Low concordance with NCCN surveillance guide seen

Concordance with National Cancer Comprehensive Network recommendations about follow-up during active surveillance for low-risk prostate cancer is generally low across urology practices in Michigan, reported researchers from the Michigan Urological Surgery Improvement Collaborative at the AUA annual meeting in San Diego.

San Diego-Concordance with National Cancer Comprehensive Network (NCCN) recommendations about follow-up during active surveillance for low-risk prostate cancer is generally low across urology practices in Michigan, reported researchers from the Michigan Urological Surgery Improvement Collaborative (MUSIC) at the AUA annual meeting in San Diego.

Failure to perform follow-up biopsy is the driving factor.

The study analyzed data for 513 patients seen in 16 of the 42 urology practices comprising MUSIC. Included in the study were practices that had enrolled more than 10 patients in active surveillance between January 2012 and September 2013, and patients who had 2 years of follow-up on active surveillance after their prostate cancer diagnosis.

Concordance with NCCN guidelines was defined by receipt of three PSA measurements and one follow-up biopsy during the 2 years on active surveillance. The analyses showed that across the 16 practices, concordance rates varied widely, ranging from 10.0% to 67.5%. The average, however, was only 26.5%.

Analyses focusing on the source of guideline discordance showed that re-biopsy was consistently being underperformed. The proportion of men who did not undergo repeat biopsy ranged from about 55% to almost 100% across the different practices, but the rate did not differ significantly across the 16 practices, and the median was 82%.

“Use of active surveillance for management of low-risk prostate cancer is increasing, but little is known about longitudinal practice patterns for men on active surveillance,” said first author Amy Luckenbaugh, MD, urology resident at the University of Michigan, Ann Arbor, who presented the data.

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“The findings of our study highlight a need to standardize pathways for active surveillance. Although it remains to be determined whether the protocol should involve continued use of annual biopsy as recommended by the NCCN and therefore a focus on improving biopsy rates or finding some alternatives that are more patient friendly, we at MUSIC feel it is important that patients using active surveillance for managing prostate cancer are followed appropriately,” added Dr. Luckenbaugh, who worked on the study with David Miller, MD, MPH, and colleagues.

Next: Number of AS patients varies widely

Number of AS patients varies widely

The number of patients in active surveillance per practice varied widely, with the range being between 12 and 93. The men included in the study had a median age of 66 years, almost three-fourths were Caucasian, and almost two-thirds had a Charlson comorbidity index of 0. Median PSA at diagnosis of 5.3 ng/mL, about two-thirds of men had clinical stage T1 disease, and 75% had a Gleason score ≤6. Clinical stage was unknown for 22% of the cohort and Gleason score was not known in 5%.

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Reasons why biopsy was not repeated were not identified in the study. Anecdotally, it was noted that monitoring by magnetic resonance imaging was likely not a contributing factor considering it is infrequently used by MUSIC urologists.

Dr. Luckenbaugh suggested that both physician- and patient-related issues were probably involved.

“Urologists need to counsel men that repeat biopsy is part of the active surveillance protocol so that when patients enroll in active surveillance, they know they are signing up for repeat biopsy,” she said.

“However, urologists also have the responsibility to make sure they are not losing these patients to follow-up, and perhaps they should be using their electronic medical record system to alert them when active surveillance patients are due for repeat biopsy.”

Across the state of Michigan, 42 practices are participating in MUSIC, and the urologists within these practices represent 85% of urologists in the state.