With more than 2 million prostate cancer survivors in the United States today, there is a demand for high-quality survivorship care. After treatment for localized prostate cancer, men face a number of long-term challenges including side effects of treatment, such as severe urinary incontinence in 10% and erectile dysfunction in nearly 80%, as well as the 10% to 40% risk of disease recurrence, depending on tumor aggressiveness.[1-3] Accordingly, a central component of prostate cancer survivorship, and a recommendation in the National Comprehensive Cancer Network (NCCN) and American Urological Association (AUA) guidelines, is the use of prostate-specific antigen (PSA) testing to monitor for disease recurrence.[4, 5] Although it is uncertain how adherence to these guidelines impacts long-term cancer outcomes, early detection of disease recurrence identifies men that may benefit from local salvage therapy and broadens treatment options for patients with asymptomatic metastatic disease. Thus, adherence to PSA surveillance recommendations may be a proxy for quality of survivorship care in patients with prostate cancer.
Given the centrality of PSA surveillance in prostate cancer survivorship, the findings by Trantham et al in this issue of Cancer raise important questions about the quality of survivorship care, particularly among racial and ethnic minorities. Although the majority of men (97%) received a PSA test within the first year after surgery, by postoperative year 5, there was a 20% reduction in testing, and non-Hispanic black and Hispanic men had lower odds of receiving a PSA test as compared to white men.
There are several potential explanations for these findings. First and foremost, using claims data to study guideline adherence is inherently challenging because administrative data sets lack the clinical detail to understand whether “noncompliance with guidelines” represents substandard care or appropriate clinical judgment. For example, large studies using claims data have demonstrated that only 0.3% to 3.2% of patients with non–muscle invasive bladder cancer received intravesical chemotherapy (IVC) following transurethral bladder tumor resection despite evidence-based guidelines supporting its routine use.[7, 8] Although these studies answer important questions about patterns of care, the most critical questions are those they fail to answer, namely, why so many men apparently did not receive the recommended treatment. How can we understand and improve upon this chasm in quality of care?
One such solution is through physician-led quality improvement projects such as the Urological Surgery Quality Collaborative (USQC). The USQC collects prospective data from several regional urology practices and gathers detailed information about clinical encounters to identify areas of quality improvement. In a recent USQC project exploring patterns of IVC use among patients with non–muscle invasive bladder cancer, approximately 35% of patients likely to benefit from IVC after transurethral bladder tumor resection received the recommended treatment, whereas IVC was withheld for a clinically appropriate reason in at least half of the remaining patients. Therefore, the actual opportunity for improvement was far lower than suspected when clinical judgment was accounted for. In addition to more accurately depicting practice patterns, regional and statewide quality improvement collaboratives have generated significant improvements in quality of care through comparative performance feedback and educational interventions.[10-12]
In the study by Trantham et al, it is possible that some proportion of the 20% of men that failed to receive a PSA test after radical prostatectomy did so for a clinically appropriate reason. However, given the use of claims data, this was not possible to determine, and any explanation of the findings remains speculative. For example, because not all patients harbor the same risk of recurrence and the NCCN and AUA guidelines do not modify surveillance recommendations based on patient risk factors, it is possible that some providers decreased the intensity of PSA surveillance testing for men they considered less likely to recur or those in poor health. Although there may be an element of thoughtful clinical decision-making to explain decreased PSA surveillance testing, quality of care variations based on nonclinical factors such as race, ethnicity, socioeconomic status, and insurance suggest the presence of a true disparity. The underlying causes of such disparities may include inadequate financial resources, poor access to care, and limited health care navigation skills. Thus, although the findings in Trantham et al raise important questions about why certain patients do not receive recommended PSA surveillance testing, they also reinforce the need to improve how we follow patients after local treatment for prostate cancer. Although collaborative quality improvement efforts such as the USQC are critical for improving our understanding of patterns of care and uncovering opportunities for quality improvement, other initiatives may be required to improve survivorship care on the national level.
Because prostate cancer survivorship care is often a shared responsibility, poor communication between radiation oncologists, medical oncologists, urologists and primary providers may result in fragmentation and gaps in follow-up care, suggesting that any plan to improve care should target all involved physicians. In 2005, the Institute of Medicine published From Cancer Patient to Cancer Survivor: Lost in Transition, which recognized survivorship as an important stage in cancer treatment and recommended the use of a written care summary and follow-up plan describing how to monitor for disease recurrence and long-term treatment effects. A survivorship care plan (SCP) has been designated as a high-priority survivorship element at a recent conference sponsored by LIVESTRONG and has been promoted as part of high-quality survivorship care by the American Society of Clinical Oncology.[15, 16] The goals of a written SCP are to improve communication and establish a “shared care” approach among physicians, standardize follow-up plans, improve guideline adherence, optimize the continuity and coordination of care, and enhance patient education.[16, 17] Although not necessarily evidence-based, SCPs “can reasonably be assumed to improve care” until proven otherwise.
With the number and longevity of prostate cancer survivors and the necessity for coordination between multiple specialists and primary providers, prostate cancer presents a unique opportunity in which a SCP may make a significant difference. This plan could include a risk-stratified surveillance protocol; directives on when and by whom surveillance testing should be performed; recommendations for the management of treatment side effects, including grounds for specialist referral; and suggestions on general health maintenance counseling. It could be a hard-copy document, either owned by the physician or patient, or integrated into an electronic medical record.
The oncology community has only just begun to use SCPs, and their use in patients with urologic diseases is limited. Currently, the LIVESTRONG foundation offers online SCPs for patients with any number of urologic malignancies, including prostate cancer, that can be generated and customized by the patient. These plans provide excellent educational resources, but lack the necessary tools for clinical coordination, communication, and follow-up. Given their familiarity with the priorities of prostate cancer survivors, urologists must assume a central role in improving the coordination and delivery of quality survivorship care to men after treatment for prostate cancer, possibly through the development of an SCP. Although an SCP is by no means a panacea to problems with guideline adherence and disparities in cancer care, it may represent a practical, inexpensive, and useful tool in the effort to improve the quality of survivorship care on the national level.