Determinants of urologist use of surveillance and confirmatory testing in favorable-risk prostate cancer: a qualitative study

Active surveillance (AS) offers an option for managing low- and favorable intermediate-risk prostate cancer without unwanted, deleterious urinary and sexual side effects commonly seen with curative treatment options. However, the adoption of AS remains deficient in community urological practice and its quality is not always optimal. We aimed to understand the factors that influence urologists’ perceptions of using AS, including their use of confirmatory testing, an important initial step in providing high quality AS. We conducted a qualitative sub-study using semi-structured interviews with 14 urologists and five practice managers from the Michigan Urological Surgery Improvement Collaborative and the Pennsylvania Urology Regional Collaborative. Interviews were guided by the Tailored Implementation for Chronic Diseases (TICD) framework. We analyzed narrative data using a rapid analytic approach and identified barriers and facilitators by TICD domains. Three facilitators and two barriers were identified. Facilitators included strong urologist support for AS, perceptions of adequate reimbursement for AS, and adherence to confirmatory testing guideline recommendations. Barriers included challenges with patient understanding of AS as an important option in low- and favorable intermediate-risk prostate cancer and difficulty in obtaining insurance reimbursement for confirmatory testing. Urologists generally described support and use of AS for men with low- and favorable intermediate-risk prostate cancer. However, to increase the adoption of high quality AS, it will be crucial to address identified barriers. Next steps include designing implementation strategies, based on the barriers and facilitators identified, and planning for implementation.