Perceived barriers to the adoption of active surveillance in low-risk prostate cancer: a qualitative analysis of community and academic urologists.
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.
['Ellis|Shellie D|SD|', 'Hwang|Soohyun|S|http://orcid.org/0000-0001-6542-0565', 'Morrow|Emily|E|', 'Kimminau|Kim S|KS|', 'Goonan|Kelly|K|', 'Petty|Laurie|L|', 'Ellerbeck|Edward|E|', 'Thrasher|J Brantley|JB|']
D003430:Cross-Sectional Studies D005260:Female D019983:Guideline Adherence D006801:Humans D008297:Male D010818:Practice Patterns, Physicians' D011471:Prostatic Neoplasms D012189:Retrospective Studies D011795:Surveys and Questionnaires D000072178:Urologists D057832:Watchful Waiting
Barriers Adoption Active surveillance Prostate cancer Low-risk disease