Assessing the quality of prostate cancer care

Association between adherence to radiation therapy quality metrics and patient reported outcomes in prostate cancer

BACKGROUND

Prior studies have shown significant variability in the quality of prostate cancer care in the US with questionable associations between quality measures and patient reported outcomes. We evaluated the impact of compliance with nationally recognized radiation therapy (RT) quality measures on patient-reported health-related quality of life (HRQOL) outcomes in the Comparative Effectiveness Analysis of Surgery and Radiation (CEASAR) cohort.

METHODS

CEASAR is a population-based, prospective cohort study of men with localized prostate cancer from which we identified 649 who received primary RT and completed HRQOL surveys for inclusion. Eight quality measures were identified based on national guidelines. We analyzed the impact of compliance with these measures on HRQOL assessed by the 26-item Expanded Prostate Index Composite at pre-specified intervals up to 5 years after treatment. Multivariable analysis was performed controlling for demographic and clinicopathologic features.

RESULTS

Among eligible participants, 566 (87%) patients received external beam radiation therapy and 83 (13%) received brachytherapy. Median age was 69 years (interquartile range: 64-73), 33% had low-, 43% intermediate-, and 23% high-risk disease. 28% received care non-compliant with at least one measure. In multivariable analyses, while some statistically significant associations were identified, there were no clinically significant associations between compliance with evaluated RT quality measures and patient reported urinary irritative, urinary incontinence, bowel, sexual or hormonal function.

CONCLUSIONS

Compliance with RT quality measures was not meaningfully associated with patient-reported outcomes after prostate cancer treatment. Further work is needed to identify patient-centered quality measures of prostate cancer care.

Quality Indicators in the Clinical Specialty of Urology: A Systematic Review

CONTEXT

In health care, monitoring of quality indicators (QIs) in general urology remains underdeveloped in comparison to other clinical specialties.

OBJECTIVE

To identify, synthesise, and appraise QIs that monitor in-hospital care for urology patients.

EVIDENCE ACQUISITION

This systematic review included peer-reviewed articles identified via Embase, MEDLINE, Web of Science, CINAHL, Global Health, Google Scholar, and grey literature from 2000 to February 19, 2021. The review was carried out under the Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) guidelines and used the Appraisal of Indicators through Research and Evaluation (AIRE) tool for quality assessment.

EVIDENCE SYNTHESIS

A total of 5111 articles and 62 government agencies were screened for QI sets. There were a total of 57 QI sets included for analysis. Most QIs focused on uro-oncology, with prostate, bladder, and testicular cancers the most represented. The most common QIs were surgical QIs in uro-oncology (positive surgical margin, surgical volume), whereas in non-oncology the QIs most frequently reported were for treatment and diagnosis. Out of 61 articles, only four scored a total of ≥50% on the AIRE tool across four domains. Aside from QIs developed in uro-oncology, general urological QIs are underdeveloped and of poor methodological quality and most lack testing for both content validity and reliability.

CONCLUSIONS

There is an urgent need for the development of methodologically robust QIs in the clinical specialty of general urology for patients to enable standardised quality of care monitoring and to improve patient outcomes.

PATIENT SUMMARY

We investigated a range of quality indicators (QIs) that provide health care professionals with feedback on the quality of their care for patients with general urological diseases. We found that aside from urological cancers, there is a lack of QIs for general urology. Hence, there is an urgent need for the development of robust and disease-specific QIs in general urology.

Contemporary prostate cancer radiation therapy in the United States: Patterns of care and compliance with quality measures

PURPOSE

Quality measures represent the standards of appropriate treatment agreed upon by experts in the field and often supported by data. The extent to which providers in the community adhere to quality measures in radiation therapy (RT) is unknown.

METHODS AND MATERIALS

The Comparative Effectiveness Analysis of Surgery and Radiation study enrolled men with clinically localized prostate cancer in 2011 and 2012. Patients completed surveys and medical records were reviewed. Patients were risk-stratified according to D'Amico classification criteria. Patterns of care and compliance with 8 quality measures as endorsed by national consortia as of 2011 were assessed.

