{'fraction_non_alphanumeric': 0.027146685308167308, 'fraction_numerical': 0.013340323896073633, 'mean_word_length': 4.7996621621621625, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Roles of general practitioners in shared decision‐making for patients with cancer: A qualitative study

Abstract Objective The shared decision‐making (SDM) process for the treatment of pancreatic and oesophageal cancer primarily takes place with healthcare professionals (HCPs) in the hospital setting. This study aims to explore the perspectives of general practitioners (GPs) on their possible roles during this SDM process, their added value and their requirements for involvement in SDM. Methods Semi‐structured interviews were conducted with 12 GPs about their views on SDM for patients with cancer. The interviews were analysed by two researchers using an inductive open coding approach. Results Five potential roles in SDM were described by the interviewed GPs, of which the role as ‘coach’ of the patient was mentioned by all. GPs see their main added value as their long‐standing relationship with the patient. To be able to participate optimally in SDM, GPs indicated that they need to be kept up to date during the patient's care process and should receive enough medical information about treatment options and contextual information. Conclusion GPs see different potential roles for themselves when involved in SDM. Hospital HCPs that want to facilitate GP involvement should take the initiative, provide the GPs with enough and timely information and must be easy to consult.


| INTRODUCTION
Shared decision-making (SDM) is very important when choosing a treatment for oesophageal and pancreatic cancer. Even if a curative treatment option is possible (in 10%-25% of cases), the prognosis is poor. The overall 5-year survival rate for both patients with pancreatic cancer and advanced oesophageal cancer is less than 5% (Fest et al., 2017;Lola Rahib et al., 2014;Short et al., 2017). Even when a potentially curative treatment option is available, this is not necessarily the obvious choice due to severe side effects, impact on quality of life and a limited chance of complete treatment success (cure). Patient preference is therefore a relevant factor, and encouraging patients to be involved in the decision-making process is important.
options with their possible consequences, are discussed. Introducing such a conversation has shown promising results with regard to experienced comfort and support by patients and increased confidence regarding the treatment decision (Noteboom et al., 2020;Wieldraaijer et al., 2019).
Previous research has additionally shown that patients may not be aware of their own role in decision-making and feel that the GP should create awareness for this role (Brom et al., 2017;Noteboom et al., 2021). Therefore, we propose that GPs could also potentially play a role by explaining the concept of SDM at the very start of the care process, from the first referral of the patient to the hospital with abdominal complaints. This may help 'empower' patients: to become more aware of their role in being a part of any (diagnostic or treatment) decision, regardless of their eventual diagnosis. Patients might be better prepared when faced with SDM in case they are diagnosed with cancer.
Research into the involvement of GPs in SDM for patients with cancer has mostly focused on the wishes of patients (Brandenbarg et al., 2017;Halkett et al., 2015;Noteboom et al., 2021) and on measuring the effectiveness of 'time-out' consultations (Noteboom et al., 2020;Perfors et al., 2020;Wieldraaijer et al., 2019). One implementation pilot study also explored views of GPs but did not report extensive qualitative results (Noteboom et al., 2020). Exploring the views of GPs with interviews could therefore be a useful addition to the body of knowledge on this topic. For example, it has not been studied which role(s) GPs see for themselves in decisionmaking for (pancreatic and oesophageal) cancer and whether they feel they are currently sufficiently equipped for these roles. The aim of this study is therefore twofold: (1) to explore how GPs see their roles during the SDM process of patients with pancreatic and oesophageal cancer and what they consider their added value in these roles and (2) to identify what GPs need from HCPs in secondary and tertiary hospitals to be able to take on these roles. The findings of this study can inform hospital HCPs on how to facilitate more GP involvement in SDM.

| Study design
A qualitative study was performed in which semi-structured in-depth interviews were held with GPs in the region Nijmegen-Eastern Netherlands.

| Setting
This study was conducted as part of the project 'Empower2Decide', which aims to improve SDM for patients with cancer and the collaboration of the HCPs involved in their care, in the region Nijmegen-Eastern Netherlands. The initial focus of this project is on patients with pancreatic or oesophageal cancer. All of these patients who have any potential wish for hospital treatment are discussed in the Multidisciplinary Tumour Board of the Radboudumc, an academic tertiary hospital. The 'talks' of the SDM model by Elwyn et al. (2012Elwyn et al. ( , 2017) also primarily take place in this hospital. The talks differ slightly from how Elwyn et al. describe them: the team talk and option talk are combined into a single consultation due to the short time frame in which decisions need to be made. The decision talk is scheduled in a second appointment. One of the goals of this project is to improve SDM not just in the tertiary centre but during the whole patient journey and thus also involving GPs and the HCPs in connected secondary hospitals.

