IntroductionRenal tumour biopsies (RTBs) can provide the histology of small renal masses (SRMs) prior to treatment decision-making. However, many urologists are reluctant to use RTB as a standard of care. This study characterizes the current use of RTB in the management of SRMs and identifies barriers to a more widespread adoption.MethodsA web-based survey was sent to members of the Canadian and Quebec Urological Associations who had registered email address (n=767) in June 2016. The survey examined physicians’ practice patterns, RTB use, and potential barriers to RTB. Chi-squared tests were used to assess for differences between respondents.ResultsThe response rate was 29% (n=223), of which 188 respondents were eligible. A minority of respondents (12%) perform RTB in >75% of cases, while 53% never perform or perform RTB in ConclusionsAdoption of RTBs remains low in Canada. Concerns about the accuracy of RTB and its ability to change clinical practice are the largest barriers to adoption. A knowledge translation strategy is needed to address these concerns. Future studies are also required in order to define where RTB is most valuable and how to best to implement it.IntroductionIncreased use and improved accuracy of abdominal imaging over the last decade has increased the number of small renal masses (SRMs) being diagnosed.1,2 While the majority of solid renal tumours measuring ≤4 cm are malignant, up to 30% are benign.3 Additionally, most malignant SRMs are low-grade and have low metastatic potential.3 Initial definitive treatment of SRMs may represent overtreatment in many cases.To justify and hopefully reduce overall treatment, with its associated burden of care, renal tumour biopsy (RTB) has been proposed as a safe, accurate, and reliable method to identify the histology of SRMs before treatment.4–7 Although the use of active surveillance for SRMs is increasing, this strategy in surgical candidates could be refined based on RTB results. RTB could be helpful in identifying higher metastatic potential tumours better suited for definitive treatment or by identifying histologically benign tumours that do not require a followup protocol as stringent as do malignant tumours.8 Thus, although debatable, RTB can influence management. However, in spite of the potential benefits, many urologists are still reluctant to adopt RTB as a standard of care for SRMs.9 Consequently, most SRMs are still treated10 and RTBs remain underused.11,12 Reasons for slow adoption of routine RTB are not well-understood, but may include concerns regarding non-diagnostic rates, discordance with final pathology, safety, and a lack of perceived impact on clinical management.9 These potential concerns have not been well-supported by studies reported over the past few years.5,6The objectives of this study were to characterize the uptake of RTB in Canada for the management of SRMs and to assess whether utilization rates varied between types of practice and training. Lastly, we aimed to better characterize the barriers to a greater adoption.MethodsFollowing approval from the University Health Network Research Ethics Board, a pilot questionnaire was developed and tested in 20 urologists in May 2016. All items were then revised according to the responses in the pilot survey. The survey questions were formatted as either multiple-choice, rating scale, or short answer. An electronic survey was then generated (www.surveymonkey.com)13 and distributed via email. The survey was distributed to all active members of the Canadian Urological Association (CUA) and the Quebec Urological Association (QUA). Two emails (one initial and one reminder) containing a link to the survey were sent out to all 767 members on June 13 and 22, 2016. Members of both associations were invited to answer a questionnaire in their language of preference (available in French and English). The survey contained questions regarding the physicians’ practice patterns, RTB use, and potential barriers of RTB (Supplementary Table 1). We excluded non-urologists, pediatric urologists, urologists who did not manage SRMs, and physicians who gave incomplete demographic information or who did not answer questions beyond the demographic ones.Continuous and categorical variables were reported using medians (interquartile range [IQR]) and proportions, respectively. Chi-squared tests were used to assess differences between specific groups of respondents (types of practice and fellowship training). To test whether different patient and tumour characteristics were associated with the likelihood of recommending a RTB, we performed paired McNemar’s tests to determine whether responses within respondents differed based on presence or absence of each factor. Univariate and multivariate condition
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