RESULTS

Overall, 926 men underwent definitive RT (69% external beam radiation therapy [EBRT]), 17% brachytherapy (BT), and 14% combined EBRT and BT with considerable variation in radiation techniques across risk groups. Most men who received EBRT had dose-escalated EBRT (>75 Gy; 93%) delivered with conventional fractionation (<2 Gy; 95%), intensity modulated RT (76%), and image guided RT (85%). Most men treated with BT received I125 (77%). Overall, 73% of the men received EBRT that was compliant with the quality measures (dose-escalation, image-guidance, appropriate use of androgen deprivation therapy, and appropriate treatment target) but only 60% of men received BT that was compliant with quality measures (postimplant dosimetry and appropriate dose). African-American men (64%) and other minorities (62%) were less likely than white men (77%) to receive EBRT that was compliant with quality measures.

CONCLUSIONS

Most men who received RT for localized prostate cancer were treated with an appropriately high dose and received image guidance and intensity modulated RT. However, compliance with some nationally recognized quality measures was relatively low and varied by race. There are significant opportunities to improve the delivery of RT and especially for men of a minority race.

Automating the Determination of Prostate Cancer Risk Strata From Electronic Medical Records

Purpose

Risk stratification underlies system-wide efforts to promote the delivery of appropriate prostate cancer care. Although the elements of risk stratum are available in the electronic medical record, manual data collection is resource intensive. Therefore, we investigated the feasibility and accuracy of an automated data extraction method using natural language processing (NLP) to determine prostate cancer risk stratum.

Methods

Manually collected clinical stage, biopsy Gleason score, and preoperative prostate-specific antigen (PSA) values from our prospective prostatectomy database were used to categorize patients as low, intermediate, or high risk by D'Amico risk classification. NLP algorithms were developed to automate the extraction of the same data points from the electronic medical record, and risk strata were recalculated. The ability of NLP to identify elements sufficient to calculate risk (recall) was calculated, and the accuracy of NLP was compared with that of manually collected data using the weighted Cohen's κ statistic.

Results

Of the 2,352 patients with available data who underwent prostatectomy from 2010 to 2014, NLP identified sufficient elements to calculate risk for 1,833 (recall, 78%). NLP had a 91% raw agreement with manual risk stratification (κ = 0.92; 95% CI, 0.90 to 0.93). The κ statistics for PSA, Gleason score, and clinical stage extraction by NLP were 0.86, 0.91, and 0.89, respectively; 91.9% of extracted PSA values were within ± 1.0 ng/mL of the manually collected PSA levels.

Conclusion

NLP can achieve more than 90% accuracy on D'Amico risk stratification of localized prostate cancer, with adequate recall. This figure is comparable to other NLP tasks and illustrates the known trade off between recall and accuracy. Automating the collection of risk characteristics could be used to power real-time decision support tools and scale up quality measurement in cancer care.

Navigating Treatment of Metastatic Castration- Resistant Prostate Cancer: Nursing Perspectives

BACKGROUND

Treatment of metastatic castration-resistant prostate cancer (mCRPC) has evolved rapidly. In particular, five new treatments that extend survival in mCRPC have been approved since 2010, including the chemotherapy cabazitaxel (Jevtana®), hormonal agents abiraterone (Zytiga®) and enzalutamide (Xtandi®), vaccine sipuleucel-T (Provenge®), and radiopharmaceutical radium-223 (Xofigo®); all have different indications and toxicity profiles.

OBJECTIVES

This review discusses treatment advances in mCRPC, including considerations for side-effect management and treatment sequencing. Studies relating to quality of care in prostate cancer are also discussed.

METHODS

Nonsystematic searches were performed on published manuscripts and abstracts from major oncology or urology congresses, focusing on practical characteristics of the previously mentioned new treatments that extend survival in mCRPC, as well as studies relating to quality of care and the role of nurses in prostate cancer management.

FINDINGS

To ensure that patients derive optimal clinical benefit, assessing overall health and proactively managing expected side effects are essential. Treatment sequencing in mCRPC is an important consideration, but clinical data in this area are limited. Despite medical advances in mCRPC, studies have identified other aspects of care in which improvement is needed. Nurses can make major contributions to addressing supportive care needs, which has been shown to improve patient care and outcomes in prostate cancer. Although patient navigation programs have improved coordination of care, inconsistent implementation among centers has been identified for prostate cancer. Greater use of outcome measures can help to identify unmet patient needs.

