Background
Methods
Setting/procedure
Measurements
Structured surveys
Semi-structured interviews
Analysis
Results
Characteristics of participants
N | % | |
---|---|---|
Sex | ||
Male | 26 | 79 |
Female | 7 | 21 |
Degree | ||
MD/DO | 28 | 85 |
NP/PA | 5 | 15 |
Graduation Year | ||
1990 or before | 7 | 21 |
1991–2003 | 14 | 42 |
2004 or after | 12 | 36 |
Survey results
Imaging for PCa Patients | ||
---|---|---|
Patient 1a: 67 year old otherwise healthy man newly diagnosed with low-risk prostate cancer (PSA level 5.2ng/ml, Gleason score 6 in 5/12 cores, clinical stage T1c, prostate volume 46 cc on TRUS). | ||
n | % | |
No imaging (GL concordant) | 30 | 91% |
MRI (GL concordant) | 3 | 9% |
Patient 1b: After reviewing treatment options, the patient described above (PSA level 5.2ng/ml, Gleason 6 in 5/12 cores, clinical stage T1c) is interested in active surveillance. | ||
n | % | |
No imaging (GL concordant) | 21 | 64% |
MRI (GL concordant) | 11 | 33% |
CT scan | 1 | 3% |
Patient 2: 64 year old otherwise healthy man newly diagnosed with low-intermediate-risk prostate cancer (PSA level 9.2ng/ml, Gleason score 3 + 4 in 3/12 cores, Gleason 6 in 2/12 cores; clinical stage T1c, prostate volume 53 cc on TRUS). | ||
n | % | |
No imaging (GL concordant) | 24 | 75% |
MRI (GL concordant) | 6 | 19% |
CT scan or bone scan | 2 | 6% |
Patient 3: 69 year old otherwise healthy man newly diagnosed with high-intermediate-risk prostate cancer (PSA level 11.1ng/ml, Gleason score 4 + 3 in 4/12 cores, Gleason 3 + 4 in in 2/12 cores; clinical stage T1c, prostate volume 47 cc on TRUS) | ||
n | % | |
No imaging | 5 | 15% |
MRI or CT or bone scan (GL concordant) | 28 | 85% |
Patient 4: 66 year old otherwise healthy man newly diagnosed with high-risk localized prostate cancer (PSA level 16.2ng/ml, Gleason score 4 + 4 in 5/12 cores, Gleason 4 + 3 in in 2/12 cores; clinical stage T2a, prostate volume 62 cc on TRUS) | ||
n | % | |
No imaging | 2 | 6% |
MRI or CT or bone scan (GL concordant) | 31 | 94% |
Imaging for AMH Patients
| ||
Patient 5: 37 year old nonsmoking female with no significant past medical history referred to you for asymptomatic microscopic hematuria (7 erythrocytes/HPF on microscopic urinalysis). Urine culture negative. | ||
n | % | |
No imaging | 3 | 9% |
Renal ultrasound | 11 | 33% |
CT urogram or flexible cystoscopy (GL concordant) | 12 | 36% |
Repeat urinalysis* | 7 | 21% |
Patient 6: 40 year old nonsmoking male with no significant past medical history referred to you for asymptomatic microscopic hematuria (> 3 erythrocytes/HPF on two separate microscopic urinalysis). Urine culture negative. | ||
n | % | |
No imaging | 5 | 15% |
Renal ultrasound | 5 | 15% |
CT urogram or flexible cystoscopy (GL concordant) | 23 | 70% |
Patient 7: 62 year old nonsmoking female with no significant past medical history referred to you for asymptomatic microscopic hematuria (> 3 erythrocytes/HPF on one microscopic urinalysis). Urine culture negative. | ||
n | % | |
No imaging | 5 | 15% |
Renal ultrasound | 7 | 21% |
CT urogram or flexible cystoscopy (GL concordant) | 16 | 48% |
Repeat urinalysis* | 5 | 15% |
Semi-structured interview results
Representative quotes related to PCa | Representative quotes relate to AMH | |
---|---|---|
External/Policy Level: National Guidelines
| ||
Follow guidelines (PCa) vs. “guideline-based” (AMH) | “The NCCN guidelines. Most guidelines suggest imaging for only high risk prostate cancer patients. So I follow those.” (Participant 2) | “…And I’m trying to think, --yeah, kind of based off the guidelines. How much blood are they seeing in the urine? If it’s an initial patient that comes in, you know, and they’re over the age of 35, they’ve had no work up whatsoever, I image them. If they’ve had previous microscopic hematuria work ups in the past, a lot of times my question is kind of how long ago have they had some imaging. And guidelines right now say to repeat the work up every three to five years.” (Participant 23) |
High quality PCa guidelines vs. low quality AMH guidelines | “Sometimes in evaluating the guidelines that the bulk of AUA guidelines are made up from urologists. NCCN guidelines do I sometimes feel have a slightly more balanced view, and they have primary care providers, radiation oncologists, medical oncologists, urologists, statisticians, epidemiologists on their guideline committees.” (Participant 15) | “And I know that most of the guidelines are like Grade C evidence or the expert opinion for microscopic hematuria. So they’re not great guidelines, but from my perspective I feel like that’s what I’ve got to work with.” (Participant 13) |
External/Policy Level: Supporting Evidence and Information Exchange
| ||
Information exchange (PCa) vs. no information exchange (AMH) | “I think most of us are alerted to our professional again through AUA organization. We do talk about patient evaluations constantly with the residents and with each other. So there’s some word of mouth certainly involved.” (Participant 36) | “I’d say I honestly don’t know because I just see what I do. That I don’t know what other people are doing.” (Participant 2) |
Literature not supporting imaging | “Just read the literature. Read the literature. If you’re treated for prostate cancer, you’ll more likely die younger than those who aren’t treated for prostate cancer.” (Participant 4) | “I know there’s literature out there that says an ultrasound is going to find 98% of anything wrong. The risk of bladder cancer is about zero. So I kind of handle it like that.” (Participant 4) |
