Understanding the Use of Prostate Biopsy Among Men with Limited Life Expectancy in a Statewide Quality Improvement Collaborative

Abstract

BackgroundThe potential harms of a prostate cancer (PCa) diagnosis may outweigh its benefits in elderly men. ObjectiveTo assess the use of prostate biopsy in men with limited life expectancy (LE) within the practices comprising the Michigan Urological Surgery Improvement Collaborative (MUSIC). Design, setting, and participantsMUSIC is a consortium of 42 practices and nearly 85% of the urologists in Michigan. From July 2013 to October 2014, clinical data were collected prospectively for all men undergoing prostate biopsy. Outcome measurements and statistical analysisWe calculated comorbidity-adjusted LE in men aged ≥66 yr and identified men with <10 yr LE (limited LE) undergoing a first biopsy. Our LE calculator was not designed for men aged <66 yr; thus these men were excluded. Multivariable models estimated the proportion of all biopsies performed for men with limited LE in each MUSIC practice, adjusting for differences in patient characteristics. We also evaluated what treatments, if any, these patients received. Results and limitationsAmong 3035 men aged ≥66 yr undergoing initial prostate biopsy, 60% had none of the measured comorbidities. Overall, 547 men (18%) had limited LE. Compared with men with a longer LE, these men had significantly higher prostate-specific antigen levels and abnormal digital rectal examination findings. The adjusted proportion of biopsies performed for men with limited LE ranged from 3.8% to 39% across MUSIC practices (p < 0.001). PCa was diagnosed in 69% of men with limited LE; among this group, 74% received any active treatment. Of these men, 46% had high-grade cancer (Gleason score 8–10). ConclusionsAmong a large and diverse group of urology practices, nearly 20% of prostate biopsies are performed in men with limited LE. These data provide useful context for quality improvement efforts aimed at optimizing patient selection for prostate biopsy. Patient summaryIn this report, nearly 2 of every 10 men undergoing prostate biopsy had a life expectancy (LE) <10 yr. Implementing LE calculators in clinical practice may help refine patient selection for prostate biopsy.