The Adoption and Assessment of Active Surveillance in Community Urology Practices - Beyond the Abstract

This retrospective study of community practices assessed the adoption of active surveillance (AS) between January 2013 and March 2014 in 9 geographically dispersed community urology practices including more than 235 urologists. The authors defined AS according to documentation of AS within 6 months of prostate cancer (PCa) diagnosis or absence of treatment with continuous follow-up, including at least one office visit and PSA measurement beyond 6 months after diagnosis. Men older than 75 years, those diagnosed outside of the participating urology practice, and men with high-risk disease were excluded. The cohort was comprised of men with intermediate-risk (45.7%), low-risk (36.2%) and very-low-risk (17.9%) disease and were managed with AS (34.2%), surgery (36.3%) radiation therapy (26.5%) or other treatments (androgen deprivation therapy, cryotherapy, and high intensity focused ultrasound). AS was selected as initial management for 74.7% of patients with very low-risk, 43.5% of men with low-risk and 10.8 % of men with intermediate-risk disease. Overall, AS was used in 53.8% of men with lower-risk disease overall (very-low and low-risk PCa)

This retrospective study of more than 2000 men provides important insight as to how PCa is managed in the large-group, single-specialty setting. Strengths of the study include the labor-intensive, manual data abstraction process, which adds rigor to the findings. The authors note that their findings are consistent with other studies, including the CaPSURE study, in which approximately 40 % of men with low-risk PCa are managed conservatively (active surveillance/watchful waiting) initially during a similar period (2010-2013).1,2,3 These findings and others reflect a growing comfort level by both physicians and patients in adopting conservative management as initial management of low-risk PCa. The authors acknowledge the much needed ‘’optimal methods for improving the rate of adoption of guideline-recommended care” and allude to the possible benefits of urology practice integration: “our findings raise the possibility that the increased infrastructure and oversight found in integrated practices might act as an accelerator for adoption of evidence-based guidelines and a bulwark against inappropriate utilization of healthcare resources.” In a prior study from one large, community-based group practice, use of comparative reporting using dashboards in which individual physician adoption rates of AS for low-risk disease were compared to the rest of the group, dashboard use significantly improved adoption rates.4 This intervention highlights the benefit of focused attention on AS uptake as a quality measure and to establish the use of best-practice standards.

However, the paper by Shelton et al, like others previously,1,5 also confirmed significant variation in use of AS at the level of the individual clinical practice. Moreover, in addition to efforts to improve the adoption of AS for low-risk disease, there is a need to improve how AS is actually performed. Prior studies suggest there is room for substantial improvement.  The Michigan Urological Surgery Improvement Collaborative (MUSIC) demonstrated that follow-up of AS patients are frequently discordant with guidelines: fully 70% of MUSIC AS patients did not receive AS in accordance with the NCCN guidelines over a 2 year period, and 54 % did not undergo any follow-up prostate biopsy according to guideline recommendations.5 Despite the observed room for improvement, these studies are an important first step in measuring our performance of AS for favorable-risk PCa. The metric that needs greater attention is the conversion rate of AS to active treatment, which is as high as 50 % over time, highlighting the need for better criteria for AS selection at the outset, and to modulate the intensity of AS according to the biology of the disease. 

Hopefully, genomic classifiers, novel imaging tests, and other advances in precision medicine may in the future provide important guidance as to the biological aggressiveness of the tumor and, in turn, help both the physician and patient choose the most appropriate management strategy. 


Written by: Franklin Gaylis MD, FACS, Matthew R. Cooperberg, MD, MPH, William J. Catalona, MD, Chief Scientific Officer, Genesis Healthcare Partners, Voluntary Professor of Urology, University of California, San Diego; Associate Professor, Depts of Urology and Epidemiology & Biostatistics, Associate Chair, Clinical Research, Dept of Urology, Helen Diller Family Chair in Urology, University of California, San Francisco, Physician Advisor, AUA Quality (AQUA); Professor of Urology,  Northwestern University’s Feinberg School of Medicine.

References:
1. Cooperberg MR, Carroll PR. Trends in management for patients with localized prostate cancer, 1990-2013. JAMA. 2015;314(1):80-82.
2. Womble et.al.  Contemporary use of initial active surveillance among men in Michigan with low-risk prostate cancer. Eur Urol. 2015 Jan;67(1):44-50.
3. Loeb et.al. Use of Conservative Management for Low-Risk Prostate Cancer in the Veterans Affairs Integrated Health Care System From 2005-2015. JAMA. 2018 Jun 5; 319(21): 2231–2233.
4. Gaylis et. al. Active Surveillance of Prostate Cancer in a Community Practice: How to Measure, Manage, and Improve? Urology. 2016;93:60-67.
5. Luckenbaugh et. al. Variation in Guideline Concordant Active Surveillance Follow-up in Diverse Urology Practices. J Urol. 2017 Mar;197(3 Pt 1):621-626

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