We examined the use of initial active surveillance for the management of men with low-risk prostate cancer across the state of Michigan. We found that initial surveillance is used much more commonly than previously reported, but the likelihood of a patient being placed on surveillance depends strongly on where he is treated.

No abstract

A statewide intervention aimed at addressing fluoroquinolone resistance reduced post-prostate biopsy infection related hospitalizations in Michigan by 53%.

Owing to concerns about overtreatment, urologists are increasingly using active surveillance (AS) as the initial management for men with low-risk prostate cancer. 1,2 Nonetheless, additional progress in this area requires a deeper understanding of the wellestablished and wide variation in use of AS. 3,4 Of particular interest from a quality improvement perspective is whether practice patterns tend to vary widely even among urologists in the same practice and/or based on her or his panel size (ie, the volume of men with low-risk prostate cancer a given urologist manages). In the context of limited resources, the availability of such information may be used to develop efficient improvement interventions aimed at optimizing the implementation of AS among diverse urologists and practice settings. Methods | The Michigan Urological Surgery Improvement Collaborative is a consortium of 43 academic and community urology practices in Michigan that maintains a prospective clinical registry with detailed and validated clinical information for men newly diagnosed as having prostate cancer seen in participating practices. For this analysis, we identified all Michigan Urological Surgery Improvement Collaborative practices with at least 5 urologists who each managed 5 or more men with low-risk prostate cancer from January 2012 through July 2016. We then examined the proportion of men managed primarily with AS across practices and among urologists within each practice, adjusting for differences in patient age and comorbidity. Finally, we fit a linear regression model to estimate the association between the proportion of patients entering AS and urologist panel size. Two-sided testing was performed, with P < .05 considered significant (StataCorp). Each practice obtained institutional review board approval of not-regulated or exempt status or had an expedited review for collaborative participation. As a part of the institutional review board process at all participating sites, it was determined that given the quality improvement focus of the Michigan Urological Surgery Improvement Collaborative and the fact that the data it houses are (1) collected for quality improvement and not human participants research and (2) is collected during routine care of patients (eg, does not require any changes or burdens beyond routine care processes), informed consent was not necessary. Results | We identified 124 urologists from 13 practices who managed 2643 men (median age, 64 years) diagnosed as having low-risk prostate cancer during the interval of interest. The

No abstract

Objective To evaluate the performance of published guidelines compared to current practice for radiographic staging of men with newly-diagnosed prostate cancer. Materials and Methods Using data from the Michigan Urological Surgery Improvement Collaborative (MUSIC) clinical registry, we identified 1,509 men diagnosed with prostate cancer from March 2012 through June 2013. Clinical data included age, prostate-specific antigen (PSA), Gleason score (GS), clinical T-stage, number of biopsy cores and bone scan (BS) results. We then fit a multivariable logistic regression model to examine the association between clinical variables and the occurrence of bone metastases. Because some patients did not undergo BS, we used established methods to correct for verification bias and estimate the diagnostic accuracy of published guidelines. Results Among 416 men who received a BS, 48 (11.5%) had evidence of bone metastases. Patients with bone metastases were older, with higher PSA and GS (all p <0.05). In multivariable analyses, PSA (p <0.001) and GS (p =0.004) were the only independent predictors of positive BS. Guidelines from the American Urology Association (AUA) and the National Comprehensive Cancer Network (NCCN) demonstrated similar performance in detecting bone metastases in our population, with fewer negative studies than the European Association of Urology (EAU) guideline. Applying the AUA recommendations (i.e., image when PSA >20 or GS ≥8) to current clinical practice, we estimate that <1% of positive studies would be missed, while the number of negative studies would be reduced by 38%. Conclusions Based on current practice patterns, more uniform application of existing guidelines would ensure that BS is performed for almost all men with bone metastases, while avoiding many negative imaging studies.

Purpose We examined the frequency of follow-up prostate-specific antigen (PSA) testing and prostate biopsy among men managed with active surveillance (AS) in academic and community urology practices comprising the Michigan Urological Surgery Improvement Collaborative (MUSIC). Materials and Methods MUSIC is a consortium of 42 practices that maintains a prospective clinical registry with validated clinical data for all patients diagnosed with prostate cancer at participating sites. We identified all patients in MUSIC practices who entered AS and had at least two years of continuous follow-up. After determining the frequency of repeat PSA testing and prostate biopsy, we calculated rates of concordance with NCCN guideline recommendations (i.e., at least three PSA tests and one surveillance biopsy) both collaborative-wide and across individual practices. Results We identified 513 patients entering AS from 1/2012–9/2013 with at least two years of follow-up. Among the 431 men (84%) that remained on AS for two years, 132 (30.6%) had follow-up surveillance testing at a frequency that was concordant with NCCN recommendations. At a practice-level, the median rate of guideline concordant follow-up was 26.5% (range 10–67.5%, p<0.001). Among patients with discordant follow-up, the absence of follow-up biopsy was common and not significantly different across practices (median rate=82.0%, p=0.35). Conclusions Among diverse community and academic practices in Michigan, there is wide variation in the proportion of men on active surveillance that meet guideline recommendations for follow-up PSA testing and repeat biopsy. These data highlight the need for standardized AS pathways that emphasize the role for repeat surveillance biopsies.

Objective To examine the association between National Comprehensive Cancer Network (NCCN) risk, number of positive biopsy cores, age, and early confirmatory test results on pathological upgrading at radical prostatectomy (RP), in order to better understand whether early confirmatory testing and better risk stratification are necessary for all men with Grade Group (GG) 1 cancers who are considering active surveillance (AS). Patients and Methods We identified men in Michigan initially diagnosed with GG1 prostate cancer, from January 2012 to November 2017, who had a RP within 1 year of diagnosis. Our endpoints were: (i) ≥GG2 cancer at RP and (ii) adverse pathology (≥GG3 and/or ≥pT3a). We compared upgrading according to NCCN risk, number of positive biopsy cores, and age. Last, we examined if confirmatory test results were associated with upgrading or adverse pathology at RP. Results Amongst 1966 patients with GG1 cancer at diagnosis, the rates of upgrading to ≥GG2 and adverse pathology were 40% and 59% (P< 0.001), and 10% and 17% (P= 0.003) for patients with very-low-and low-risk cancers, respectively. Upgrading by volume ranged from 49% to 67% for ≥GG2, and 16% to 23% for adverse pathology. Generally, more patients aged ≥70 vs <70 years had adverse pathology. Unreassuring confirmatory test results had a higher likelihood of adverse pathology than reassuring tests (35% vs 18%, P= 0.017). Conclusions Upgrading and adverse pathology are common amongst patients initially diagnosed with GG1 prostate cancer. Early use of confirmatory testing may facilitate the identification of patients with more aggressive disease ensuring improved risk classification and safer selection of patients for AS.