Why is perioperative chemotherapy for bladder cancer underutilized?

Patafio, Francis M.; Mackillop, William J.; Feldman‐Stewart, Deb; Booth, Christopher M.

doi:10.1016/j.urolonc.2013.11.003

Cited by 18 publications

(15 citation statements)

References 29 publications

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“…Consistent with other reports, our results suggest that a multidisciplinary approach to MIBC management is critical to increase referral and rates of chemotherapy uptake (16,18,28). Further, our results support the need for physician advocates and institutional support and policy to increase chemotherapy uptake (16,28).…”

Section: Walker Et Al Barriers and Enablers Of Chemotherapy For Bladdsupporting

confidence: 91%

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Perioperative chemotherapy for bladder cancer: A qualitative study of physician knowledge, attitudes, and behaviour

Walker

d’Oiron

French

et al. 2017

CUAJ

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Introduction: Use of chemotherapy for muscle-invasive bladder cancer (MIBC) is known to be low. To understand factors driving practice we use the Theoretical Domains Framework (TDF) to identify barriers and enablers of chemotherapy use. Methods: A convenience sample of Canadian urologists, medical oncologists (MOs) and radiation oncologists (ROs) participated in individual, semi-structured, one-hour telephone interviews. An interview guide was developed using the TDF to assess potential barriers and enablers of chemotherapy use. Interviews were recorded and transcribed. Two investigators independently identified barriers and enablers and assigned them to specific themes. Participant recruitment continued until saturation. Results: A total of 71 physicians were invited to participate and 34 (48%) agreed to be interviewed: 13 urologists, 10 MOs, and 11 ROs. We identified the following barriers to the use of chemotherapy (relevant TDF domains in parentheses): (1) belief that the benefits of chemotherapy are not clinically important (beliefs about consequences); (2) inadequate multidisciplinary collaboration (environmental context and resources); (3) absence of 'champions' advocating the use of chemotherapy (social and professional role); and (4) a lack of organizational clarity/policy regarding the referral process (environmental context and resources). The predominant enablers identified included: (1) 'champions' who believe in the value of chemotherapy (social and professional role); (2) urologists who refer all patients to MO

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Section: Walker Et Al Barriers and Enablers Of Chemotherapy For Bladdsupporting

confidence: 91%

“…There is limited literature that evaluates barriers and enablers to chemotherapy for bladder cancer (11,16). Most studies are surveys that describe self-reported practice patterns but do not investigate underlying knowledge, attitude, and beliefs (17)(18).…”

Section: Introductionmentioning

confidence: 99%

Perioperative chemotherapy for bladder cancer: A qualitative study of physician knowledge, attitudes, and behaviour

Walker

d’Oiron

French

et al. 2017

CUAJ

Self Cite

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“…Having completed a comprehensive study of practice and outcome, we have identified gaps in care that suggest the presence of barriers at the level of the upstream urologist and the downstream medical oncologist 2 . Although countless editorials call for improved utilization of nact or act in bladder cancer, we are not aware of any studies that have used a validated kt framework to systematically look at barriers and enablers 6 . Understanding the barriers and enablers to use of nact or act in clinical practice will provide novel information that can help to close the gap between what is known and what is done with that knowledge.…”

Section: Environmental Context and Resourcesmentioning

confidence: 99%

“…Based on the existing literature, we identified a number of potential reasons for low utilization at the levels of the urologist, the medical oncologist, and the patient 6 . Physicians, for example, might be unaware of the evidence; or aware of the evidence, but of the belief that their patients are not medically eligible for perioperative chemotherapy; or of the perception that the magnitude of benefit is not clinically important.…”

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confidence: 99%

A Call for Theory-Informed Approaches to Knowledge Translation Studies: An Example of Chemotherapy for Bladder Cancer

et al. 2015

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There is a clear evidence-to-practice gap in bladder cancer care. International guidelines recommend that patients with muscle-invasive bladder cancer (mibc) receive some form of perioperative chemotherapy, with stronger evidence for the use of neoadjuvant (nact) than of adjuvant (act) chemotherapy 1 . Delivery of perioperative chemotherapy involves close collaboration and communication between at least two physician subspecialties: the urologist who makes the initial diagnosis of bladder cancer and undertakes surgery, and the medical oncologist who delivers the chemotherapy. Urologists are the "gatekeepers" to nact or act because they make the upstream decision about whether to refer the patient to a medical oncologist. We recently described very low concordance with the guideline recommendations for patients with mibc in Ontario: 4% and 18% of patients in Ontario received nact or act respectively 2 . We also found that only 18% of patients were referred to a medical oncologist for consideration of nact, with 25% of that group subsequently receiving treatment. Of the 39% of patients who were referred to a medical oncologist after surgery, 51% received act 3 . Those findings suggest the presence of barriers to treatment at both the upstream level of the urologist and the downstream level of the medical oncologist, and yet there is a critical lack of information about why urologists and medical oncologists do not recommend the use of chemotherapy. Similarly, the literature concerning why patients might decline referral to medical oncology or recommended nact or act is sparse.Most existing studies about the barriers and enablers to the use of nact or act for bladder cancer are brief surveys that describe self-reported practice patterns, but that do not investigate the underlying knowledge, attitudes, and beliefs of clinicians about this clinical decision 4,5 . Based on the existing literature, we identified a number of potential reasons for low utilization at the levels of the urologist, the medical oncologist, and the patient 6 . Physicians, for example, might be unaware of the evidence; or aware of the evidence, but of the belief that their patients are not medically eligible for perioperative chemotherapy; or of the perception that the magnitude of benefit is not clinically important. To our knowledge, no studies have used a knowledge translation (kt) conceptual framework to describe the barriers and enablers to utilization of perioperative chemotherapy. The use of such a framework would guide a systematic approach to barrier and enabler identification and subsequent development of a targeted kt strategy at the physician level. In this commentary, we use our own program of research in bladder cancer to illustrate how a kt framework can be used to investigate the barriers and enablers to knowledge use, thus potentially informing the development of a behaviour change intervention.T he u lt imate goa l of a resea rch prog ra m t hat identifies evidence-to-practice gaps in cancer care is to improve concordance with...

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“…[9][10][11] Potential reasons for underuse of NAC are not well-understood, but may relate to clinicians prioritizing local treatment, medical contraindications to chemotherapy, and patient preferences. 12 More recent data suggest use of perioperative chemotherapy may be increasing. Using the National Cancer Database in the U.S., Reardon et al found that use of any perioperative chemotherapy (i.e., NAC or AC) increased from 30% to 40% (p<0.001); most of this increase was driven by uptake of NAC, which increased from 10% to 21% (p=0.005).…”

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confidence: 99%

Why is perioperative chemotherapy for bladder cancer underutilized?

Cited by 18 publications

References 29 publications

Perioperative chemotherapy for bladder cancer: A qualitative study of physician knowledge, attitudes, and behaviour

Perioperative chemotherapy for bladder cancer: A qualitative study of physician knowledge, attitudes, and behaviour

A Call for Theory-Informed Approaches to Knowledge Translation Studies: An Example of Chemotherapy for Bladder Cancer

Perioperative chemotherapy for muscle-invasive bladder cancer: Closing the gap between evidence and practice

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