Active surveillance for low-grade ductal carcinoma in situ: A mixed-methods systematic review of patient, clinician, and health-system perspectives

Abstract

Background: Low-grade ductal carcinoma in situ (DCIS) is increasingly detected through breast screening, raising concerns about overtreatment. Active surveillance (AS) has emerged as an alternative to immediate surgery. We synthesized patient, clinician, and health-system perspectives relevant to AS adoption.

Methods: We conducted a mixed-methods systematic review (MMSR) following PRISMA, integrating quantitative, qualitative, and mixed-methods studies using a convergent integrated synthesis approach (PROSPERO CRD420250656621). PubMed, Embase, and the Cochrane Library were searched from 2000 to 2025. Risk of bias (RoB) was assessed using standardized tools.

Results: Fourteen studies were included. Patient preferences varied widely and were influenced by anxiety, terminology, perceived risk, and trust. Clinicians highlighted concerns about progression risk, pathology variability, medicolegal exposure, and limited long-term evidence. Institutional readiness was constrained by gaps in surveillance pathways, risk-stratification tools, and implementation support. Overall RoB was low to moderate.

Conclusion: Adoption of AS for low-grade DCIS depends not only on clinical evidence but also on psychological, communication, and organizational factors that shape decision-making across patients, clinicians, and health systems.

Keywords: Active surveillance; Clinician perspectives; Ductal carcinoma in situ; Mixed-methods systematic review; Patient preferences.