The Delivery of Prostate Cancer Care in the United States: Implications for Delivery System Reform

Evaluating the Importance of Practice-Level Factors on Adherence to Prostate Cancer Treatment Guidelines in Urology

OBJECTIVE

To evaluate adherence to treatment guideline recommendations across the continuum of prostate cancer care by US community urologists using several prostate cancer (PCa) specific performance indicators (PIs). Additionally, to determine which practice-related factors, such as having a designated PCa patient champion, active patient management in a patient portal, and in-office dispensing of medications, were associated with improved PI performance.

METHODS

Electronic medical record data was collected retrospectively from the PPS Analytics Patient Population Health Management Platform. The cohort consisted of adult patients with a PCa-related service visit during the period 7/1/2019 to 6/30/2022. Five PIs were reviewed: dual-energy x-ray absorptiometry (DEXA) scanning with androgen deprivation therapy (ADT), systemic therapy in metastatic PCa, external beam radiation therapy (EBRT) concurrent with ADT, image monitoring, and regular testosterone testing and monitoring.

RESULTS

A total of 101,186 patients were identified from 95 urology practices. PI adherence rates ranged from a low of 13.6% for a DEXA scan within 6-months of ADT initiation to a high of 72.3% for EBRT concurrent with ADT in intermediate/high risk localized PCa. The results also demonstrated that several practice-related features were associated with better PI adherence.

CONCLUSIONS

The findings suggest there exists a wide range in PI adherence rates for urologists in the delivery of community urology care in the Unites States compared to clinical guideline recommendations. Future research should examine the factors associated with PI nonadherence and promote implementation of interventions that enhance guideline concordant care.

Understanding Active Surveillance for Prostate Cancer

PURPOSE

To assess how active surveillance for prostate cancer is apportioned across specialties and how testing patterns and transition to treatment vary by specialty.

METHODS

We used a 20% national sample of Medicare claims to identify men diagnosed with prostate cancer from 2010 through 2016 initiating surveillance (N = 13,048). Patients were assigned to the physician responsible for the bulk of surveillance care based on billing patterns. Freedom from treatment was assessed by specialty of the responsible physician (urology, radiation oncology, medical oncology, and primary care). Multinomial logistic regression models were used to examine associations between specialty and treatment patterns.

RESULTS

Urologists were responsible for surveillance in 93.7% of patients in 2010 and 96.2% of patients in 2016 (P for trend = .01). Testing patterns varied by specialty. For example, patients of medical oncologists had more frequent prostate-specific antigen testing compared with patients of urologists (1.85 v 2.39 tests per year, respectively; P < .01). Three years after diagnosis, a significantly smaller proportion of patients managed by radiation oncologists (64.3%) remained on surveillance compared with patients managed by other physicians (75.8%-79.5%; P < .01). Although radiation was the most common treatment among all men who transitioned to treatment, a disproportionate percentage of patients followed by radiation oncologists (28.9%) ultimately underwent radiation compared with patients followed by other physicians (15.1%-15.4%; P < .01).

CONCLUSION

Nontrivial percentages of patients on active surveillance are managed by physicians outside of urology. Given the interspecialty variations observed, efforts to strengthen the evidence underlying surveillance pathways and to engage other specialties in guideline development are needed.

Non-oncologist Physician Knowledge of Radiation Therapy at an Urban Community Hospital

Radiation therapy (RT) is a crucial part of cancer care, but previous work suggests that many non-radiation oncologist physicians are uncomfortable referring for RT. To evaluate training and understanding of RT, the authors sent invitations to complete an online questionnaire to all physicians at a community hospital in Bronx, NY, which asked about oncology training and self-rated and objective knowledge of RT. Out of 247 invited participants, 87 responded (35%). Among responders, 19 were attending physicians (22%) and 66 (76%) were residents. Seventy-two percent of respondents reported caring for > 5 cancer patients in the past month, but 54% reported never referring patients for RT. Sixty-nine percent of respondents stated they received no radiation oncology training in medical school, and 36% reported no general oncology training. Approximately half believed themselves to be "somewhat knowledgeable" about RT indications (48%), benefits (53%), and side effects (55%). Objective assessment mean score was 6.2/12 (median 7) for all respondents; Respondents with internal medicine specialization scored higher than others (mean 7.7 vs 3.5; p < 0.01). Scores did not differ between attending and resident physicians, resident post-graduate levels, or receiving oncology training in medical school. The factors most commonly cited as affecting RT referral decisions were type of cancer, patient wishes, family wishes, poor functional status, and life expectancy. Many physicians are unaware of RT effectiveness or indications, which may affect referral patterns. Previous oncology training was not associated with higher knowledge scores.

Determinants of quality prostate cancer survivorship care across the primary and specialty care interface: Lessons from the Veterans Health Administration

Background

With over 3 million US prostate cancer survivors, ensuring high‐quality, coordinated cancer survivorship care is important. However, implementation of recommended team‐based cancer care has lagged, and determinants of quality care across primary and specialty care remain unclear. Guided by the theoretical domains framework (TDF), we explored multidisciplinary determinants of quality survivorship care in an integrated delivery system.