| Sampling and recruitment
Participants in this study were GPs within the referral area of the Radboudumc. We included GPs who had seen a patient with pancreatic or oesophageal cancer in the past year in their practice, until data saturation was reached. This was done by first selecting relevant patients and then approaching their GPs. The surgery department selected 46 patients who had previously been discussed in the Multidisciplinary Tumour Board of the Radboudumc, starting with those scheduled around 3 months back. Patients were selected who had been seen in a variety of secondary hospitals in the region, with the aim of achieving some spread in the location of the GP practices (purposeful sampling). The GPs of these patients were then sent an invitation letter by the surgery department of the Radboudumc, with the request to contact the researchers if they wanted to participate.
After 1 month, a reminder was sent to GPs who had not responded to the invitation letter. Participating GPs were offered a gift voucher of 50 euros. The researchers remained unaware of the identity of the patients throughout the study.

| Data analysis
The data were analysed in Atlas.ti 8.4.20 by thematic analysis, follow- ing an inductive open coding approach (Lester et al., 2020). The first three interviews were analysed separately by researchers IA and LR. The assigned codes were compared and discussed until consensus was reached on the codes for the first draft of the codebook. They also started axial coding in which codes were linked together and combined into subthemes. This process continued throughout the coding of the subsequent interviews, in which LR analysed the interviews first, adding new codes if needed, after which IA checked the coded interviews for agreement. Frequent meetings were held between IA and LR to discuss the codes and (sub)themes. When needed, coding of previously coded interviews was adapted in an iterative process. Together, they adapted the codebook throughout this process and created a first overview of the themes and subthemes. Finally, the findings were discussed with PW and RH, and the final themes and subthemes were decided upon.

| Ethical statement
This type of study does not fall within the scope of the Dutch Medical Research Involving Human Subjects Act (WMO). We obtained an official exemption from the local Medical Ethics Committee CMO Arnhem-Nijmegen (file number 2020-6243). All study participants received written and oral information and signed an informed consent form.

| Characteristics PARTICIPANTS
Of the 46 approached GPs, 17 (37%) responded to the invitation letter. Three GPs declined participation, and two GPs intended to participate but eventually declined, due to lack of time and the inability to access patient files due to death of the patient. In total, 12 interviews were conducted. The last few interviews provided little new information; therefore, it was decided to not send out more invitations at this stage as data saturation was presumably reached.
Participant characteristics are shown in Table 2.

Interview phase
Main questions/topics 1: Healthcare process of the recent patient with pancreatic or oesophageal cancer • What did the healthcare process of your patient look like?
• How were you involved as GP and how did you experience this?
• How did you experience the communication/collaboration with the local hospital(s)?

2: Shared decision-makingopen questions
• (How) were you involved in the SDM process of your patient regarding hospital treatment?
• How would you ideally like to be involved in the SDM process of patients with (pancreatic and oesophageal) cancer? In which situations, and why?
• What do you need from the hospital(s) in order to fulfil your desired roles in the SDM process?
3. Shared decision-makingprompts on the ideas within the Empower2Decide project • Opinion on implementing a standard 'time-out consultation' • Opinion on the GP introducing the concept of SDM when referring patient to the hospital

| Identified themes
The identified themes and subthemes on GPs' perspectives regarding SDM are shown in Table 3. We found four main themes: situations in which GPs add value to SDM, GP roles in SDM, added value of the GP to the SDM process and GP needs for conducting SDM.

| Situations in which GPs add value to SDM
All interviewed GPs were interested in being involved in the SDM process of patients with pancreatic or oesophageal cancer by talking with the patient separately from the patient's SDM talks in the hospital. However, most GPs did not consider this necessary in all situations. GPs described two situations in which GPs add value to SDM. The first was when there is a non-straightforward treatment decision. GPs generally considered the treatment decision easy when a patient in relatively good health has a curative option. They indicated that they mainly see a role for themselves when the decision is more complex, for example, for frail patients with ( The interviewed GPs also mentioned a role as a guide for the SDM process in the hospital. They can, for example, help a patient formulate their questions for the specialist. Furthermore, some GPs indicated that sometimes when they first refer a patient to the hospital, they make sure the patient knows they will have a choice regarding potential future treatment. Only one GP actively mentioned informing patients about their role in future choices before being specifically prompted to reflect on this as part of the interview guide (see Table 1, Phase 3). In the context of our prompt, the interviewed GPs indicated they do not feel that introducing patients to the concept of SDM at the time of referral is always suitable, because no diagnosis has been set yet and it may unduly worry patients. They feel that it should always remain up to their own estimation whether the information should be provided at that given moment. A GP can be kept generally up to date via letter, but many GPs also mention that personal contact with the specialist (i.e. a telephone call) at key moments is also essential, for example, when a new diagnosis is set or when no more treatment options are possible for a patient. GPs also feel they should be able to easily consult the specialist if they have questions themselves.
Closely related to the first theme is the initiative for involving the GP. Some GPs would like the specialist to actively contact them when the specialist considers the involvement of the GP in SDM desirable.
Several GPs also mentioned that they would like the specialist to suggest to the patient that they could contact their GP to discuss their treatment options.
Most interviewed GPs mentioned that when they are part of the SDM process, they need enough medical information to talk with the patient about their treatment options. Lastly, some of the GPs mentioned that supporting tools for SDM might be useful, such as a discussion guide or checklist for during the consultation itself, or more generally an e-learning module or training on how to hold SDM conversations about cancer treatment options.

