Primary Care Physician and Urologist Perspectives on Optimizing Active Surveillance for Low-Risk Prostate Cancer

Archana Radhakrishnan; Lalita Subramanian; Aaron J. Rankin; Michael D. Fetters; Daniela A. Wittmann; Kevin B. Ginsburg; Sarah T. Hawley; Ted A. Skolarus

doi:10.1370/afm.3057

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Table 1.

Summary of Most-Referenced TDF Domains and Constructs for Active Surveillance of Low-Risk Prostate Cancer

TDF Domain and Construct^{^a}	PCP		Urologist
TDF Domain and Construct^{^a}	Summary	Example Quote	Summary	Example Quote
Knowledge (awareness of the existence of something)
Patient: the informed patient	Active surveillance can be confusing (ie, terminology, difference from watchful waiting). Patients need to understand what active surveillance is and, ideally, education should start at the time of prostate cancer screening.	“The first thing I try to make sure that they know about is that it’s different than just waiting. It’s not just watchful waiting because they get confused about what they hear on the news and on the internet. And so I walk them through that active surveillance is actually sort of very close monitoring … there’s very specific laboratory tests, biopsy schedules are anticipated, imaging, and then this is done in collaboration with the urologist…” “…I think they’re [patient] more likely to follow the active surveillance if they understand the what and the why about it.”	Patients need education about active surveillance, such as what it is and what to expect, which will help promote adherence.	“Like everything else, it’s just education and educating them that it is important … well, that active surveillance is different than, for example, observation, that the patient ultimately may require treatment, that the cancer can change over time. It can become more aggressive and it can grow to a point where the patient does need active treatment …”
Physician: procedural knowledge	PCPs lack knowledge about active surveillance and need more education. For PCPs to be involved effectively, they need explicit guidance on active surveillance follow-up.	“Better education for the PCP I think. I can’t say in my residency I had, and even in my boards, that question doesn’t really come up very often. Even though… in clinical practice, [active surveillance] does come up … how often and what is concerning, what is less concerning. I don’t think we have that nuance at all.” “I think for some of these patients on active surveillance, it would be helpful if not only just routing the auto note, but like making it clear what they’re [urologists] looking for, especially if we’re going to follow them in the future, or making it clear what we’re looking for that would trigger the next step …”	Urologists are very knowledgeable about active surveillance and can educate patients.	“First we determine their overall health, and we estimate what their life expectancy is. Then we look at their tumor characteristics and … we also talk about their concerns in terms of quality of life issues, in terms of urinary function, sexual function, and then using those parameters we come up with a potential plan.”
Environmental context and resources (any circumstance of a person’s situation or environment that discourages or encourages the development of skills and abilities, independence, social competence, and adaptive behavior)
Barrier: becoming lost to follow-up	Patient lack of understanding about active surveillance can lead to not receiving follow-up.	“I think the problem with active surveillance, you know where they’re checking something every 6 months to a year, they can get this false sense of security after a couple of years that it’s not changing, I don’t really need to do that.”	Lack of structured database (eg, those integrated into the EHR) can lead to not receiving follow-up.	“I know some people have the infrastructure to keep all these patient names in a database, and if they don’t follow up, they can call them and things like that, and I just don’t have that.”
Facilitator: communication and organizational culture	Although EHRs facilitate effective communication between physicians, collegial relationships (from working in smaller practices, proximity) with specialists makes communication easier.	“The nonencounter message system inside MyChart is really important for this function for me because I feel like I can just tap the specialist on the shoulder and say, ‘Hey, what about this?’ … But I think my trigger is a little easier to start a conversation if I just know it’s just going to be like just bumping into somebody in the hallway.”	Although EHRs facilitate effective communication between physicians, collegial relationships (from working in smaller practices, proximity) with specialists makes communication easier.	“Communication is mostly through notes. Occasionally, I may pick up a phone but I mean, nobody talks on phones anymore, so we’re messaging. In [name of city], it was a smaller community, so it was a lot more picking up the phone and talking to people.”
Barrier and facilitator: PCP involvement in active surveillance care delivery (ie, shared care)	PCPs can collaboratively work with urologists to support patient management (eg, review specialist visits with patients and reiterate information). Patients trust their PCP and turn to them for guidance.	“But I think having a good relationship with your primary care and having an investment in your primary care relationship, both from the physician side and the patient side is key … if I have a man who I have a lot of touch points with because I’m also seeing him for like his diabetes and hypertension and COPD … I’m apt to see him more in clinic, and be like hey, ‘I’ve noticed you haven’t had your surveillance for your prostate cancer and it looks like you were supposed to see so-and-so 6 months ago and you didn’t’…”	PCPs’ primary role in active surveillance should involve working collaboratively with urologists to support patient management.	“… a few times a year I’ll say [to the patient], ‘You should go talk to your primary care [doctor] and talk to them.’ And if I don’t know where [PCP] stands, or if I really feel strongly that this guy’s like looking to get out of treatment and needs it or looking to have treatment when he shouldn’t have it, I’ll actually just call the primary [care physician] and I’ll say, ‘Listen, this guy needs X or this guy needs Y, and here’s why I think so. So do you mind reaching out to him or if he reaches out to you, just confirming that you agree?’”

COM-B = Behavior Change Wheel’s Capability, Opportunity, and Motivation; COPD = chronic obstructive pulmonary disease; EHR = electronic health record; PCP = primary care physician; TDF = Theoretical Domains Framework.
↵a The TDF knowledge domain mapped onto the COM-B model capability domain. The TDF environmental context and resources domain mapped onto the COM-B opportunity domain.