Methods

We conducted semistructured interviews with primary (4) and specialty (7) care providers across 6 Veterans Health Administration clinic sites. Using template analysis, we coded interview transcripts into the TDF, mapping statements to specific constructs within each domain. We assessed whether each construct was perceived a barrier or facilitator, examining results for both primary care providers (PCPs) and prostate cancer specialists.

Results

Cancer specialists and PCPs identified 2 primary TDF domains impacting their prostate cancer survivorship care: Knowledge and Environmental context and resources. Both groups noted knowledge (about survivorship care) and procedural knowledge (about how to deliver survivorship care) as positive determinants or facilitators, whereas resources/material resources (to deliver survivorship care) was noted as a negative determinant or barrier to care. Additional domains more commonly referenced by cancer specialists included Social/professional role and identity and Goals, while PCPs reported the domain Beliefs about capabilities as relevant.

Conclusions

We used the TDF to identify several behavioral domains acting as determinants of high‐quality, team‐based prostate cancer survivorship care. These results can inform prostate cancer survivorship care plan content, and may guide tailored, multidisciplinary implementation strategies to improve survivorship care across the primary and specialty care interface.

Physician visits and the timing of skeletal-related events among men newly diagnosed with metastatic prostate cancer: A cohort analysis

INTRODUCTION

Men diagnosed with metastatic prostate cancer (PCa) are at increased risk for skeletal complications which are associated with significant morbidity and mortality. Although both the urologist and the medical oncologist play important roles in the management of patients with advanced PCa, there is limited information regarding their role in the context of skeletal complications. The current study investigated these relationships among newly diagnosed metastatic patients with PCa.

METHODS AND MATERIALS

This retrospective cohort study used Surveillance, Epidemiology and End Results cancer registry data for incident stage IV metastatic (M1) cases diagnosed from 2000 to 2007 with linked Medicare claims. Postdiagnosis urologist and medical oncologist visits were identified using billing codes. We considered skeletal-related events (SREs) that occurred after the urologist or medical oncologist visit. We used Cox proportional hazards models to examine the relationship between a physician visit and the timing of the first SRE with and without propensity-score matching to account for observable selection.

RESULTS

The sample included 5,572 patients with stage IV M1 prostate cancer. Seventy-six percent of the patients were non-Hispanic White, 16% were non-Hispanic African American, and 8% were of other races; 75% of patients saw a urologist (median time to first visit = 19 days) and 44% saw an oncologist (median = 80 days), whereas 41% experienced at least one SRE (median = 309 days). Covariate-adjusted Cox models showed a longer time to an SRE for patients with only a medical oncologist visit (hazard ratio [HR] = 0.53, 95% CI: 0.45-0.61), only a urologist visit (HR = 0.35, 95% CI: 0.31-0.39) or both a urologist and medical oncologist visit (HR = 0.34, 95% CI: 0.31-0.38), compared to individuals without these visits. Among men with a urologist visit, a medical oncologist visit was not associated with the time to the first SRE (HR = 0.97, 95% CI: 0.90-1.05). Among those without a urologist visit a medical oncologist visit was associated with a longer time to an SRE (HR = 0.54, 95% CI: 0.46-0.64). Results were comparable using propensity-score matched samples.

CONCLUSION

Among men newly diagnosed with metastatic PCa, 4 of 10 patients experienced an SRE. Patients experienced a delay in skeletal complications when managed by a urologist or a medical oncologist compared to patients who did not see either specialist.

Enhancing prostate cancer survivorship care through self-management

The lack of clear roles for prostate cancer survivorship care providers places prostate cancer survivors at significant risk of inappropriate use of services delivered piecemeal by different providers, persistent bothersome symptoms, and silent suffering. Optimizing quality of care for prostate cancer survivors hinges on decreasing fragmentation of care, and providing quality symptom management. This is achieved through comprehensive, appropriate medical, surgical, pharmacological and psychosocial care, coupled with self-management, as highlighted in several recent resources addressing long-term and late effects of treatment. Although further study is warranted, prostate cancer survivors engaging in self-management may reduce the negative impact of prostate cancer in their lives through better quality of care (better symptom management and efficient use of services) and quality of life.

Optimizing veteran-centered prostate cancer survivorship care: study protocol for a randomized controlled trial

Background

Although prostate cancer is the most common cancer among veterans receiving care in the Veterans Health Administration (VA), more needs to be done to understand and improve survivorship care for this large population. This study, funded by VA Health Services Research & Development (HSR&D), seeks to address the need to improve patient-centered survivorship care for veterans with prostate cancer.

Methods/Design

This is a two-armed randomized controlled trial (RCT) with a target enrollment of up to 325 prostate cancer survivors per study arm (total anticipated n = 600). Patients will be recruited from four VA sites. Patient eligibility criteria include age range of 40–80 years, one to ten years post-treatment, and currently experiencing prostate cancer symptom burden. We will compare the “Building Your New Normal” program, a personally-tailored automated telephone symptom management intervention for improving symptom self-management to usual care enhanced with a non-tailored newsletter about symptom management. Primary outcomes include changes in symptom burden, bother, and health services utilization at five and 12 months after enrollment. Secondary outcomes include long-term psychosocial outcomes (e.g. subjective health, perceived cancer control). We will use multivariable regression analysis to evaluate the impact of the intervention on primary and secondary outcomes. We will conduct a process evaluation to understand the effective intervention components and explore possibilities for broader implementation and dissemination.

