To our knowledge, this is the first study to explore cancer-related malnutrition governance and management, health professional knowledge and education needs relating to cancer malnutrition in the Australian primary care and community sector. This study revealed that screening for malnutrition risk using a validated screening tool is not routinely conducted in general practice and community health centres. The majority of GPs, GPNs and dietitians working in primary care and community settings agreed that patients with cancer-related malnutrition were going unrecognised in their service. We found that for sectors such as community rehabilitation, in which nutrition governance standards are in place, reported compliance with these standards was good. The addition of nutrition standards outlining the importance of malnutrition screening at regular intervals and early referral to a dietitian to existing quality standards is an avenue to support improved adherence to malnutrition screening in the primary care and community sector.
The majority of GPs and GPNs in this study reported they would like access to a validated malnutrition screening tool and overwhelmingly agreed that responsibility for malnutrition risk screening should be shared across disciplines. These results are supported by a previous Australian study indicating that the majority of GPs perceive their role to include the assessment of malnutrition risk  and a recent survey of cancer clinicians which reported a strong perception of responsibility across multidisciplinary clinicians for recognising malnutrition and initiating appropriate management . This perception of shared responsibility aligns strongly with a position statement on cancer malnutrition and sarcopenia, which emphasises that a broad range of health professionals across the multidisciplinary team should have the skills and confidence to recognise cancer-related malnutrition and facilitate timely referrals and treatment . Further work is required to increase GP and GPN knowledge of and access to valid and reliable malnutrition screening tools and identification of enablers to translate this into effective nutrition care for patients.
GPs surveyed in this study reported low levels of referrals to primary care and community-based dietitians, with limited availability, wait times and cost to the patient identified as key barriers. These findings align with previous research exploring how GPs refer to dietitians in both general  and diabetic patient populations , where limited availability, long wait lists and cost to the patient were also cited as barriers to dietitian referral. GPs should be supported with information on referral pathways to dietitians working in community health centres (where fees are means tested)  and encouraged to utilise chronic disease management plans, incorporating a GP management plan or team care arrangement with private dietitians  as a means of reducing the financial barriers and wait times associated with accessing a dietitian.
This study also found the transition of nutrition care from the hospital sector to primary and community care following cancer treatment was poor. The reasons underpinning this are multifactorial and include lack of provision of a nutrition care plan to GPs at the completion of treatment, ongoing care provided in the acute hospital and complex care needs of some patients that may be better suited to the acute hospital environment. Strategies that dietitians could be encouraged to use that have previously proven beneficial to assist this transition of care include enhanced multidisciplinary discharge summary templates, transfer of care letter templates and the use of survivorship care plans [21, 35, 36]. Rather than providing ongoing nutrition care in the outpatient setting, hospital dietitians should give early consideration during or immediately after cancer treatment to referral of appropriate patients into the primary care and community sectors for nutrition care and rehabilitation. Stratified cancer follow-up care pathways depending on the patient’s specific needs have been suggested as a means of reducing the burden on acute cancer services . Patients with lower nutrition risk could be supported to self-manage their nutrition needs; intermediate risk patients could be supported utilizing models of shared care between hospital and community practitioners [21, 35, 37]; whilst patients with complex care needs continue to be managed by specialist oncology dietitians .
GPs and GPNs participating in this study reported poor knowledge of cancer malnutrition and available cancer nutrition resources. Low confidence amongst Australian GPs and GPNs in providing general nutrition and cancer nutrition advice has been documented in previous studies [29, 38]. Similarly, a recent study of 610 healthcare professionals in the UK found that only 9% of GPs were aware of nutritional guidelines for cancer patients and 47% of GPs reported low confidence in providing nutrition advice . The majority of GPs reported the need for further training on the nutritional care of cancer patients, with dietary advice specific to cancer type and stage and the assessment of nutritional status identified as key areas for nutrition education .
Targeted education and training are required to ensure patients with cancer receive appropriate and consistent nutrition advice in the primary care and community sector. Efforts should be made to increase awareness of existing cancer-related malnutrition resources and to develop new resources specifically for GPs and GPNs. Consideration should be given to the way in which education is delivered, being mindful of the limited protected time GPs have for professional development . Decision support aids and patient-specific shared care plans (providing additional information about common issues or including integrated links to relevant guidelines) have been identified as promising tools to support primary care clinicians’ knowledge of cancer care [40–42].
Strengths and limitations
The large sample of Victorian dietitians working with patients with cancer across the continuum of care, in both metropolitan and regional areas is a key strength of this study. However, there are some limitations. The methodology did not allow for the calculation of a response rate and despite an extension to the closing date and the addition of an incentive to complete the survey, GP and GPN recruitment was low. Furthermore, GPs and GPNs with an interest in nutrition and cancer may have been more likely to respond, thus skewing the survey results.