DE-IMPLEMENTING CURATIVE THERAPY IN LOW-RISK PROSTATE CANCER: PRELIMINARY EVIDENCE OF UROLOGISTS' UNLEARNING

Purpose:

Use of curative therapy, such as radical prostatectomy and radiation therapy, to treat low-risk prostate cancer has declined in the last decade. Using the Theory of Unlearning, we sought to identify factors which facilitated urologists' de-implementation of curative therapy to provide empirical validation of the theory and inform future de-implementation interventions.

Method:

We analyzed 22 retrospective, semi-structured, qualitative interviews conducted with practicing urologists across the United States. Urologists were recruited to represent a variety of practice settings: academic medical centers, Veterans’ Administration facilities, private practice, rural practice, and intensity-modulated radiation therapy (IMRT) centers. We identified factors instrumental to de-implementing curative therapy and mapped them to features theorized to promote unlearning.

Result:

Twenty-one male and one female urologist participated, representing all four regions of the US. Urologists described seven concepts consistent with the individual components of the theory of unlearning that influenced de-implementation of curative therapy. No organizational elements of unlearning were described by urologists in this sample; they described processing external influences directly without organizational mediation. Urologists demonstrated deliberate unlearning of curative therapy, rather than unconscious forgetting. Facilitators of de-implementation represented both wiping (imposed changes with little emotional impact that slowly impact behavior) and deep unlearning (unexpected individual experience with significant emotional impact that suddenly impacts cognitive processes underlying behavior). Facilitators to de-implementation that corresponded to wiping included: clinical trials of active surveillance demonstrating the safety of that management strategy; publications suggesting potential harms of surgery and radiation; and general knowledge that patients may regret treatment decisions. Facilitators to de-implementation that corresponded to wiping include personal experience with positive surveillance outcomes; strong emotional reactions to US Preventive Services Task Force screening guidelines, which urologists perceived to negatively impact many men; corresponding public scrutiny around overtreatment of low-risk prostate cancer; and sensitivity among some urologists about physician-induced demand.

Conclusion:

Elements of individual unlearning, particularly wiping and deep unlearning, were present in some urologists' narratives describing changes in use of curative therapy in low-risk prostate cancer. Research to compare perceptions of urologists who did and did not change practice patterns is needed. Interventions that highlight gradually accumulating evidence addressing multiple angles of an issue and introduce policy changes which abruptly challenge physicians' world views may be necessary to accelerate de-implementation. Unintended consequences require further evaluation.