Discussion

Our central hypothesis is that intervention group participants will have improved and more confident symptom self-management and prostate cancer quality of life following the intervention and that these outcomes will translate to more efficient use of health services. The study results will provide much needed information about how to optimize the quality of care, and life, of veteran prostate cancer survivors.

Trial registration

ClinicalTrials.gov ID NCT01900561; Registered on 22 July 2013.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-1925-4) contains supplementary material, which is available to authorized users.

American Cancer Society prostate cancer survivorship care guidelines

Prostate cancer survivors approach 2.8 million in number and represent 1 in 5 of all cancer survivors in the United States. While guidelines exist for timely treatment and surveillance for recurrent disease, there is limited availability of guidelines that facilitate the provision of posttreatment clinical follow-up care to address the myriad of long-term and late effects that survivors may face. Based on recommendations set forth by a National Cancer Survivorship Resource Center expert panel, the American Cancer Society developed clinical follow-up care guidelines to facilitate the provision of posttreatment care by primary care clinicians. These guidelines were developed using a combined approach of evidence synthesis and expert consensus. Existing guidelines for health promotion, surveillance, and screening for second primary cancers were referenced when available. To promote comprehensive follow-up care and optimal health and quality of life for the posttreatment survivor, the guidelines address health promotion, surveillance for prostate cancer recurrence, screening for second primary cancers, long-term and late effects assessment and management, psychosocial issues, and care coordination among the oncology team, primary care clinicians, and nononcology specialists. A key challenge to the development of these guidelines was the limited availability of published evidence for management of prostate cancer survivors after treatment. Much of the evidence relies on studies with small sample sizes and retrospective analyses of facility-specific and population databases.

A checklist for ascertaining study cohorts in oncology health services research using secondary data: report of the ISPOR oncology good outcomes research practices working group

OBJECTIVES

The ISPOR Oncology Special Interest Group formed a working group at the end of 2010 to develop standards for conducting oncology health services research using secondary data. The first mission of the group was to develop a checklist focused on issues specific to selection of a sample of oncology patients using a secondary data source.

METHODS

A systematic review of the published literature from 2006 to 2010 was conducted to characterize the use of secondary data sources in oncology and inform the leadership of the working group prior to the construction of the checklist. A draft checklist was subsequently presented to the ISPOR membership in 2011 with subsequent feedback from the larger Oncology Special Interest Group also incorporated into the final checklist.

RESULTS

The checklist includes six elements: identification of the cancer to be studied, selection of an appropriate data source, evaluation of the applicability of published algorithms, development of custom algorithms (if needed), validation of the custom algorithm, and reporting and discussions of the ascertainment criteria. The checklist was intended to be applicable to various types of secondary data sources, including cancer registries, claims databases, electronic medical records, and others.

CONCLUSIONS

This checklist makes two important contributions to oncology health services research. First, it can assist decision makers and reviewers in evaluating the quality of studies using secondary data. Second, it highlights methodological issues to be considered when researchers are constructing a study cohort from a secondary data source.

Understanding fragmentation of prostate cancer survivorship care: implications for cost and quality

BACKGROUND

Cancer survivors are particularly prone to the effects of a fragmented health care delivery system. The implications of fragmented cancer care across providers likely include greater spending and worse quality of care. For this reason, the authors measured relations between increasing fragmentation of cancer care, expenditures, and quality of care among prostate cancer survivors.

METHODS

A total of 67,736 patients diagnosed with prostate cancer between 1992 and 2005 were identified using Surveillance, Epidemiology, and End Results (SEER)-Medicare data. Using the Herfindahl-Hirschman Index and a measure of the average number of prostate cancer providers over time, patients were sorted into 3 fragmentation groups (low, intermediate, and high). The authors then examined annual per capita survivorship expenditures and a measure of quality (ie, repetitive prostate-specific antigen [PSA] testing within 30 days) according to their fragmentation exposure using multinomial logistic regression.

RESULTS

Patients with highly fragmented cancer care tended to be younger, white, and of higher socioeconomic status (all P < .001). Prostate cancer survivorship interventions were most common among patients with the highest fragmentation of care across providers (P < .001). After adjustment for clinical characteristics and prostate cancer survivorship interventions, higher degrees of fragmentation continued to be associated with repetitive PSA testing (13.6% for high vs 7.0% for low fragmentation; P < .001) and greater spending, particularly among patients not treated with androgen deprivation therapy.

CONCLUSIONS

Fragmented prostate cancer survivorship care is expensive and associated with potentially unnecessary services. Efforts to improve care coordination via current policy initiatives, electronic medical records, and the implementation of cancer survivorship tools may help to decrease fragmentation of care and mitigate downstream consequences for prostate cancer survivors.