“Active surveillance of prostate cancer in a community practice; how to measure manage and improve” is an analysis of a quality improvement initiative to enhance the utilization of active surveillance for clinically localized low risk prostate cancer in a large urology practice group. The group, Genesis Healthcare Partners, in San Diego CA, developed their active surveillance criteria in collaboration with UC San Diego, using NCCN guidelines as a template.
They measured their traditional AS utilization for men with low risk prostate cancer by various definitions, instituted physician instruction to their partners, and initiated report cards so that the members could evaluate their own practices and the rates of AS utilization among their partners. The utilization of AS over the three-year period of the study improved dramatically. When analyzing a group of men with very low risk prostate cancer by NCCN criteria essentially considered “the most selective best practice group”, the utilization of AS increased from 43.75% to 82.61% after provider education and report cards were initiated.
Although the targets used in this collaborative quality improvement initiative were arbitrary and simply agreed on by the participants they seemed reasonable and achievable for the urologists in the group. Lacking in this project was a patient educational tool to enhance active surveillance acceptance by patients. This is certainly a planned and critical next step for the group. Although long-term outcome data in terms of progression to treatment or prostate cancer outcomes are lacking in this relatively short follow up initiative, the process improvement is very significant. This really should be viewed as the demonstration of a potential model to enhance the utilization of a beneficial healthcare process.
If the goal of screening, detection and treatment of prostate cancer is to reduce prostate cancer mortality then we must come to terms with a common byproduct of prostate cancer detection; the over detection and treatment of indolent cancer. Although a “one size fits all” approach to prostate cancer management is inappropriate, some thoughtful standards and measurement of desirable processes to enhance care is a rational first step. Inherent in any guideline is that there will be some patients, because of age, ethnicity, family history, or intolerance of active surveillance processes, who choose treatment for very low risk prostate cancer. In order to keep faith with detecting men who would benefit most from treatment, we must acknowledge that there is a large group of men with currently defined low-grade prostate cancer who likely would be best served with no active treatment or perhaps no detection.
The overtreatment of low risk prostate cancer is complex and there can be tremendous momentum toward treatment of newly diagnosed men both from physicians and from patients. The momentum to treat is partially patient driven because of the term “cancer” as well as the rational fear of advanced disease and death from prostate cancer. Many patients and families are initially very resistant to the concept of active surveillance fearing that it is incomplete or undesirable management. So there is an educational hurdle that can be challenging to clear depending on patient educational level and health literacy. Many men and their families, after education about active surveillance, are greatly relieved to understand the low metastatic potential of low risk prostate cancer and are eager to avoid the side effects of treatment. Introducing the concept of active surveillance prior to screening or prostate biopsy can be effective.
The momentum toward treatment for physicians is multifactorial, sometimes due to fear of adverse oncologic outcomes for their patients or because of lack of knowledge or experience about active surveillance. In some situations, business influences may be a factor. Therefore, education is useful for both physicians and other healthcare providers.
The other aspect of this article that may be lost on some readers is the collaborative effort between UC San Diego, the major academic medical center in San Diego, and a large urology practice group in San Diego that employs the majority of the private practice urologists. Working together on a quality initiative for the good of our patients has benefitted relationships between the urologists in San Diego. We are now jointly working on additional quality initiatives and embarking on a clinically integrated network.
In summary, this article demonstrates the potential impact of physician directed quality initiatives to change physician behavior and practice patterns for the benefit of patients. Key elements in this initiative are inclusion of the physicians in the process, using evidence-based guidelines and comparative reporting processes for frequent physician performance feedback.
Written by: Christopher J. Kane, MD. Chair of Urology Department Professor of Surgery - Joseph D. Schmidt MD Presidential Chair in Urology University of California San Diego, CA. USA. and Franklin D. Gaylis, MD. Chief Scientific Officer, Genesis Healthcare Partners, San Diego, CA, USA.; Voluntary Professor, Department of Urology, UC San Diego, San Diego, CA, USA.