Organization/Practice Level: Organization of the Imaging Pathways
| ||
Pre-appointment imaging | “Yeah. The way that our practice is set up is such that anybody in multidisciplinary clinic is where our new prostate cancer patients come through. The schedulers already know what the criteria are. And so they will order the appropriate tests. And I very rarely have to direct any of that. It just happens naturally based upon our algorithm.” (Participant 48) | “And in our health system, most primary care physicians are the ones that are finding the microscopic hematuria. And our kind of best practice is that they already get imaging for them sent to us.” (Participant 36) |
Outside institution imaging | “If they’re a patient that’s referred from an outside institution, we may not actually have the images to view, which is sometimes challenging. We’ll have to request them, and sometimes that delays care. Or we’ll just have a report of our outside radiologist’s interpretation without being able to look at the images ourselves to confirm that we agree with that radiologist. So that sometimes delays care. But if those two scenarios are the case, then we obtain that imaging from whatever center did it, send it to us, and then we review it at our institution.” (Participant 15) | -- |
Electronic health record systems | -- | “I think it’s, --well, to make it a little more convoluted, when we used the electronic note templates that we have set up, we have one that we use in our department for asymptomatic microscopic hematuria. And so we just plug in that template and there’s a drop down menu saying CT urogram according to AUA guidelines, or a drop down menu renal ultrasound…. But you can do drop down menus saying, okay, I’m getting a CT urogram in accordance with the AUA guidelines, or you can say this patient has renal insufficiency and cannot tolerate a CT urogram. I’m obtaining them a renal ultrasound.“ (Participant 15) |
Individual/Patient Level: Patients’ Clinical and Risk Factors
| ||
Patient clinical/ sociodemographic factors | “Well, I have a lot of old patients. So, I look at the bulk, the grade, physical exam, the age of the patient, and the PSA.“ (Participant 4) | “And so patients that are older, definitely I image. Smokers I image. If they’ve had a history of stones and they haven’t had any recent imaging, sometimes I’ll image them.“ (Participant 23) |
“Risk-based approach” (AMH) | -- | “I’m just assuming that probably some people are very more strictly adhering to the guidelines and then others like myself do a little bit more of a risk based approach.“ (Participant 2) |
Reconfirm AMH diagnosis | -- | “…If they have asymptomatic microscopic hematuria, the first thing I do is double check that that’s actually what they have because most people have a dipstick and it’s like one plus urine…. So I would just say that once I’ve confirmed that, greater than three red blood cells per high power field then I will move on to the workup…” (Participant 2) |
Counseling patients on imaging | “I usually really use the score of the digital rectal exam and PSA to determine whether they get imaged or not, not based on whether a patient wants the image or really wants to skip imaging. I try to counsel them on the need when it’s appropriate.“ (Participant 2) | “One thing I have learned over the years to do is when I counsel patients upfront about hematuria, I proactively tell them that we are not here to explain every case of hematuria because that’s one thing the patients often want to know is like, “Well, why, because I’ve been told this is like this abnormal thing. I feel like I should understand why.” I proactively counsel them, “Well, that’s actually not the goal with hematuria workup because the data are that we’ll find maybe tops, one out of four, we’ll be able to attribute the hematuria to something. But for most people, we can’t find that reliable cause for it,” so yeah. (Participant 48) |
Individual/Provider Level: Clinicians’ Beliefs and Experiences Regarding Imaging
| ||
Imaging does not improve patient care | “I feel like the nomograms because it allows us to say, “You have a 1% chance of having any cancer in your lymph nodes, so it just makes no sense to image a node. You have essentially a negligible chance, somewhere between zero and 0.001 chance, of having cancer in your bones, so we just should not do this.” (Participant 48) | “If you came in here and you had microscopic hematuria and no symptoms whatsoever, and let’s say, --we do dipsticks, so small to a trace, I would tell you, --and you don’t smoke. You don’t have any symptoms. And I’d say, yeah, there’s probably less than 1% chance you having anything bad. Does that bother you? And people say, “What? How low?” Less than 1%….So it’s a very low risk.“ (Participant 4) |
Legal protection by following guidelines (AMH) | -- | “… certainly the medical/legal environment, I think, also is I think something that is always in the back of people’s minds here in the United States. It’s hard to quantify how much that risk is because I think the system tends to be somewhat arbitrary and precious, and so it’s kind of hard to predict. Maybe that makes it even worse since it is so hard to predict what is and is not an exposure and then you’re maybe best served by being as cautious as you can going right by the guidelines.“ (Participant 48) |