| DISCUSSION
This study showed that GPs can take on several different roles in the SDM process of patients with pancreatic and oesophageal cancer, both with regard to supporting the patients and their family and with regard to supporting the specialist in their deliberations. GPs consider their main added value their long-standing relationship with the patient, meaning they are likely to know the patient and their context better than the specialist. To be able to take a role in SDM, GPs consider it important that they are kept up to date during the patient's care process, with the specialist actively taking the initiative to involve the GP when this may be beneficial. Furthermore, GPs require enough information about the treatment options as well as contextual information.
Several studies have been conducted in which the actual and/or desired role of GPs in cancer care or cancer-related SDM is described from the patient perspective (Anvik et al., 2006;Brandenbarg et al., 2017;Halkett et al., 2015;Lang et al., 2017;Lundstrom et al., 2011;Noteboom et al., 2020Noteboom et al., , 2021Wallner et al., 2016). Similar roles for GPs compared to our study can be recognised in these studies, such as the role of coach in decision-making (Brandenbarg et al., 2017;Halkett et al., 2015;Noteboom et al., 2021), supporter of the family (Brandenbarg et al., 2017;Halkett et al., 2015;Lang et al., 2017) and provider of information (Lundstrom et al., 2011;Wallner et al., 2016), though the studies also show that GPs do not always take on these roles even when this is desired by patients. Noteboom et al. (2020) found that the discussion of cancer treatment decisions with the GP is often lacking. They suggest this may be because GPs do not recognise this need in patients or because GPs feel they do not have enough medical expertise (Anvik et al., 2006;Noteboom et al., 2021). Our study additionally suggests that not all GPs consider it their role to provide or repeat medical information about cancer treatments.
The value of easy contact and good coordination between GP and specialist as well as the need for GPs to be kept up to date by the specialist has been described before in the context of patients with cancer (Anvik et al., 2006;de Wit, 2017;Jiwa et al., 2013;Lang et al., 2017;Lundstrom et al., 2011). Previous studies also showed that cancer patients dislike it if the GP does not proactively contact them (Brandenbarg et al., 2017;Noteboom et al., 2020) and that satisfaction with GP involvement is higher if they do (Brandenbarg et al., 2017;Noteboom et al., 2021). In addition, a recent study showed that scheduling a timely time-out consultation does often not work out if left up to the patient (Perfors et al., 2020). This underlines the need expressed by GPs in this study that the specialist should take the initiative for involving the GP.

| Conclusion
GPs see different potential roles for themselves when involved in SDM for patients with pancreatic and oesophageal cancer, which include both supporting the patient and the specialist in their deliberations. To be able to take a role in SDM, GPs consider it important that they are kept up to date during the patient's care process, with the hospital specialist actively taking the initiative to involve the GP when this may be beneficial. Furthermore, GPs require enough information about the treatment options as well as contextual information. In general, the field may benefit from developing guidelines in which the ideal involvement of the GP is described. Future research should study the added value of GP involvement in SDM from both the patient and the GP perspective. Both interviewers were female, had no existing relationship with the participants and had no assumptions before the study started as this was a new topic to both researchers. IA has followed several interview trainings and qualitative data analysis courses and has been involved in several interviews studies previously. LR had followed a course on qualitative research (including interview training) before commencement of the study.
Data processing: All data collected during this study were stored on a secured server of the Radboudumc. Only IA and LR had access to the personal details of the participants. Transcription was conducted partly by LR and partly by a transcription service that is affiliated with Radboudumc and that ensures privacy. All transcripts were anonymised before being uploaded into Atlas.ti.