Adherence to surveillance high in large urology practices

November 2, 2018

A study of men diagnosed with prostate cancer in the setting of a community urology practice showed that adherence with active surveillance is good after 3 years of follow-up.

Chicago-A study of men diagnosed with prostate cancer in the setting of a community urology practice showed that adherence with active surveillance is good after 3 years of follow-up, reported Jeremy Shelton, MD, at the LUGPA annual meeting in Chicago.

“A majority of urologic care is delivered in community practices, but there is a lack of information about active surveillance management and adherence in contemporary community practice. Our study gives insights into these issues from a large contemporary patient cohort,” said Dr. Shelton, assistant professor of urology at UCLA School of Medicine, Los Angeles.

“Most of the excellent research on active surveillance has come primarily from academic medical centers. It is reassuring to see that adherence rates are similarly high in our community-based study and that conversion to curative therapy is being driven by appropriate clinical factors.”

The study presented by Dr. Shelton involves nine large community urology practices that are located in eight states across the nation. It included 557 men who selected active surveillance for initial management of their prostate cancer. Men were identified for the study through retrospective chart review that looked for patients diagnosed between January 2013 and May 2014 with very low-, low-, and intermediate-risk prostate cancer (National Comprehensive Cancer Network [NCCN] classification). About 90% of the cohort had very low- or low-risk disease.

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After a median follow-up of 3.35 years, approximately 90% of men were still being seen in the practice where they were initially diagnosed and about one-third had discontinued active surveillance to go onto curative therapy. Dr. Shelton commented that the data on retention was somewhat surprising considering population mobility and shifting insurance plans and interesting considering that the effectiveness of active surveillance depends on patient adherence with ongoing follow-up.

“Active surveillance for prostate cancers essentially asks patients with a potentially life-threatening disease to forgo treatment and puts the onus on patients and their physicians to maintain regular follow-up over a period of 10-plus years,” he said.

Analyses were conducted to identify factors associated with receipt of curative therapy. Variables assessed included race, age, family history of prostate cancer, practice, initial diagnosis stage, PSA density, Gleason score, NCCN risk group, and use of genetic testing. In multivariate analysis, only increased NCCN risk group and increased PSA density independently predicted receipt of curative therapy.

“The factors we found that were associated with conversion from active surveillance to curative therapy are consistent with those reported in prior studies,” Dr. Shelton said.

Additional analyses focused on the subgroup of men who went on to curative treatment and showed that they were about equally split between surgery and radiation. A multivariate regression analysis was also done to identify factors associated with the receipt of surgery versus radiation. It found that age was the only significant predictor; as age increased, men were increasingly likely to be treated with radiation. Notably, race, insurance, comorbidity, NCCN risk group, and practice were not associated with treatment choice.

“These findings are also encouraging because they indicate that men being cared for in community practices are seeking curative secondary therapy for their prostate cancer based on appropriate clinical characteristics and not by sociodemographic factors,” Dr. Shelton said.

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Twenty-two percent of the men who went on to curative therapy opted to have genetic profiling that was offered at the time of diagnosis using two commercially available tests. Men whose result indicated they were in a high-risk group were about twice as likely than men whose test indicated they had less aggressive disease to go on to curative therapy.

“Because of the small size of our sample, our study did not have the power to show a statistically significant effect of the genetic profiling information,” said Dr. Shelton.

“I found it interesting, however, to see that a relatively high proportion of men chose to have genetic profiling considering that the tests had only been recently introduced and were not yet recommended by NCCN guidelines.”

Dr. Shelton observed that in general, the characteristics of the subgroup that had genetic testing match the criteria that are listed in the NCCN guidelines for using genetic testing for risk stratification at time of diagnosis.

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“To my knowledge, this is a relatively rare example of documenting a new technology being adopted appropriately in clinical practice before it becomes accepted as standard of care based on guideline recommendations,” Dr. Shelton said.

While he noted he is a strong proponent of using clinical guidelines to measure quality of care, he said, “This experience shows that doctors and patients were ahead of the curve in choosing appropriate care, highlighting the importance of innovation in clinical practice and remembering the limitations of measuring quality of care with guidelines alone.”

Dr. Shelton cautions that this study does have limitations, foremost of which is that participating sites self selected and were not a random sample.

The research was supported by an unrestricted grant from Genomic Health.