Purpose: To better understand physician decision-making concerning adoption of new technology, particularly catheter-based accelerated partial breast irradiation (APBI) for breast cancer prior to Phase III randomized trial (RCT) publication. APBI requires treatment twice daily for 5 days instead of daily for 5-7 weeks.
Method: Qualitative analysis of interviews based in grounded theory with 8 surgeons and 9 radiation oncologists across the United States identified through purposive sampling to obtain varied perspectives of community-based (private/HMO, urban/non-urban) physicians.
Result: Physicians averaged 21 years (range: 1.5-50) in practice, with a mean of 40% (range: 7-98%) breast cancer patients at time of interview. Although most physicians learn about new technologies elsewhere, the decision to adopt a new technology was discussed and agreed upon within their social networks at their home institution and local geographic area, requiring partnership between surgeon and radiation oncologist. No definitive level of evidence was requisite before technology adoption; RCTs were preferred, but because technology evolves quickly, physicians must be ready to act on often-limited information or intuition and by practicing the “art” of medicine. Several barriers, facilitators, and pressures for adoption were raised: physician motivation is required for adoption, but radiation oncologists often were described as too “old” or “conservative” to learn new technologies; radiation oncologists must be present for each APBI treatment, altering workflow; surgeons may threaten to refer patients elsewhere if a radiation oncologist does not adopt APBI; physicians must be cautious because poor outcomes can decimate one’s program/practice; patients aware of new technology often exert pressure for adoption; community standards, not necessarily high-quality evidence, pressure physicians to adopt technology to keep up with peers; and device companies facilitate matches between, and training for, surgeons and radiation oncologists interested in adopting APBI. Financial incentives seem to play a role in technology adoption, particularly for surgeons who would not otherwise benefit from radiotherapy, and non-financial adoption incentives would lead to increased income indirectly.
Conclusion: Preference for high-quality evidence often gives way to patient pressure, financial incentives, and community norms. Unique to APBI, surgeons and radiation oncologists cannot adopt independently and must develop partnerships and agree to adoption. Although radiation oncologists may be concerned about declining income-per-patient due to APBI, the trade-off between fractions-per-patient and number of patients seen works in favor of APBI.
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