured interviews were used, as they were able to facilitate rich, in-depth exploration of each participant’s perspective and allowed them the freedom to provide detailed, frank feedback on the resources they were presented with, which could not have been achieved with a quantitative methodology. While the interview guide itself was not formally altered during the study, it was flexible enough as a tool to enable interview themes to evolve over the data-collection period.

Interview data were securely stored on password-locked devices, as per the ethics approval requirements.

Data analysis

Transcribed interview data were organised by EL using NVivo 12. Transcripts were reviewed and coded by EL and double coded by JM, JC and JE. Thematic analysis was conducted by EL with supervision from JE and JM using an inductive approach.15,16

An inductive approach was used, as it allowed similarities in concepts and viewpoints to naturally emerge from the data over time, and for themes to be agreed upon by the researchers as a way of accurately representing the common views and responses of the sample. This method also allowed the analysis conducted on earlier interview data to inform how later interviews were conducted (while using the same interview guide).

The authors report the methods and results according to current reporting guidelines.17

Results

Fifteen semi-structured interviews with GPs (n = 9), oncology nurses (n = 2) and medical oncologists (n = 4) were conducted. Participants of different ages, genders, remoteness, years of practice and experience with managing cancer patients were recruited.

The mean length of the interview was 33 minutes (range: 23–42 minutes).

All oncology nurses and medical oncologists worked in major city practices or hospitals, whereas four GPs worked in major city practices, and the remainder in inner regional practices.

Some GPs (44%) reported only a small proportion of their patients being on active cancer treatment (<5% patients in past 12 months), whereas 22% of GPs reported seeing a much larger proportion than this (>50 of their patients in the past 12 months).

Few GP participants were aware of eviQ or the specific GP-focused resources prior to the interview.

The following themes were identified from the interview responses.

Theme 1. GPs not feeling part of the cancer team

GPs often felt they were not part of the treating team following a cancer diagnosis, when care of the patient is taken over by the cancer team:

We kind of sit outside the loop … Once we’ve sent them in for the treatment, we don’t really hear much back. (GP 3, major city)

GPs found patients may not present to them until they are unwell or experiencing side effects, at which time the GP may not have any information from the cancer team about what treatment the patient was on or the expected side effects.

GPs found that communication with the cancer team could be difficult at times, and that a lack of communication from the cancer team impacted their ability to safely manage problems in cancer patients:

If the GPs actually know what’s happening in terms of the treatment … and what sort of side effect to expect, it means that when the patient does come along to us, that we’ll be better able to look after them. (GP 3, major city)

GPs were keen to be an active part of the cancer team if they were adequately supported in this role:

We actually are really important, and not just told we’re part of the team, but to actually be included. (GP 4, major city)

All participants agreed that communication needs to improve so that GPs can take on a greater role in collaborative cancer care as cancer diagnoses increase:1

I really think we absolutely need the GPs to be helping out, because we are packed to the rafters here. (Oncology nurse 2, major city hospital)

Theme 2. The potential role of the eviQ resources in clinical practice for GPs

The consensus from GPs interviewed was that the eviQ resources were acceptable and likely to be very useful; however, they recognised they would still need timely correspondence from the cancer team detailing individual patient information for the resources to be useful:

I think they’re quite good. (GP 9, inner regional)

I like that there’s good clear timing of reviews and … time frames to get in contact with oncology team is good. Yeah, very useful. (GP 2, major city)

In general, the resources were endorsed by oncology clinicians, although some concerns were raised about giving general advice and grouping medications together by class when individual medications can have diverse side effect profiles within a class:

The information is so broad that … ultimately they’ll still be in the same position where they’ll have to call the hospital to … talk to an oncologist to see what they should do. (Medical oncologist 2, major city)

The ‘managing problems’ section was thought to be the most useful by GP participants, especially recognising and managing side effects of the newer treatment types:

This is really good … the managing problems section. (GP 2, major city)

Information on skin reactions and safe vaccination of patients on cancer treatment was also seen as particularly useful:

I think the vaccination thing is really good, because I think that causes confusion. (GP 6, inner regional)

Other more general wellbeing sections of the resources were seen as less useful, particularly by more experienced GPs. However, GP participants appreciated the difficulty of developing a resource that speaks to all levels of GP experience.

Theme 3. Barriers and facilitators to resource use: Awareness, ease of access and ease of use

Participants recognised that regardless of how good the resource is, the real challenge will be in its adoption and use. Not being familiar with eviQ as an information source was identified as a key barrier to GPs accessing the resources:

I think the key, once you’re happy with the resource, is … making it known to both oncologists who will refer GPs to it, and GPs to know about it if someone turns up in their practice, they’ve got somewhere to go to get the information. (Medical oncologist 1, major city)

Having a link attached to a letter or discharge summary from the cancer team was an acceptable way to disseminate the resources according to GPs; however, oncology clinicians were less sure about the feasibility of this approach because of time constraints, resource use and having to rely on remembering to include it:

With anything that relies on doctors remembering to do something, it’s always difficult. (Medical oncologist 4, major city)

Incorporating the eviQ resources into an existing information resource that GPs already access, such as Healthpathways,18 was seen as a facilitator to implementation, as it would remove the onus from the oncology team to ensure a link was attached to each piece of correspondence sent out to the GP.

