Who should provide care for patients receiving palliative chemotherapy? A qualitative study among Dutch general practitioners and oncologists

Figures & data

Table 1. Description of the six scenarios discussed with the participated GPs and oncologists to express their views about the provision of different elements of care.

Scenario 1 - Treatment of physical symptoms possibly related to the cancer or palliative chemotherapy:

Patient A, 48-year old female, diagnosed with metastasized breast cancer with disease progression on chemotherapy. In another hospital she had participated briefly in a phase 1 study, until a brain metastasis was diagnosed. She is on oral palliative chemotherapy (capecitabine). At the end of the second treatment cycle she developed respiratory symptoms without fever.

Scenario 2 - Physical symptoms, most likely not related to the cancer or palliative chemotherapy:

Patient B, 70-year old male, diagnosed with metastasized colon cancer for which he underwent surgery and palliative chemotherapy. A recent CT scan showed treatment response. For a long time he has reported progressive pain in his right knee. He is worried that it is a metastasis.

Scenario 3 - Pain management:

Patient C, 70-year old male, diagnosed with advanced pancreas cancer for which he is receiving palliative chemotherapy. The last few weeks he has experienced increasing abdominal pain; CT investigations have not found a cause. He was started on fentanyl in hospital and the dose was increased by the GP on call last weekend. The abdominal pain has got worse in the last few days.

Scenario 4 - Treatment of physical side effects of palliative chemotherapy:

Patient D, 59-year old female, diagnosed with metastasized breast cancer that has progressed despite chemotherapy. She is currently on oral palliative chemotherapy (capecitabine). She has recently developed soreness, redness, and peeling on the palms of the hands (and soles of the feet), which causes pain.

Scenario 5 – Decision support:

Patient E, 69-year old male, diagnosed with advanced pancreas cancer for which he receives palliative chemotherapy. He found treatment physically difficult. A recent CT scan has shown disease progression. The oncologist has offered him second-line chemotherapy within a clinical trial. The patient has been given information about the treatment, side effects, and prognosis. He is uncertain whether to have this treatment because of his poor physical condition and previous experience with the first-line chemotherapy and wants to discuss the situation with a health professional.

Scenario 6 – End-of-life care:

Patient F, 39-year old female, diagnosed with metastasized breast cancer that has progressed despite chemotherapy. Because of her age and wish for treatment she has been given two different palliative chemotherapy treatments. She has developed brain metastasis, treated with radiation. The disease has progressed, causing multiple symptoms. As treatment has been discontinued, plans must be made for her care in the future.

Table 2. Characteristics of participated GPs and oncologists in the Netherlands (n = 22).

	GPs (n = 12)	Oncologists (n = 10)
Age in years, mean (range)	47 (31–62)	46 (34–61)
Years’ experience, mean (range)	14 (0–35)	11 (0–25)
Gender, n (%)
Male	6 (50%)	6 (60%)
Female	6 (50%)	4 (40%)
Description hospital/ practice, n (%)
Non-academic		7 (70%)
Academic		3 (30%)
Urban	10 (83.3%)
Rural (up to 20,000 inhabitants)	2 (16.7%)
Number of days working per week, mean (range)	3.4 (1^a–5)	4.7 (4–5)

^aAlso working in an out-of-office GP centre.

Figure 1. Who should be the ideal provider of care for patients receiving palliative chemotherapy according to the participated GPs and oncologists per scenario. Horizontal axis shows the participants: GP = general practitioner, O = oncologist. Vertical axis shows the ideal provider of care for patients receiving palliative chemotherapy: Both/no preference = the oncologist and the GP should see the patient or no preference.

Table 3. Arguments derived from the interviews with GPs and oncologist about who should provide care for patients receiving palliative chemotherapy.