Impact of Adherence to Quality Measures for Localized Prostate Cancer on Patient-reported Health-related Quality of Life Outcomes, Patient Satisfaction, and Treatment-related Complications

BACKGROUND AND OBJECTIVE

Quality measures used in pay-for-performance systems are intended to address specific quality goals, such as safety, efficiency, effectiveness, timeliness, equity, and patient-centeredness. Given the small number of narrowly focused measures in prostate cancer care, we sought to determine whether adherence to any of the available payer-driven quality measures influences patient-centered outcomes, including health-related quality of life (HRQOL), patient satisfaction, and treatment-related complications.

METHODS

The Comparative Effectiveness Analysis of Surgery and Radiation study is a population-based, prospective cohort study that enrolled 3708 men with clinically localized prostate cancer during 2011 and 2012, of whom 2601 completed the 1-year survey and underwent complete chart abstraction. Compliance with 6 quality indicators endorsed by national consortia was assessed. Multivariable regression was used to determine the relationship between indicator compliance and Expanded Prostate Cancer Index Composite (EPIC-26) instrument summary scores, satisfaction scale scores (service satisfaction scale for cancer care), and treatment-related complications.

RESULTS

Overall rates of compliance with these quality measures ranged between 64% and 88%. Three of the 6 measures were weakly associated with 1-year sexual function and bowel function scores (β=-4.6, 1.69, and 2.93, respectively; P≤0.05), whereas the remaining measures had no significant relationship with patient-reported HRQOL outcomes. Satisfaction scores and treatment-related complications were not associated with quality measure compliance.

CONCLUSIONS

Compliance with available nationally endorsed quality indicators, which were designed to incentivize effective and efficient care, was not associated with clinically important changes in patient-centered outcomes (HRQOL, satisfaction, or complications) within 1-year.

Using a population-based observational cohort study to address difficult comparative effectiveness research questions: the CEASAR study

BACKGROUND

While randomized controlled trials represent the highest level of evidence we can generate in comparative effectiveness research, there are clinical scenarios where this type of study design is not feasible. The Comparative Effectiveness Analyses of Surgery and Radiation in localized prostate cancer (CEASAR) study is an observational study designed to compare the effectiveness and harms of different treatments for localized prostate cancer, a clinical scenario in which randomized controlled trials have been difficult to execute and, when completed, have been difficult to generalize to the population at large.

METHODS

CEASAR employs a population-based, prospective cohort study design, using tumor registries as cohort inception tools. The primary outcome is quality of life after treatment, measured by validated instruments. Risk adjustment is facilitated by capture of traditional and nontraditional confounders before treatment and by propensity score analysis.

RESULTS

We have accrued a diverse, representative cohort of 3691 men in the USA with clinically localized prostate cancer. Half of the men invited to participate enrolled, and 86% of patients who enrolled have completed the 6-month survey.

CONCLUSION

Challenging comparative effectiveness research questions can be addressed using well-designed observational studies. The CEASAR study provides an opportunity to determine what treatments work best, for which patients, and in whose hands.

Racial variation in the pattern and quality of care for prostate cancer in the USA: mind the gap

OBJECTIVE

To review the literature on racial variation in the pattern of care (PoC) and quality of care (QoC) for prostate cancer, as there are known racial disparities in the incidence and outcomes of prostate cancer. While there are some biological explanations for these differences, they do not completely explain the variation. Differences in the appropriateness and QoC delivered to men of different racial groups may contribute to disparities in outcome.

METHODS

We searched the USA National Library of Medicine PubMed system for articles pertaining to quality indicators in prostate cancer and racial disparities in QoC for prostate cancer.

RESULTS

While standards for appropriate treatment are not clearly defined, racial variation in the PoC has been reported in several studies, suggesting that African-American men may receive less aggressive treatment. There are validated QoC indicators in prostate cancer, and researchers have begun to evaluate racial variation in adherence to these quality indicators. Further quality comparisons, particularly in structural measures, may need to be performed to fully evaluate differences in QoC.

