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 inResults: 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.

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

“…However, physicians’ predictions of a patient’s ability to adhere to a treatment protocol have been shown to be unreliable, whether made solely on subjective judgments of patient characteristics or based on patient behavior evidence in the medical record [ 64 , 65 ]. A potential solution is implementation of shared decision making, which may be underused in urology practice [ 66 , 67 ]. Rather than deciding subjectively who might have trouble adhering to an AS protocol, the urologist or care team could instead elicit values from the fully informed patient to arrive at treatment selection together.…”

Active surveillance for low-risk prostate cancer: well established, yet avoided?

“…as biases of patient treatment preferences in favor of physician's own specialty treatment represented key barriers to choosing AS [10]. Ellis et al reported that urologists' major concerns in regard to offering AS to PC patients were risk of disease underestimation with limited technology, lack of a standard evidence-based protocol, perceived probability of patient's non-adherence, patients being anxious about biopsy side-effects, and several limitations resulting from various environmental factors [11]. Improving care and clinical outcomes in patients diagnosed with low-risk PC is an important challenge…”