Preventing Overtreatment of Prostate Cancer: New Model Identifies Ideal Patients for Active Surveillance
A new care model for patients with low-risk prostate cancer may help prevent disease overtreatment.
A new care model for patients with low-risk prostate cancer may help prevent disease overtreatment. This evidence-based approach uses best practices to select patients to avoid disease overtreatment. Results from a 3-year study recently published in Urology indicate that active surveillance (AS) rates nearly doubled after this model was adopted.1
“We tracked the patients who are newly diagnosed by each urologist in the group, determined those that fit the active surveillance criteria, and measured how often each urologist offered and enrolled any patient on AS, versus recommending radiation therapy or surgery. Each urologist was shown his or her data and the AS enrollment record of each of his or her peers,” said senior study author Christopher Kane, MD, chair of the Department of Urology at the University of California San Diego (UCSD) Health.
Dr Kane said there is a large group of men with a form of low-grade prostate cancer whose long-term survival is not affected by non-treatment, and that these men should be identified. He and his team developed a novel identification approach, which includes provider education and a standardized report card. Urologists at Genesis Healthcare in San Diego, California and UCSD Health jointly developed a reporting mechanism to improve the process of tracking patients with prostate cancer; through this collaboration they were able monitor 190 patients undergoing AS.
Using scientific literature, the research team developed standardized selection criteria for patients to undergo AS according to tumor characteristics, including clinical cancer staging, Gleason scores, and prostate-specific antigen (PSA) scores. Comparative dashboards were developed to show individual physician AS adoption rates in contrast with his or her peers. “The dashboards are used to give physician feedback. The use of this process increased the utilization of AS for the best AS candidates from approximately 40% to more than 80% in 3 years, avoiding overtreatment of prostate cancer in a large group of men,” Dr Kane told Cancer Therapy Advisor.
The study demonstrated that AS increased from 43.75% to 82.6% among low-risk patients and highlighted not only potentially significant improvements in quality of life for patients, but also cost-savings. The investigators noted that this model may be particularly helpful as the United States switches from a volume-based to value-based system of care for reimbursement. Dr Kane said clinicians need to be vigilant in measuring and improving quality of care in this patient population.
Patient Selection is Critical
“First, we educated the urologists in the group about the acceptability of AS. We discussed the different populations of newly diagnosed patients who were the best candidates for AS,” said Dr Kane.
Careful patient selection is important and clinicians are now better able to use PSA screening and other tools to identify the best candidates. Gerald Andriole, MD, chief of urologic surgery and vice chair of the Department of Surgery at Washington University School of Medicine in St. Louis, Missouri, said that new imaging modalities are now making it possible to better identify those patients who may be best suited to AS. He said there is now a greater awareness among clinicians about how best to use PSA values in conjunction with other criteria.
Several new diagnostic tools look promising and, as technology progresses, clinicians should have much better tools for identifying optimal candidates for AS. “There has been more surveillance, so there is less overtreatment. But are things optimal? No. The way forward will be made possible by better markers than PSA. These markers will be better at identifying men with aggressive cancer and will reduce biopsies in men who harbor non-aggressive cancer,” Dr Andriole told Cancer Therapy Advisor. “Improved biopsies, MRIs, and other markers that can more accurately gauge the tumor's significance will better tailor treatment."
1. Gaylis F, Cohen E, Calabrese R, Prime H, Dato P, Kane CJ. Active surveillance of prostate cancer in a community practice: how to measure, manage, and improve? [published online ahead of print February 12, 2016]. Urology. doi: 10.1016/j.urology.2015.11.053.