Progress in Management of Low-risk Prostate Cancer: How Registries May Change the World

Abstract

EUROPEAN UROLOGY 67 (2015) 51–52 available at www.sciencedirect.com journal homepage: www.europeanurology.com Platinum Priority – Editorial Referring to the article published on pp. 44–50 of this issue Progress in Management of Low-risk Prostate Cancer: How Registries May Change the World Matthew R. Cooperberg * Departments of Urology and Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA Age-standardized population mortality rates for prostate cancer have fallen nearly 50% since the early 1990s, a remarkable epidemiologic trend explicable in large part by early detection efforts together with improvements in treatments [1]. The cost of this gain, however, has been high. Early detection overdiagnoses many prostate cancers– perhaps the majority of those found–which are biologically indolent. Men with such low-risk tumors often do not benefit from treatment [2], yet traditionally the vast majority undergo surgery, radiation, hormonal therapy, and other interventions [3,4] that expose them to risks [5] and incur high costs [6]. Despite multiple endorsements of active surveillance as an alternative, until recently, this option has been very much underused in the United States outside of a few academic centers [3]. Reasons for this pattern include financial incentives favoring treatment, legal fears regard- ing potentially missing progression, and psychological pressures favoring aggressive treatment. Furthermore, most providers receive no regular feedback on their own practices or outcomes and have little or no knowledge of how they compare with their peers. In a sharp departure from prior US reports, in this month’s issue of European Urology, Womble et al. observe that across the state of Michigan, over 17 mo ending August 2013, fully 49% of men newly diagnosed with low-risk disease were managed initially with surveillance [7]. This remarkable figure is no fluke: As an outlier, it reflects the implementation of Michigan Urological Surgery Improve- ment Collaborative (MUSIC), a unique statewide registry. Funded richly by Blue Cross and Blue Shield of Michigan, the dominant insurer in the state, MUSIC provides for data collection via detailed chart abstraction at >40 urologic practices including nearly 90% of the urologists in the state. A key aspect of the registry effort is that collected data—on practice patterns, process quality metrics, and outcomes— are shared directly with the practices, and each practice is shown its own performance benchmarked against those aggregated from the other practices. The urologists also meet periodically in person [8]. Although no pre–MUSIC data were reported for comparison, there is no reason to suspect that Michigan’s surveillance rate has been higher historically than that of the rest of the country. Precedents exist in urology for similar efforts. A national effort in Sweden focused on appropriateness of bone scans for low-risk disease drove down overuse from 45% to 3% over a decade, again, by feeding back quality performance data directly to providers [9]. MUSIC, although more focused geographically, is much more ambitious in terms of the depth and breadth of data collected. The individual practices varied in their use of surveil- lance: One practice reached 80%, but even the lowest utilizing practices used surveillance 25–30% of the time. Surveillance was used relatively uncommonly for younger and healthier men, suggesting—even in MUSIC—a bias against surveillance for men who could have avoided treatment for years in many cases [10]. Womble et al. also provide an early look at surveillance quality. The over- whelming majority of men received a prostate-specific antigen test within the first year, but few underwent confirmatory biopsy, and less than half underwent any biopsy within 18 mo. About 15% underwent active treatment within that time frame [7]. Further follow-up of surveillance quality and outcomes will be essential. DOI of original article: http://dx.doi.org/10.1016/j.eururo.2014.08.024. * Departments of Urology and Epidemiology and Biostatistics, University of California, San Francisco, 1600 Divisadero St, Box 1695, San Francisco, CA 94143-1695, USA. E-mail address: mcooperberg@urology.ucsf.edu. http://dx.doi.org/10.1016/j.eururo.2014.09.008 0302-2838/# 2014 European Association of Urology. Published by Elsevier B.V. All rights reserved.