CONCLUSIONS

There is mounting evidence for racial variation in the PoC and QoC for prostate cancer, which may contribute to observed differences in outcome. While some of the sources of racial variation in quality and outcome have been identified through the development of evidence-based guidelines and validated quality indicators, opportunities exist to identify, study and attempt to resolve other components of the quality gap.

[What is most important is what comes across : Urological guidelines from the target group's point of view]

BACKGROUND

Guidelines are developed to improve the quality of patient care. The effect of German urologic guidelines has not been evaluated so far. Therefore, we aimed to systematically investigate the acceptance, use, and quality of the published guidelines from a user's perspective.

METHODS

A link to an online questionnaire concerning use and barriers to the application of guidelines was distributed via e-mail by the German Society of Urology (DGU). German urologists' opinions on differences in national guideline quality were evaluated regarding prostate cancer (PCA), bladder cancer, germ cell tumors (GCT), renal cell carcinomas, and erectile dysfunction.

RESULTS

Four hundred sixty-seven German urologists participated. More than 90% of the participants considered guidelines to be helpful. The Internet as the main tool for guideline distribution was favored by 28.4%, followed by publication in Urologe A. The main barrier to guideline usage was attributed to the lack of up-to date clinical data. Guidelines for GCT scored best in all quality categories and reached the highest level of use (65.8%), and 40.5% of participating urologists considered the additional establishment of comprehensive care centers for GCT as more effective for quality improvement than guideline development alone. For the other urologic tumors, especially PCA, guideline development was favored as a tool for quality improvement.

CONCLUSION

More than 90% of participating urologists accept clinical guidelines as useful instruments in clinical practice and for therapeutic decisions. Our results should be integrated into guideline dissemination and implementation strategies in order to achieve a higher degree of treatment conformation to guidelines.

Perfil epidemiológico e fatores prognósticos no tratamento cirúrgico do adenocarcinoma de próstata clinicamente localizado

OBJETIVO: Avaliar a evolução e os fatores prognósticos da prostatectomia radical. MÉTODOS: Um total de 500 pacientes foi submetido à prostatectomia radical, entre 2000 e 2006. Estádio clínico, PSA pré-operatório e escore de Gleason foram avaliados em conjunto com o estádio patológico e margens cirúrgicas. O seguimento foi feito pela monitorização do PSA e correlação com diversos critérios. RESULTADOS: Dos 500 pacientes com doença clinicamente localizada tiveram seguimento médio de 36,7 ± 18,8 meses. O tempo operatório foi de 190 ± 45 minutos e o sangramento intra-operatório de 630 mL. O PSA pré-operatório médio foi de 7,8 ± 4,5 ng/dL, com maior proporção de escore de Gleason<6 (72%) e estádio TNM pT2c (65%). As complicações pós-operatórias foram incontinência em 2% pacientes e 46% com impotência sexual. CONCLUSÃO: A chance de recorrência esteve diretamente associada com PSA=10 ng/mL, escores de Gleason maiores e inversamente proporcionais à idade dos pacientes.

Association of Preexisting Symptoms with Treatment Decisions among Newly Diagnosed Prostate Cancer Patients

BACKGROUND: The choice between surgical versus non-surgical treatment options is a fundamental decision for men with local stage prostate cancer because of differences in risks of genitourinary side effects among available treatments. OBJECTIVES: We assessed whether preexisting genitourinary symptoms at the time of diagnosis influenced men's preferences for surgery versus other management options. METHODS: We recruited 593 patients with newly diagnosed local stage prostate cancer prior to initiating treatment from an integrated health care system, an academic urology center, and community urology clinics. Using logistic regression we compared whether men had a preference for non-surgical options or only preferred surgery. RESULTS: Nearly 60% indicated they were considering non-surgical options. Age and clinical characteristics but not preexisting genitourinary symptoms influenced the decision between preferences for surgical or non-surgical options. A total of 62% of men reported side effects as a main factor in their treatment decision. Men with more aggressive tumor types were less likely to consider side effects, however, men who reported poor ability to have an erection were more likely to consider side effects (p<0.001). CONCLUSION: Sexual dysfunction at time of diagnosis, but not other genitourinary symptoms, is associated with men considering treatment-related side effects when considering surgery versus other options. Men who are not experiencing sexual dysfunction at diagnosis may discount the risks of side effects in the decision making process.