Who should provide care?	Pros and cons provided by GPs (n = 12) and oncologists (n = 10)
Oncologist
+	More cancer specific knowledge (expertise)
	Part of cancer treatment (expertise)
	Can adjust treatment immediately (expertise)
	Retains overview (continuity)
	Frequent contact with patient (continuity)
	Easier access to additional diagnostic testing and results (accessibility)
	Provision of good transfer of end-of-life care to the GP (relationship)
	Better doctor-patient relationship - oncologist (relationship)
_	Not enough generalist knowledge (expertise)
	No continuity of care (continuity)
	Patient loses contact with GP (continuity)
	Does not look at the context of the patient – GP (continuity)
	Difficult to provide customized patient care because of lack of network in neighbourhood - GP (continuity/accessibility)
	More difficult to access and approach (accessibility)
	May perform unnecessary diagnostic / treatment (accessibility)
	Hospital is a barrier to the patient - GP (accessibility)
GP
+	Has enough knowledge and expertise (expertise)
	Provides continuity of care (continuity)
	Better accessible and approachable (accessibility)
	Ability to keep in contact with the patient (continuity)
	Better overview of the patient / context (continuity)
	First-contact care/triage (accessibility/expertise)
	Can provide and coordinate care in home situation (accessibility)
	Serves as a mentor for the patient (relationship)
	Better doctor–patient relationship (relationship)
_	Insufficient knowledge and expertise (expertise)
	Much consultation needed with secondary care (expertise)
	Oncologist loses overview (continuity)
	Challenging to get (rapid) access to additional diagnostics and results (accessibility)
Both
+	Patients’ choice
	Collaboration
	Different vision in whether to continue or stop the treatment
_	Lack of advanced care planning (oncologist)
	Lack of overview of new prescribed medication (oncologist)

The oncologist or the GP only mentioned the themes in italic. + is mentioned as an advantage by the participants. – is mentioned as a disadvantage by the participants. In parenthesis shows the corresponding theme.

Table 4. Quotes made by the GPs and oncologists on the six scenarios about who should provide care for patients receiving palliative chemotherapy.

	Who should see the patient?
Scenarios	GP	Oncologist
1. Physical symptoms, possibly related to palliative chemotherapy	I can imagine if you experience these symptoms (running nose, cough, and no fever), you will first visit your GP – please listen to my lungs, do I need antibiotics? I mean, I think a GP would be able to assess this. (quote of oncologist – GP provides first-contact care (triage))	For us, it is easier to send someone to the lab or to take an X-ray of the lungs. Because when someone is neutropenic and they have an infection, you have to adjust the next chemotherapy session. (quote of oncologist – oncologist has easier access to additional diagnostic testing and results)
2. Physical symptoms, most likely not related to the cancer or palliative chemotherapy	I think we are better trained to deal with musculoskeletal problems. And we have more experience with their management. So if the problem is about mobility, I think we as GPs know what to do. (quote of GP – GP has enough knowledge and expertise)	The patient’s needs are leading. So, if someone feels ‘happy’ in the hospital and appreciates getting all his care there because they have to be there often. Then I think that’s fine. (quote of GP – oncologist has frequent contact with patient)
3. Continuation pain management	We would like to be told of new developments in the patient’s illness or complications of chemotherapy. And problems that are clearly not treatment related should be seen by the GP, because it is also good for the GP to keep in contact with the patient. (quote of oncologist – ability for GP to keep contact with the patient)	I would find it very frustrating if I were treating this man and the GP sent him, without consulting me, directly to a pain clinic. Because I will lose sight of the patient, and then I would wonder who is in charge of him. (quote of oncologist - oncologist loses overview)
4. Treatment of physical symptoms, a side effect of the palliative chemotherapy	No, well you know, most of the time the patient is tired of having to go to the hospital and if they can consult someone outside of the hospital, I do not mind at all. (quote of GP - GP is better accessible and approachable	I have no clue whether this is a result of chemotherapy. Looking at this symptom as a GP, I think what does the tongue look like, could it be a virus? Well, I have no idea. (quote of GP – GP has not enough knowledge and expertise)
5. Decision support	You have known the man for years and years, you know how he thinks about sickness and health (…) and especially when decisions have to be taken in a short time frame. Then I think it is really good, and valuable, if the patient can talk to his GP, whom he has known for several years. (quote of GP - GP has better doctor-patient relationship)	I think that it is difficult, because I have no knowledge of chemotherapy. Well, some of course but well, I do not know its exact pros and cons and the expected benefit. (quote of GP- oncologist has more cancer specific knowledge)
6. End-of-life care	When I think I cannot cure this anymore, I tell the patient to ensure that she has a good relationship with her GP, because she’s going to need the GP at some stage. I can treat the tumour to a certain extent, but those last 6 weeks at home, I will not be there. (quote of oncologist – GP can evaluate and coordinate care in home situation)	This has a lot to do with the relationship we build with patients over time. And then you are one step behind as a GP, which can give the patient the feeling they are getting dumped. So I always call them after a week or two. (quote of oncologist - providing good transfer of end-of-life care to the GP)