Practice- vs Physician-Level Variation in Use of Active Surveillance for Men With Low-Risk Prostate Cancer

Abstract

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

PSMA Ligand PET/MRI for Primary Prostate Cancer: Staging Performance and Clinical Impact

“…Remarkably, all 19 patients changed back to active surveillance with the knowledge of the PSMA-PET/mpMRI result with 16 follow-up patients still not having primary treatment until July 2018. This subgroup is of special interest as it is known that a significant number of patients do not want to choose or stay in an active surveillance strategy for several reasons like the anxiety for having or developing metastatic disease (32,33). Increasing the security of not having significant cancer in case of a negative PSMA-PET/mpMRI scan supports clinicians as well as patients and could therefore reduce the costs of potential overtreatment.…”

Active surveillance for prostate cancer: a systematic review of contemporary worldwide practices

“…However, in the last 10 years a trend towards AS adoption in LRPC has been reported by many large database studies, with some variation still noted between countries, practices and physicians ( 37 ). Most notable are the upward trends seen in North America, Australia and Europe.…”

Determinants for choosing and adhering to active surveillance for localised prostate cancer: a nationwide population-based study

“…In Sweden, uptake of AS has increased steadily over the past decade and is now 80%–90% 3. However, the proportion of men with low-risk cancer who are on AS varies substantially between and within countries2 4 Although notable rising trends are seen in, for example, North America, Australia and Europe,5 a 2014 survey in Japan noted that roughly half of urologists used AS in <5% of men with low-risk PC and that only 27% stated that they would want to offer AS more frequently in the future 6. Additionally, a considerable proportion of men on AS diverge to treatment over time without any clear evidence of disease progression 7 8…”