Perceived barriers to the adoption of active surveillance in low-risk prostate cancer: a qualitative analysis of community and academic urologists

Abstract

Background Clinical practice guidelines recommend active surveillance as the preferred treatment option for low-risk prostate cancer, but only a minority of eligible men receive active surveillance, and practice variation is substantial. The aim of this study is to describe barriers to urologists’ recommendation of active surveillance in low-risk prostate cancer and explore variation of barriers by setting. Methods We conducted semi-structured interviews among 22 practicing urologists, evenly distributed between academic and community practice. We coded barriers to active surveillance according to a conceptual model of determinants of treatment quality to identify potential opportunities for intervention. Results Community and academic urologists were generally in agreement on factors influencing active surveillance. Urologists perceived patient-level factors to have the greatest influence on recommendations, particularly tumor pathology, patient age, and judgements about the patient’s ability to adhere to follow-up protocols. They also noted cross-cutting clinical barriers, including concerns about the adequacy of biopsy samples, inconsistent protocols to guide active surveillance, and side effects of biopsy procedures. Urologists had differing opinions on the impact of environmental factors, such as financial disincentives and fear of litigation. Conclusions Despite national and international recommendations, both academic and community urologists note a variety of barriers to implementing active surveillance in low risk prostate cancer. These barriers will need to be specifically addressed in efforts to help urologists offer active surveillance more consistently.

Active Surveillance for Low-Risk Prostate Cancer: The Uphill Battles and the Unnecessary Ones

“…In a qualitative study, diagnostic inaccuracy, lack of evidence supporting AS protocols and patients' compliance were paramount concerns among both community and academic urologists. 9 Indeed, more work needs to be done in the campaign for AS in low-risk prostate cancer, and there is a pressing need to refine the selection criteria as well as the protocol of surveillance. Tumor volume is still being defined by number of positive biopsy cores and percentage biopsy core involvement.…”

Low‐risk prostate lesions: An evidence review to inform discussion on losing the “cancer” label

“…The use of active surveillance for low‐risk lesions has increased in recent years, but there remains substantial variation in uptake between countries 14–17 (ranging from 50% in United States of America 14 to >90% in England and Wales 17 ), and within countries, with lower uptake noted among minoritized racial groups 18 and those outside metropolitan areas 15,18 . Clinicians may not recommend active surveillance to patients because of a patient's clinical and personal characteristics (e.g., younger age), and perceptions of: patient disinterest, inadequacy of biopsy sampling, inconsistency in active surveillance guidelines, and inability of some patients to adhere to follow‐up protocols 19,20 . While a clinician's recommendation is the most important factor in influencing a patient's decision to undergo active surveillance, 21,22 patients may also be unaware of conservative management options, or have difficulty understanding and weighing up treatment options 22–25 .…”

Upgrading on Per Protocol versus For Cause surveillance prostate biopsies: An opportunity to decreasing the burden of active surveillance

“…12 While AS has slowly become more accepted among providers and patients, regularly scheduled prostate biopsies remain a barrier to broader AS implementation. 13,14 Thus, we have begun to wonder whether PPSBx are worthwhile in men with otherwise stable parameters. Herein, we examined the proportion of men with upgrading when meeting criteria for FCSBx versus PPSBx.…”

“…Although necessary at times, surveillance biopsies have measurable morbidity with substantial patient discomfort, risk of urinary tract infections, sepsis, and hospitalization, further placing additional financial strain on the healthcare system 12 . While AS has slowly become more accepted among providers and patients, regularly scheduled prostate biopsies remain a barrier to broader AS implementation 13,14 . Thus, we have begun to wonder whether PPSBx are worthwhile in men with otherwise stable parameters.…”