Anxiety, culture, and expectations: Oncologist-perceived factors associated with use of nonrecommended serum tumor marker tests for surveillance of early-stage breast cancer

Abstract

Purpose Breast cancer offers several opportunities for reducing use of ineffective practices based onAmerican SocietyofClinicalOncologyguidelines.Weassessedoncologist-perceived factors associated with use of one such practice-serum tumor markers for post-treatment breast cancer surveillance-focusing on medical oncologists with high, medium, or low test use. Methods Using a mixed-methods design,weidentified patientswhohad beentreated for early-stage breast cancer diagnosed between January 1, 2009, and December 31, 2012, within Kaiser Permanente Southern California and calculated the number of tests ordered from January 1, 2010, to December 31, 2014. We identified oncologists with high, medium, or low use and subsequently performed semistructured interviews.Weused patient satisfaction data to assess association between pattern of use and satisfaction score. Results Weidentified 7,363 patients,with 40,114 tests ordered.High-use oncologists were defined as those ordering at least one test annually for 35% of patients or more, low-use oncologists as those ordering at least one test for 5% of patients or less; 42% of oncologists were high, 27%low, and31%mediumusers.Weinterviewed17 oncologists: six high, eight low, and three mediumusers. Factors associated with high use included: perceived patient anxiety, oncologist anxiety, belief that there was nothing else to offer, concern about satisfaction, patient competition, peer use, and system barriers. Factors associated with low use included: beliefs about consequences (eg, causes harms) and medical center culture (eg, collective decision to follow guidelines). We found no association between satisfaction score and pattern of use. Conclusion Barriers to deimplementation are numerous and complex. Traditional strategies of practice change alone are unlikely to be effective. Multifaceted, multilevel strategies deployed to address patient-, clinician-, and system-related barriers may be required.