Variation in Guideline Concordant Active Surveillance Followup in Diverse Urology Practices

Abstract

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.

Interventions for prostate cancer survivorship: A systematic review of reviews

“…The monitoring guidelines in the ACS/ASCO framework are based on expert consensus, and while experts agree that routine monitoring is necessary, the exact intervals and recommendations for surveillance vary depending on clinical and treatment factors and continue to evolve . Research from America, Australia, and Europe has reported that many men undergoing active surveillance may not be adhering to the recommended surveillance protocols, with between 13% and 30% of patients not adhering to PSA and biopsy testing guidelines in the first 2 years postdiagnosis . Evidence suggests that exercise interventions can delay the transition to active therapy in men undergoing active surveillance and current RCTs are underway to investigate further .…”

Perceived barriers to the adoption of active surveillance in low-risk prostate cancer: A Qualitative Analysis of Community and Academic Urologists

“…Our study did not observe the actual AS protocols followed by the urologists and thus, we cannot know if AS protocols were carried out as intended. Previous research has shown variation in the percentage of patients receiving guideline-concordant AS follow-up care [31,79], which may be attributable to patient non-adherence in addition to the lack of a standardized follow-up protocol in the practice. More research on the objective impact on clinical practice is warranted.…”

“…Reimbursement, physician factors, [27], and practice setting may in uence the care that is delivered [28,29]. However, few studies have comprehensively investigated the physician, organizational, and policy factors and treatment characteristics that may shape urologists' beliefs about the appropriateness of AS [12,30,31]. We sought to 1) identify a comprehensive array of physician-perceived barriers to the offer of AS, and 2) explore variability in experience by the urologists' practice setting (academic or community), including the potentially disparate nancial pressures, patient populations, and organizational supports for following treatment protocols.…”

Improving quality through clinical registries in urology

“…In a recent study of National Comprehensive Cancer Network (NCCN) guideline concordance for follow-up surveillance testing among active surveillance patients, MUSIC investigators reported wide variations in guideline compliance (10 to 68%) – a finding that the investigators then leveraged to reduce variations in these services. [12**] Other recent interesting findings from MUSIC include the variation in the use of prostate biopsy among men with limited life expectancy[13]; variation in the use of postoperative radiotherapy among high-risk men following radical prostatectomy[14]; variation in anastomotic and gastrointestinal events after radical prostatectomy[15]; and variation in the use of active surveillance for prostate cancer patients. [16] While these variations in and of themselves are indeed thought provoking, the real value of these studies, and by extension the quality collaborative, is the ability to use these findings as the basis for quality improvement interventions that result in tangible reductions in outcome variation.…”