Twenty (n = 20) participants were in three states of Australia, across metropolitan, outer-metropolitan, semi-rural, rural, or remote settings. Years of experience as a GP varied from < 5 to > 40 years (Table 2). Interviews ranged from 15 to 45 min. Data analysis yielded three main themes including role of GP; perceptions and philosophies of cancer management; and priorities for care. Eight subthemes were formulated from the overarching themes see Fig. 1.
Role of the GP
The first theme explored the positioning of the GP in being able to support FT.
GPs identified their core business is to care for their patients beyond the disease process:
… there is a responsibility there in terms of it is something that’s impacting on your patient’s wellbeing… the GP needs to be aware and front-and-center with that sort of thing. (GP9)
Further, their role as a ‘a trusted information provider’ (GP15) and ‘care coordinator and advocate for the patient’ (GP16) put them in a favourable position to address the FT of cancer patients. Long-term relationships can also result in patients confiding with their GP about issues beyond their cancer, including financial concerns:
If the relationship is longstanding or there’s a fair bit of trust, I'll find the patients, even if they don’t need to, will actually come in during their treatments [to discuss financial stress]. (GP17)
GPs also identified that their experience with managing mental health was something that situated them well to manage the psychological and psychosocial effects that FT can impose.
Level of involvement in supporting FT
In contrast to the positive reinforcement for the role of a GP in addressing the financial burden of cancer patients, GPs identified challenges in meeting this role. These challenges were particularly related to their knowledge of diagnostic, treatment, and specialist costings. ‘This was related to the fact that ‘anyone can charge anything’ (GP17):
I unfortunately wouldn’t be informed as to how much out-of-pocket expenses they might have … Broaching a topic that you have no knowledge about, is tantamount to opening a Pandora’s Box. (GP14)
This was presented partially as a system barrier but also not necessarily the responsibility of the GP to provide in-depth counselling in relation to costs that were essentially out of their control. ‘I don’t see it as my role to actually … find financial solutions or to counsel them through those sorts of costs in detail’ (GP13).
GPs also highlighted that, while for some cancers managing financial concerns may be achievable, the complexity and heterogeneity of cancer care made it a challenge to address FT:
For prostate, breast, melanoma even, we do have a sense of what that [pathway] might look like, but for cancers which are less common I think it is harder for us to know … to give meaningful financial counselling. (GP4)
There were also questions about whose role it might be in this setting. ‘The ideal thing would be to have a permanent general practice social worker who came and worked in the practice’ (GP2). Practice nurses, depending on experience, were also identified as having a role.
Role in the multidisciplinary team (MDT)
One of the significant barriers to GPs addressing FT beyond the diagnostic phase was the limited communication and collaboration with the specialist teams, including access to survivorship plans:
We’re often not involved in a multidisciplinary team discussion … It’s often not very transparent … surrounding cost; so how long will the care occur for, and what the journey would often look like for a patient. (GP4)
The disconnect between the GP and the treating team impacted the established and trusted GP–patient relationship. This relationship is important for managing issues such as FT. ‘It can cause them to often get a bit disengaged from the GPs. It’s one of the significant issues’ (GP9).
Perceptions and philosophies of cancer management
Conversations relating to FT were driven by perceptions of the needs of cancer patients and philosophies about how cancer care should be managed.
GPs believed that at diagnosis, their primary role was to facilitate an appropriate pathway for patients with cancer. In this setting, cost implications and discussions were often guided by perceptions of patient’s priorities:
I would say, Look. This is going to be expensive … More often than not they would just say, “Look. I don’t care. Our priority is this, getting this sorted, getting me back on track, getting me back to work and getting me back into my family life” (GP2).
One of the challenges that GPs identified in relation to the prioritisation of quick access to care is the vulnerability of people. This is related to the acuity of cancer leading to an urgency in decision-making which often leads to costly choices. ‘They’ve been given this word called “cancer” … a lot of the rational thinking goes out the window’ (GP11). The impact of FT was perceived by most GPs as something that became an issue later in the cancer trajectory.
Treatment pathway facilitation
Beyond their broad role as a financial advocate, GPs varied in the way they counselled their patients in making care pathway decisions. On one hand, they saw their role as information provider. On the other, they felt their experience and local knowledge put them in the position to steer a patient in a certain direction. Conversations were also often driven by private health insurance and a perception that people with a high socioeconomic status had a low risk of FT. ‘I have to confess here … I work in a very affluent area, and the costs of whatever care is required, is usually not discussed’ (GP14).
Discussion was also driven by the GP’s own experience and philosophies related to each type of healthcare system. These philosophies varied from ‘The public system is a little bit poor in providing access to novel treatments … (GP5) to … I saw that patients were getting the same treatment … But when they were private, they had a much bigger bill’ (GP8). GPs who had recent experience working in tertiary public hospitals often saw public as the best option for patients with cancer due to their multidisciplinary approach to care.
Perceptions and philosophies changed when discussions turned to palliative care. GPs identified that patients and family expectations change over time, and this may contain costs: ‘… they’re not going down every rabbit hole looking for a cure … cost tends to be a lot more contained’ (GP11). GPs’ philosophies also changed when the goal of care shifted away from cure. Most GPs changed their billing structure, as this was seen as their ‘civic duty’:
I’ve never charged a patient to undertake palliative care, that includes going to their homes which can be some distance away … My personal philosophy is that someone that’s dying from cancer should not be given a bill … (GP1)
Priorities for care
Training and education and accessible support were seen as priorities to better facilitate FT support by GPs.
Improved cost information provision
GPs identified that information about costs was learnt ‘along the way’ and from patient-reported experiences. Many felt that additional cost information would improve their knowledge as specialists did not always provide clear information about this:
I think it probably would be interesting to have a bit more knowledge when people are trying to make those early decisions about if they go private, what are the costs to be expected. (GP6)
Many GPs were not aware of the scope of not-for-profit cancer organisations and their ability to help patients and practitioners. Further, the information and training provided by cancer organisations were considered biomedically driven rather than focusing on psychosocial concerns which would be useful ‘… maybe Cancer Australia needs to not talk about cancer and treatment of the cancer but have an awareness week about financial toxicity’ (GP20). Primary Health Networks (PHN) were identified as ideally situated to help disseminate local resource and health pathway information.
GPs identified that having a thorough cost repository (centralised source of costing data) was unlikely to be achievable but agreed that an online openly accessible resource relating to pathways and locally available resources and support services would be beneficial. Alternatively, some GPs suggested that a telephone advice line would be useful to guide decision-making and to support FT when it arose in the clinic:
This is where being able to actually give GPs a tool guide where someone with cancer goes, “I’m really struggling,” … If you’ve got issues particularly with financial toxicity. Let's just review what things you can do. (GP20)
Although not all GPs used telehealth, most who had been exposed to it offered it as an avenue for collaboration with cancer care teams. Furthermore, they felt that government support did not equate with the level of expectation imposed on GPs in supporting cancer care. GPs identified that more Medicare funding was needed to alleviate the financial burden imposed on patients to complete complex health forms and support survivorship initiatives:
With survivorship we’re all going down the pathway of promoting those lifestyle things … there needs to be either more item numbers specific to cancer survivorship … the government and the health department should be supporting that for the community. (GP9)