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Strategies to improve adherence to active surveillance in low‐intermediate risk prostate cancer

Student thesis: Doctoral ThesisDoctor of Philosophy

Background and aims 
Despite support for active surveillance as a first treatment choice for men with low‐risk prostate cancer, this strategy is largely underutilised and when chosen the drop‐out rate is high (up to 38%) in the first 5 years (even where there is no evidence of cancer progression). In order to decrease the over treatment of men with low‐risk prostate cancer it is important to understand the barriers and facilitators to active surveillance to consider in the design of future interventions to increase active surveillance choice and adherence. 
Methods 
A four stage modified Delphi technique was employed to achieve consensus on supportive care measures for active surveillance. Stage 1 Data collection; a 5 year review of an active surveillance intervention aimed at active surveillance adherence, review of contemporary active surveillance cohorts worldwide, and a systematic review of the barriers and facilitators to active surveillance choice and adherence. Stage 2 Qualitative study; semi‐structured interviews with men who had opted out of surveillance without evidence of cancer progression Stage 3 Data synthesis and Delphi survey; meta aggregation of qualitative and quantitative data from stages 1 and 2 to inform a two round patient and public involvement Delphi survey Stage 4 Consensus; Expert active surveillance reference group consensus statements 
Results 
Key themes influence both choice and adherence to AS, which are interlinked in respect to experience: (1) cancer characteristics (tumour volume, grade, PSA marker); (2) patient factors (age, co‐morbidities, knowledge, socioeconomic status, family history, fear of progression/side‐effects); (3) family and social support; (4) provider (communication, attitudes, diagnostic experience); (5) healthcare organisation (administration, education, support) and (6) health policy (guidelines, awareness). Patients and healthcare professionals have different ideas concerning the priorities for active surveillance supportive care; however, the Active Surveillance Reference Group agreed 24 consensus statements for best practice in supportive care for active surveillance in respect of; (1) principles of an active surveillance programme; (2) structure of consultations; (3) content: Information and Support; (4) delivery of information. 
Conclusion
Many factors influence both men’s choice and adherence to AS, with health care professionals prioritising different aspects of supportive care to those of patients. It is therefore essential to implement a robust patient and public consultation process during both the evidence acquisition phase as well as the design phase of future interventions aimed at increasing AS adherence.
Original languageEnglish
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Award date1 Jun 2019

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