Table 4.

Summary table of determinants of choice and adherence to active surveillance among men with low-risk prostate cancer found in the systematic review

Level	Factor	Potentially targetable interventions for future research and quality improvement initiatives	References
1. Cancer characteristics	Cancer risk, stage, grade, PSA, tumour volume	Harmonizing national/local guidelines; Developing consensus-based appropriateness criteria	[11,22–31]
2. Patient	Shared or collaborative role in decision-making; preferences; seeking information; feeling informed; knowledge	Shared decision-making; appropriate, reliable, and unbiased information; personal information; not contradictory and not stressful; increased availability of educational resources from trusted medical organizations for patients and families	[27,32,41,46,50]
	Patient characteristics (age, comorbidities, race, family history of prostate cancer, education, employment, insurance, socioeconomic status) and	Physician judgment and recommendation in shared decision-making with patient preference.	[11,12,22–29,31–37,40,46,68]
	Impact of active treatment on: side-effects (urinary function, sexual function); preservation of HRQoL; time to accept diagnosis and to decide; “buying time”	Patient education and information	[25,27,28,32,40–43,46,47,53,60–62,64–67, 69,70,75]
	Self-management support; preference-style for diet, exercise and complimentary therapies; increased awareness and control of health; hope for prolonged and improved health; symptom monitoring; life-style	Patient education and information; self-management through diet and exercise, stress management, digital technology	[25,32,40,46,50,83]
	Preference for immediate cure; “cut it out”; desiring treatment efficacy/cure; avoid future regret	Patient education and information; supportive counselling	[27,31,40,43,45,80]
	Perceived cancer risk; cancer worry; fear of disease progression; illness uncertainty; anxiety and distress	Patient education and information; support; coping; manage anxiety; cognitive reframing; mindfulness; meditation; empowering; support groups; peer community; socialization; connect to others; shared activities; a sense of belonging; provide patients with a sense of meaning and control, robust monitoring processes, widespread agreement on monitoring process.	[14,25,27,30,32,33,40,41, 44–46,50,53,59,60,62, 63,65,66,71,72,74, 78–82,86]
	Monitoring stressors; Coping with anxiety, frequent PSA testing and repeat biopsies	Patient education and information; support; coping	[25,27,32,40, 46–48,60,92,93]
	Awareness and acceptance of AS; survival expectation on AS	Availability of AS “success stories”	[47,50,59,73,78]
	Unknown factors	Qualitative interview studies with physicians and patients	[40,45,46,52]
3. Family and social support	Advice/pressure from partner/spouse/children/friends; marital status; family member with PC	Supportive counselling and information; patient not having to justify decision to others; support; education; reassurance	[32,40–42,45,46,62,85]
	Awareness and acceptance of AS	Public role models managed with AS and patient advocates	[40,42,45–47,85,86]
	Fear of progression; disagreement about safety; preference to “eradicate the cancer”	Counselling and information; Enhanced recognition with information sources, treatment support, medical consultations	[45–47,50]
4. Provider	Physician’s recommendation; consistency in medical/nursing personnel	Training specialists to use a systematic approach to counselling patients about treatment options; communicating clearly and with confidence; using nudging narratives and framing techniques from behavioural science theory; maintain a positive and hopeful attitude; provide support and reassurance; public reporting of physicians’ cancer management profiles	[26,30,32–34,40–42, 44–47,50,52,53,89]
	Specialty of physician giving treatment information	Multi-disciplinary team of specialists	[22,26,32,56]
	Provision of information and support	Provide and direct patients to accurate and unbiased information rather than describing AS as “doing nothing” or “no treatment” or scaring patients to active treatment, access to AS support groups. Establish consistency of support through nurse specialist roles.	[26,28,32,40,43,46, 47,50,55,56,59,83,88,89]
	Physician attitudes; reluctance; concern about disease progression; perceived lack of data	Raise awareness, ongoing discussions at national meetings, quality improvement initiatives; having clear plans and stopping rules; systematic counselling on AS	[40,44–47,51,52]
	Lack of availability of physicians recommending AS	Advocacy; subspecialty within urology	[40,47]
	Confidence and trust in health professionals; closeness with physician; share control over treatment decision making	Improved community and medical education about treatment options, prognosis, side-effects; raise awareness of AS; consistent, unbiased treatment information; decisional support information; building trust in physician; patient trusting the physician’s monitoring; patient feeling AS is an organized, supportive process;	[40,46,51,52,89]
5. Health care organization/practice	Urology practice site; hospital referral region; geographic region	Quality improvement initiatives to harmonize practice sites within networks	[26,35–37,46,47]
	Degree to which physician shared control over treatment decision making	System-levels determinants of trust, closeness and shared decision-making; organizational changes, e.g. longer consultation times	[40,51,52]
	Consultation at a multidisciplinary clinic; University hospital setting; academic hospital or high volume of PC patients	Multidisciplinary clinic may reduce the bias that specialists prefer the modality of treatment they themselves deliver and patients receive a balance perspective of risks and benefits of options	[11,22,24,35–37]
	Differences in surveillance strategies	National/International consensus of safe AS. Selection, monitoring and progression, patient information on large AS cohorts	[11,12,23,26,88,93]
6. Health policy level	Guideline recommendations	Harmonizing national/local guidelines; developing appropriateness criteria; national guideline recommending AS; real-time feedback to units on adherence to national guideline in terms of annual report publicly available online	[11,47,52,53]
	Trial/cohort data; year of diagnosis	Monitoring and future publications from ongoing prospective protocol-based AS cohorts and registries	[11,35,47,52]
	Awareness and acceptance	Guidelines; consensus; discussions at meetings; AS-specific billing code	[47,52]