Other potential barriers identified were length of time to absorb key information, knowing where to find the resources and remembering the resource exists:

Essentially the hardest thing is to get the GPs to find the information. (GP 3, major city)

Discussion

This study highlights some of the key issues faced by GPs when managing patients on unfamiliar cancer treatments and provides insights from a select group of clinicians into how a specific set of resources could be used to support GPs in this role.

GPs in this study often felt external to the treating team once cancer treatment had commenced, even if they continued to manage and support the patient during this time. GPs would benefit from reliable, published cancer treatment resources, such as those published by eviQ, to safely and confidently manage patients on new, often unfamiliar cancer treatments in the community; however, this would not remove the need for up-to-date, individualised patient correspondence from the cancer team. The GPs were, however, unaware of the resources that were available.

Oncology clinicians endorsed the eviQ GP-focused resources but identified that it was unlikely to be feasible for the cancer team to communicate the resources to GPs. Merging with another GP-focused resource, such as Healthpathways,18 was raised as a more feasible way of implementing the eviQ resources. In keeping with the existing literature, our study reiterated the importance of good communication between the GP and cancer centre.19 Patients not seeing their GP after a diagnosis of cancer has also been identified previously,19 along with the unique challenges this can pose for GPs when they do see a patient during this period.

The importance of the role of the oncology nurse linking general practice and the cancer centre was also evident.

Jefford et al looked specifically at the distribution of chemotherapy information to GPs via fax and found this to be an efficient and inexpensive way of oncologists being able to support GPs, and GPs had greater confidence in managing chemotherapy side effects as a result.20 The eviQ resources could be used in a similar but more efficient way using current technology.

Implications for general practice

For the eviQ resources to be successful, oncology clinicians will need to be comfortable with the content, and patients on active cancer treatment will also need to feel confident that their GP has access to enough reliable information to be able to safely support them in the community.

GPs and oncologists will both need to be educated about these specific GP-focused resources in order for them to be used.

Further research could explore the use of the resources in practice when applied to real patient encounters, and opportunities exist for eviQ to engage with GPs to improve awareness of the resources at conferences and continuing professional development events. There are also opportunities for eviQ to approach Healthpathways to explore the feasibility of having links to the eviQ resources accessible from the Healthpathways cancer treatment pages.18

There is also the possibility that these resources will be useful to other clinicians not familiar with new and emerging systemic cancer therapies, such as emergency department and intensive care clinicians, and those in other non-oncology specialities.

There is the opportunity for future research to focus on how to ensure GPs who have patients on active cancer treatment are kept up to date with their patients’ current treatment and progress. As electronic medical record platforms evolve and the sharing of patient information becomes more secure, this may remove some of the barriers to timely communication that remains the key to collaborative cancer care between GP and oncologist.

While the results of this study will be relevant to GPs, the data may also be of interest to oncologists, as they could assist in improving communication between the two groups.

Study limitations

The study looked at a specific set of resources and clinicians’ responses to them. The sample size was small, so the findings potentially lack generalisability.

The question guide may have been influenced by the experiences of researchers, given that two of the researchers had input into developing the eviQ resources and three of the researchers are GPs themselves.

The method of recruitment meant those interviewed may have already had an interest in research, which may have influenced responses, and there was a risk of sampling bias given the sampling method used. As four of the GPs who were interviewed were registrars at the time, it is quite possible that they had fewer consultations with cancer patients, and therefore, limited understanding of the need for the resources. Younger GPs might also be more adept at accessing online resources, which might also be a limitation of our findings. Despite this, a broad range of GPs from different age groups was included in the study.

Conclusion

This study demonstrates how published resources could support GPs encountering patients on new and unfamiliar anticancer therapies, but also highlights the need for the GP to be actively included as part of the cancer treatment team.

Competing interests: This study was completed as a part of EL’s Academic General Practice Registrar Special Skills post in 2019–2020.
Provenance and peer review: Not commissioned, externally peer reviewed.
Funding: This study was supported by The Royal Australian College of General Practitioners with funding from the Australian Government under the Australian General Practice Training Program.
Correspondence to:
eleanor.i.lynch@gmail.com
Acknowledgements
The authors would like to acknowledge the role of eviQ in contributing to cancer treatment information and the use of their recently published general practitioner–focused resources in this study.
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