Table 2 The four general themes with accompanying sub-themes and representative quotes

Treatment selection

Not applicable

(ID# 0021) “I mean usually, somebody with low risk prostate cancer … I’m going to be talking with them depending on their age and health about active surveillance versus prostatectomy versus … brachytherapy versus … external beam radiation. I honestly haven’t incorporated SBRT uh into my standard recommendation set just because it’s relatively new and I, I have zero experience with SBRT for prostate cancer.”

Comparative effectiveness

Clinical factors

(ID# 0008) “… more than 10 years ago, evaluating the feasibility of SBRT … we decided that the patients who would be offered this would be those with um … you know, low-volume, low-risk disease defined by … Gleason score would be 6, or 3 + 4 … 25% or fewer of the cores from the biopsy would be found to be involved with cancer, that PSA would be < 10, and that most importantly that the volume of the prostate would be < 60 cc. So we extracted a lot of what we learned from … our brachytherapy alone experience and applied it to SBRT. Uh … and the patient meeting those criteria, largely is the patient today offered SBRT uh … as an equivalent to IMRT or any other standard therapies.”

Lack of randomized control trial data

(ID# 0007) “Yeah … that’s where there’s even more concerns about projections on long-term toxicity, so, SBRT has been done on individual … single institutional studies, um … these people have reported that the … control is good, toxicity is good … but there hasn’t been yet a very good, a randomized trial of SBRT versus a standard fractionated or even at least a hypofractionated treatment, so … whereas the hypofractionated treatments, there is now an ASTRO, GU ASCO, there were multiple presentations on NRG randomized trials that showed, within up to 5 years they are pretty much equivalent … with SBRT there is no such data, so with SBRT there is even more concern about am I going to hurt my patient and there’s so much uncertainty about is this really as effective and as safe as a standard fractionated treatment. So, um … in my mind, I would feel comfortable offering SBRT only on a clinical trial …”

Preliminary evidence

(ID# 0008) “… Where we’ve seen some differences that are probably meaningful are in quality of life scores and, um, acute toxicities between the two, and generally in favor of stereotactic therapy, that the acute urethritis and cystitis that folks suffered during radiation therapy, um, happens over a compressed period of time with SBRT versus IMRT. Typically patients will begin to accrue these symptoms about 3 weeks or so into their course of IMRT and then they persist till the end, and then for some number of weeks thereafter. What we’ve observed with SBRT is that the return to baseline urinary scores usually occurs much more rapidly after the end of that treatment and the total length in which there is compromise that is measurable is far less.”

Barriers

Health insurance coverage

(ID# 0013) “… Up until very recently and with lots of effort, um, on some of our parts, insurance coverage of SBRT was a major barrier. That thankfully, um, is less of a problem than it used to be. All major Medicare contractors, Medicare administrative contractors, now in one fashion or another across the US cover SBRT, so that’s a good help. Of the private payers, Humana, Aetna, Cigna, cover SBRT, umm, Blue Cross Blue Shield is still spotty … it’s not 100% covered, but many areas of Blue Cross Blue Shield policy cover as well. So, non-coverage which, of course, is a pretty big barrier to adoption …”

Reimbursement differences

(ID# 0025) “Yes, in the late 1990s, when IMRT came on the scene, uhm the, the uh powers at be managed this really good reimbursement for IMRT.”

(ID# 0014) “… one of the barriers are, if, if we give 9 weeks of radiation versus a week of SBRT … it cuts your revenue stream and so that … I hate to say it that way, but I think that’s a barrier for some people.”

Practice inertia

(ID# 0019) “So people who don’t want to do SBRT honestly are arguing that you need this technology, you need that piece of equipment, maybe spacers between the prostate and the rectum … but that’s just not true, I mean most of the um experience with uh, with uh prostate … is not necessarily using equipment that’s totally unique you know so you know, yeah there’s a lot of experience with the Cyberknife, but that’s, it’s just not true that you can’t use anything else.”

(ID# 0028) “… I think uhm adoption of this technology into a community practice setting, uhm, uhm you know may be a little bit of a challenge, uhm, if they’re not used to [it].”

(ID# 0030) “… just like what they mean on the advanced kind of complex technology, it’s usually larger centers that can uhm you know reach the critical mass of expertise to get these things off the ground.”

(ID# 0028) “… so your margin of error should be smaller … cause you know if you miss one fraction of IMRT, well you’ve got 39 others or whatever to make up for it. If you’re off on one fraction of SBRT, that’s a big deal.”

Future treatment use

Not applicable

(ID# 0012) “… Ultimately, as the technology improves, as we’re able to monitor for prostate motion and be very accurate in how we deliver the dose, and … as with everything else, radiation is going to go to fewer fractions and tighter margins … but using better technology.”

(ID# 0011) “Well I think there is going to be an increase in use of the stereotactic, SBRT, mainly because there’s going to be pressure form the insurance companies and government to do it cheaper. You think of how much it costs Medicare every time we treat some uh 70 year-old guy with prostate cancer with external beam radiotherapy? And, if you could show that with stereotactic at least 5-year, 10-year results don’t seem to be much different, they are going to push it, they are going to push it. I think that we are going to see economical considerations being used to push a particular type of treatment.”