Key Determinants Influencing Treatment Decision-Making for and Adherence to Active Surveillance for Prostate Cancer: A Systematic Review

Abstract

Background/Objectives: Men choosing active surveillance (AS) for low- and intermediate risk prostate cancer (PCa) must weigh its harms and benefits against those of active treatment (AT). To understand factors influencing treatment decision-making (TDM) for and adherence to AS, we performed a systematic review. Methods: This systematic review followed the PRISMA guidelines and was registered with PROSPERO (ID CRD42024490427). A comprehensive search strategy from 1990 to 2024 was executed across multiple databases, including Medline and Embase. Studies were included if they examined factors influencing TDM for AS or active monitoring (AM) and adherence to AS/AM. Results: Of the 8316 articles identified, 223 articles were eligible for inclusion. The decision for AS was influenced by different factors, including comprehensive information about treatment options, social support, and wanting to avoid side-effects. Key reasons to choose AT over AS included a lack of information from healthcare professionals about AS and fear of disease progression. Reasons for adhering to the AS protocol included better quality of life and social support. While non-adherence to the AS protocol is prompted by, e.g., biopsy burden and uncertainty, AS discontinuation is generally a results of medical reasons (namely disease upgrading) or from anxiety and family pressure. Conclusions: Numerous factors influence men's treatment pathway choices. Involving family members in shared decision-making and ensuring that patients have detailed information about AS as a treatment option could help to improve AS uptake. Addressing psychosocial challenges through education and family involvement could improve AS adherence. These insights can help healthcare providers by addressing men's needs during TDM and AS.

Keywords: active surveillance; discontinuation; prostate cancer; treatment choice adherence; treatment decision.

Figure 1

PRISMA flowchart.

Figure 2

Factors influencing an active surveillance (AS) pathway in alphabetical order ** The percentages represent the proportion of studies reporting each factor. These percentages do not total 100%, as individual studies often addressed multiple factors.