Optimizing active surveillance for low-risk prostate cancer: Characterizing provider and patient perspectives.
Authors: Archana Radhakrishnan, Lalita Subramanian, Aaron Rankin, Ted A. Skolarus, Daniela Wittmann, Sarah T. Hawley, Michael Fetters
Journal: Journal of Clinical Oncology (2021)

250 Background: The number of men on active surveillance (AS) for low-risk prostate cancer is rapidly increasing. While AS requires routine clinical exams, labs, imaging, and prostate biopsies, many men do not receive all recommended components. Understanding the perspectives of key stakeholders regarding recommended surveillance is critical to ensuring the optimization of AS as a management strategy. Methods: We conducted in-depth, semi-structured, virtual interviews with a purposive sample of 15 men with low-risk prostate cancer who were on AS as their primary management strategy and their partners, and 15 urologists and 19 primary care providers (PCPs) with experience in AS management between June 2020 and March 2021. We used the Theoretical Domains Framework (TDF), an implementation science framework developed to understand determinants of behaviors and to inform the design of interventions, to guide our interview guide. Questions assessed knowledge, barriers and facilitators, and preferences for provider roles in AS management. Interviews were recorded, transcribed, and deductively coded into TDF domains and constructs. Three independent coders iteratively developed and used a shared coding framework. Participant recruitment continued until data saturation by group. Results: Our study included 15 men (on AS between 1-16 years), 5 partners, 15 urologists (3 female, 5 in private practice, 3 in academic medical centers), and 19 PCPs (9 female, 4 in community practices, 15 in academic medical centers). The TDF domain of “knowledge” and the construct, “barriers and facilitators” were most commonly reported as factors impacting receipt of recommended surveillance across all groups. While urologists were most knowledgeable about AS, PCPs noted limitations in understanding for whom AS is recommended, and what it entails. Patients who had made an effort to research or learn about AS found that this knowledge enabled them to be proactive about receiving all recommended components. Urologists and patients noted several common procedural barriers to receiving recommended surveillance, including pain with repeated biopsies, and becoming lost to follow-up. Patients and PCPs were uncertain about what tests were needed and when. Urologists were concerned about PCP knowledge while PCPs described insufficient communication from urologists as barriers to shared care. Procedural facilitators included electronic medical records (EMR) to remind providers and patients of frequency and timing of tests. Conclusions: Key opportunities for optimizing AS include improving patient and PCP knowledge about the components and delivery of AS, facilitating communication between providers, and leveraging EMR to ensure those on AS are followed. The development of an intervention that combines several of these components will be critical to ensuring men on AS receive the recommended surveillance.