Table 3 Quotes for each subtheme illustrating similarities and differences between prostate cancer (PCa) and asymptomatic microscopic hematuria (AMH)

External/Policy Level: National Guidelines

Follow guidelines (PCa) vs.

“guideline-based” (AMH)

“The NCCN guidelines. Most guidelines suggest imaging for only high risk prostate cancer patients. So I follow those.” (Participant 2)

“…And I’m trying to think, --yeah, kind of based off the guidelines. How much blood are they seeing in the urine? If it’s an initial patient that comes in, you know, and they’re over the age of 35, they’ve had no work up whatsoever, I image them. If they’ve had previous microscopic hematuria work ups in the past, a lot of times my question is kind of how long ago have they had some imaging. And guidelines right now say to repeat the work up every three to five years.”

(Participant 23)

High quality PCa guidelines vs.

low quality AMH guidelines

“Sometimes in evaluating the guidelines that the bulk of AUA guidelines are made up from urologists. NCCN guidelines do I sometimes feel have a slightly more balanced view, and they have primary care providers, radiation oncologists, medical oncologists, urologists, statisticians, epidemiologists on their guideline committees.” (Participant 15)

“And I know that most of the guidelines are like Grade C evidence or the expert opinion for microscopic hematuria. So they’re not great guidelines, but from my perspective I feel like that’s what I’ve got to work with.” (Participant 13)

External/Policy Level: Supporting Evidence and Information Exchange

Information exchange (PCa) vs.

no information exchange (AMH)

“I think most of us are alerted to our professional again through AUA organization. We do talk about patient evaluations constantly with the residents and with each other. So there’s some word of mouth certainly involved.” (Participant 36)

“I’d say I honestly don’t know because I just see what I do. That I don’t know what other people are doing.” (Participant 2)

Literature not supporting imaging

“Just read the literature. Read the literature. If you’re treated for prostate cancer, you’ll more likely die younger than those who aren’t treated for prostate cancer.” (Participant 4)

“I know there’s literature out there that says an ultrasound is going to find 98% of anything wrong. The risk of bladder cancer is about zero. So I kind of handle it like that.” (Participant 4)

Organization/Practice Level: Organization of the Imaging Pathways

Pre-appointment imaging

“Yeah. The way that our practice is set up is such that anybody in multidisciplinary clinic is where our new prostate cancer patients come through. The schedulers already know what the criteria are. And so they will order the appropriate tests. And I very rarely have to direct any of that. It just happens naturally based upon our algorithm.” (Participant 48)

“And in our health system, most primary care physicians are the ones that are finding the microscopic hematuria. And our kind of best practice is that they already get imaging for them sent to us.” (Participant 36)

Outside institution imaging

“If they’re a patient that’s referred from an outside institution, we may not actually have the images to view, which is sometimes challenging. We’ll have to request them, and sometimes that delays care. Or we’ll just have a report of our outside radiologist’s interpretation without being able to look at the images ourselves to confirm that we agree with that radiologist. So that sometimes delays care. But if those two scenarios are the case, then we obtain that imaging from whatever center did it, send it to us, and then we review it at our institution.” (Participant 15)

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Electronic health record systems

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“I think it’s, --well, to make it a little more convoluted, when we used the electronic note templates that we have set up, we have one that we use in our department for asymptomatic microscopic hematuria. And so we just plug in that template and there’s a drop down menu saying CT urogram according to AUA guidelines, or a drop down menu renal ultrasound…. But you can do drop down menus saying, okay, I’m getting a CT urogram in accordance with the AUA guidelines, or you can say this patient has renal insufficiency and cannot tolerate a CT urogram. I’m obtaining them a renal ultrasound.“ (Participant 15)

Individual/Patient Level: Patients’ Clinical and Risk Factors

Patient clinical/ sociodemographic factors

“Well, I have a lot of old patients. So, I look at the bulk, the grade, physical exam, the age of the patient, and the PSA.“ (Participant 4)

“And so patients that are older, definitely I image. Smokers I image. If they’ve had a history of stones and they haven’t had any recent imaging, sometimes I’ll image them.“ (Participant 23)

“Risk-based approach” (AMH)

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“I’m just assuming that probably some people are very more strictly adhering to the guidelines and then others like myself do a little bit more of a risk based approach.“ (Participant 2)

Reconfirm AMH diagnosis

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“…If they have asymptomatic microscopic hematuria, the first thing I do is double check that that’s actually what they have because most people have a dipstick and it’s like one plus urine…. So I would just say that once I’ve confirmed that, greater than three red blood cells per high power field then I will move on to the workup…” (Participant 2)

Counseling patients on imaging

“I usually really use the score of the digital rectal exam and PSA to determine whether they get imaged or not, not based on whether a patient wants the image or really wants to skip imaging. I try to counsel them on the need when it’s appropriate.“ (Participant 2)

“One thing I have learned over the years to do is when I counsel patients upfront about hematuria, I proactively tell them that we are not here to explain every case of hematuria because that’s one thing the patients often want to know is like, “Well, why, because I’ve been told this is like this abnormal thing. I feel like I should understand why.” I proactively counsel them, “Well, that’s actually not the goal with hematuria workup because the data are that we’ll find maybe tops, one out of four, we’ll be able to attribute the hematuria to something. But for most people, we can’t find that reliable cause for it,” so yeah. (Participant 48)

Individual/Provider Level: Clinicians’ Beliefs and Experiences Regarding Imaging

Imaging does not improve patient care

“I feel like the nomograms because it allows us to say, “You have a 1% chance of having any cancer in your lymph nodes, so it just makes no sense to image a node. You have essentially a negligible chance, somewhere between zero and 0.001 chance, of having cancer in your bones, so we just should not do this.” (Participant 48)

“If you came in here and you had microscopic hematuria and no symptoms whatsoever, and let’s say, --we do dipsticks, so small to a trace, I would tell you, --and you don’t smoke. You don’t have any symptoms. And I’d say, yeah, there’s probably less than 1% chance you having anything bad. Does that bother you? And people say, “What? How low?” Less than 1%….So it’s a very low risk.“ (Participant 4)

Legal protection by following guidelines (AMH)

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“… certainly the medical/legal environment, I think, also is I think something that is always in the back of people’s minds here in the United States. It’s hard to quantify how much that risk is because I think the system tends to be somewhat arbitrary and precious, and so it’s kind of hard to predict. Maybe that makes it even worse since it is so hard to predict what is and is not an exposure and then you’re maybe best served by being as cautious as you can going right by the guidelines.“ (Participant 48)