External/Policy level: National Guidelines
“I would probably look first to the AUA. I think they have guidelines for localized prostate cancer, or I would look at the National Comprehensive Cancer or the National Cancer Center Network, NCCN. I think that’s the other source of guidelines that I typically go to.” (Participant 48)
“Often I have to log in to the AUA website sometimes and I can’t remember my user ID and password…. NCCN usually has a fairly easy to understand algorithm that you can just kind of follow the boxes on what to do.” (Participant 15)
“most of the guidelines are like Grade C evidence or the expert opinion for microscopic hematuria. So they’re not great guidelines.” (Participant 13)
“there’s not a lot of clear-cut guidelines in patients that have stones, kind of what you do with those patients.” (Participant 23)
External/Policy level: supporting evidence and Information Exchange
“…so I’m usually pretty firm with folks about why I don’t think it’s helpful and what the probability is. I feel like the nomograms…allows us to say, “You have a 1% chance of having any cancer in your lymph nodes, so it just makes no sense to [image] a node. You have essentially a negligible chance, somewhere between zero and 0.001 chance, of having cancer in your bones, so we just should not do this.”” (Participant 48)
“But when we see repeated, repeated, repeated papers…that catch a lot of headlines saying, hey, we can reduce the radiation and just get an ultrasound…” (Participant 15)
“there are certainly papers that have been published about doing these kinds of things where you streamline the hematuria pathway.” (Participant 48)
“I just generally use the guidelines. I’ve seen information on Twitter [and] many places.” (Participant 2)
Organization/Practice Level: Organization of the imaging pathways
“The schedulers already know what the [PCa imaging] criteria are. And so they will order the appropriate tests. And I very rarely have to direct any of that. It just happens naturally based upon our algorithm.” (Participant 2)
“If they’re a patient that’s referred from an outside institution, we may not actually have the images to view, which is sometimes challenging. We’ll have to request them…. Or we’ll just have a report of our outside radiologist’s interpretation without being able to look at the images ourselves to confirm that we agree with that radiologist…. But if those two scenarios are the case, then we obtain that imaging from whatever center did it, send it to us, and then we review it at our institution.” (Participant 15)
“In our health system, more primary care physicians are the ones that are finding the microscopic hematuria. And our kind of best practice is that they [the primary care providers] already get imaging for them [the patients] sent to us.” (Participant 36)
“I would order this [imaging] myself. It’s more individualized.” (Participant 2)
Individual/Patient level: patients’ clinical and other Risk factors
“I will for sure get them a second urinalysis to confirm that they truly have asymptomatic microscopic hematuria. I won’t pull the trigger on imaging and cystoscopy until we’ve had more than one urinalysis showing that.” (Participant 15)
“One thing I have learned over the years to do is when I counsel patients upfront about hematuria, I proactively tell them that we are not here to explain every case of hematuria because that’s one thing the patients often want to know is like, ‘Well, why, because I’ve been told this is like this abnormal thing. I feel like I should understand why.” I proactively counsel them, “Well, that’s actually not the goal with hematuria workup because the data are that we’ll find maybe tops, one out of four, we’ll be able to attribute the hematuria to something. But for most people, we can’t find that reliable cause for it.” (Participant 48)
“I usually really use the score of the digital rectal exam and PSA to determine whether they get imaged or not, not based on whether a patient wants the image or really wants to skip imaging. I try to counsel them on the need when it’s appropriate.” (Participant 15)
Individual/Provider level: Clinicians’ beliefs and experiences regarding imaging
“And I know the chance of dying from disease itself is very low for most of these things.” (Participant 4)“…so we don’t necessarily have great data that [imaging] improves patient outcomes.” (Participant 23)
“…so I think the problem, there is certainly radiation exposure to the patients, costs to the patient and the healthcare system. I think those are the two biggest things. There is some potential harm from exposure to contrast, which is typically part of the guideline concordant evaluation for hematuria.” (Participant 2)“If you came in here and you had microscopic hematuria and no symptoms whatsoever, and let’s say, --we do dipsticks, so small to a trace, I would tell you, --and you don’t smoke. You don’t have any symptoms. And I’d say, yeah, there’s probably less than one percent chance you having anything bad.” (Participant 4)
“Effectively, we’d have to put them through cystoscopy, which can be uncomfortable and also have a number of downstream effects such as urinary tract infection and recurrent bleeding and things like that.” (Participant 15)
“…I mean you’re setting yourself up from a liability standpoint [for practicing outside the guidelines].” (Participant 36)