A call for theory-informed approaches to knowledge translation studies: an example of chemotherapy for bladder cancer.

There is a clear evidence-to-practice gap in bladder cancer care. International guidelines recommend that patients with muscle-invasive bladder cancer (mibc) receive some form of perioperative chemotherapy, with stronger evidence for the use of neoadjuvant (nact) than of adjuvant (act) chemotherapy1. Delivery of perioperative chemotherapy involves close collaboration and communication between at least two physician subspecialties: the urologist who makes the initial diagnosis of bladder cancer and undertakes surgery, and the medical oncologist who delivers the chemotherapy. Urologists are the “gatekeepers” to nact or act because they make the upstream decision about whether to refer the patient to a medical oncologist. We recently described very low concordance with the guideline recommendations for patients with mibc in Ontario: 4% and 18% of patients in Ontario received nact or act respectively2. We also found that only 18% of patients were referred to a medical oncologist for consideration of nact, with 25% of that group subsequently receiving treatment. Of the 39% of patients who were referred to a medical oncologist after surgery, 51% received act3. Those findings suggest the presence of barriers to treatment at both the upstream level of the urologist and the downstream level of the medical oncologist, and yet there is a critical lack of information about why urologists and medical oncologists do not recommend the use of chemotherapy. Similarly, the literature concerning why patients might decline referral to medical oncology or recommended nact or act is sparse. Most existing studies about the barriers and enablers to the use of nact or act for bladder cancer are brief surveys that describe self-reported practice patterns, but that do not investigate the underlying knowledge, attitudes, and beliefs of clinicians about this clinical decision4,5. Based on the existing literature, we identified a number of potential reasons for low utilization at the levels of the urologist, the medical oncologist, and the patient6. Physicians, for example, might be unaware of the evidence; or aware of the evidence, but of the belief that their patients are not medically eligible for perioperative chemotherapy; or of the perception that the magnitude of benefit is not clinically important. To our knowledge, no studies have used a knowledge translation (kt) conceptual framework to describe the barriers and enablers to utilization of perioperative chemotherapy. The use of such a framework would guide a systematic approach to barrier and enabler identification and subsequent development of a targeted kt strategy at the physician level. In this commentary, we use our own program of research in bladder cancer to illustrate how a kt framework can be used to investigate the barriers and enablers to knowledge use, thus potentially informing the development of a behaviour change intervention. The u lt imate goa l of a resea rch prog ra m t hat identifies evidence-to-practice gaps in cancer care is to improve concordance with guidelines and patient outcomes. However, intervention studies designed to improve the uptake of evidence into clinical practice is known, in several disease settings, to have had limited and varied effects—a result that could be, in part, the result of a lack of explicit rationale for the intervention choice and the use of inappropriate methods to design the interventions7,8. By using a systematic approach guided by well-grounded theory to study barriers and enablers, study results can be linked to effective behaviour change techniques, hence increasing the potential for sustainable change. Having identified gaps in care delivered to patients with bladder cancer in routine practice, we are now initiating a study funded by the Canadian Cancer Society Research Institute to understand the knowledge, attitude, and beliefs of urologists and medical oncologists. A four-step systematic approach for the development of theory-based behaviour change interventions has been described in the literature (Table i)7. The process7 guides