Table 2 Physician and nurse themes, sub-themes and key quotes

1. Clinical and patient factors (stage of the disease, treatment risk/benefit profile, the potential reduction in the risk of recurrence, age, performance status/ general health, comorbidities, level of social support, and the patients’ ability to report treatment toxicities)

1. “If people have IIIC or IIID disease, I’m probably a bit stronger with encouraging them to have adjuvant (immuno)therapy.” Medical Oncologist, participant #5

2. “The people (patients) with the higher stages of stage III (melanoma) should be prioritised (for immunotherapy); we know there are statistically significant differences (patient outcomes are poorer with higher stage melanoma).” Surgeon, #7

3. “I think (adjuvant immunotherapy should be discussed with) every patient who has stage III disease..unless they’re 90 and incoherent, they should be seeing a medical oncologist, it’s only a scan or a symptom away, and they’re Stage IV.” Surgeon, #9

4. “Particularly young people I think can feel a bit superhero … just cut it out (melanoma), and I’ll be fine” Medical Oncologist, #2

5. “I think people who can tolerate it, people who are in good health, people with the greatest potential absolute benefit, people with the most to lose in terms of life, so younger people you’d be encouraging those people more than people in their late 80s. I think it’s a similar conversation with everyone; it’s more to determine whether it’s right for them. I think there’s a natural tendency that younger people with worse disease would want to have it.” Surgeon, #12

6. “I’d certainly look at life expectancy from comorbidities and factor that into a recommendation. In the extreme, someone who has a chronic disease with limited life expectancy and is living in a nursing home … I suggest that adjuvant therapy is not going to offer very much.” Medical Oncologist, #1

7. “Patient awareness to handle, manage, report (immunotherapy) toxicities promptly is very important. I would not be keen to give adjuvant immunotherapy to a patient who was not reliable in terms of engaging & communicating with the treating team.” Medical Oncologist, #2

8. “You could have a Sydney-based patient who just doesn’t communicate and doesn’t tell you when things are potentially problematic; maybe actually location isn’t necessarily what the issue is, maybe it’s more about (a lack of) communication.” Surgeon, #9

2. Treatment information provision

i. Presentation of benefits and harms

1. “There is a group of patients where I don’t feel that uncomfortable about not offering them drug (immunotherapy) because it isn’t just the amount of benefit you think they’ll get for the risk of side effects. You’re probably much nearer to equipoise with the risks and benefits.” Medical Oncologist, #4

2. “I leave a lot of the nitty-gritty discussion up to the medical oncologists. They’re the best people to discuss all of the trial options available, the potential side-effects of treatment, the percentage benefit, and risk; I leave most of that nitty-gritty discussion to them.” Surgeon,#13

3. “I outline the concept of adjuvant therapy and the types of adjuvant therapy that will be offered, but I try to avoid being too detailed about the risks and benefits. I talk about it in very general terms; I expect the people who are handling the drugs (medical oncologist) to be more specific about the information that is provided.” Surgeon, #7

ii. Evidence-based facts

1. “(Patients) all get written information, they’ll all get verbal information from the doctor and us (Clinical Nurse Consultant, CNC),..and then we’ve also got the videos that we (melanoma centre) made.” CNC, Medical Oncology, #25

2. “We (melanoma centre) would highly suggest that’s not standard (care), and if you want to have treatment (immunotherapy), you have to be on the clinical trials. That’s our approach.” Medical Oncologist, #6 ^a

iii. Physician/Nurse influence

1. “I think that people (patients) think through; “Is it (immunotherapy) worth it?” and they think quite a lot (about weighing up the treatment benefits and harms), I think (patients) can be swayed by the impression their clinician gives them about treatment.” CNC, Medical Oncology, #18

2. “I don’t want to scare them (the patient) off the idea of immunotherapy, and I want to emphasise the benefit more so than the side effects.” Surgeon, #13

3. “The trickiest one is when you don’t think they (the patient) should be treated (with immunotherapy) because they have dementia and are in a nursing home … you can’t see that their quality of life will improve, I’ll go pretty aggressive on not wanting to give them treatment. I certainly wouldn’t give treatment to a patient that will harm them and give them no benefit.” Medical Oncologist, #1

Theme

Sub-theme

Physicians and nurses quotes

2. Treatment information provision (continued)

iv. Uncertainty about individual treatment efficacy

1. “We don’t really know if it may be better to prevent it now (treat melanoma with adjuvant immunotherapy after surgery) than to treat it (using immunotherapy) when it happens later (if the melanoma recurs).” Surgeon, #12

2. “I had a young lady with stage III disease who’d said no to immunotherapy … she grasped that we didn’t know whether giving adjuvant (treatment) upfront or if it metastasised was better … She said, there’s no evidence, if it’s better treating it when it becomes Stage IV, she’s young, with a young child … she made an informed decision.” Surgeon, #11

3. “Some patients struggle with adjuvant (therapy) generally about has the drug (immunotherapy) worked. So there’s always this question at the end of treatment, so am I good now? That’s much easier with advanced cancer..you start a drug, the scan looks better, it’s working, the scan looks worse, it’s not working,..the idea that you might consider it like insurance or improving your odds.” Medical Oncologist, #3

3. Individual physician/ nurse factors

1. “The most severe toxicity I had with adjuvant (immunotherapy) was someone I saw as an opinion who pushed very hard for treatment at home,..they had a 6-month hospital admission, they were in ICU for 2 months very unwell, so clearly that person had a strong indication for treatment, but you know they were not far off dying from treatment. I think it does subconsciously alter your threshold for how you discuss the treatment options.” Medical Oncologist, #3

2. “Comparing (adjuvant immunotherapy) to other adjuvant treatments like they do in breast cancer, you’ve got 6 months, basically where your life is definitely written off because they will be very ill. With this (immunotherapy), although there is the risk of side effects, it’s a bit more unpredictable; the chances are, you’ll be fine.” Medical Oncologist, #4

3. “Immunotherapy is very different to chemotherapy. It is generally much better tolerated than chemotherapy, and I specifically say things like your hair won’t fall out, you’re not going to become very sick and have lots of nausea and vomiting.” Surgeon,#19

4. “If the patient is motivated … we (Australia) have compassionate access (to immunotherapy) … we can refer patients to local doctors, and they have this Link program (immunotherapy program enabling infusion delivery in the patients home).” Medical Oncologist, #10