Enhanced Diagnosis Safely Reduces Prostate Treatment Risk

The following is an interview with Kaynaat Syed, MHA, clinical project manager at Health Care Improvement Foundation and Adam Reese, MD, chief of Urologic Oncology, program director of the Urology Residency Program at Temple University, and chair of the Pennsylvania Urologic Regional Collaborative (PURC) Active Surveillance working group.

The Health Care Improvement Foundation (HCIF) is an independent nonprofit organization that drives high-value health care through stakeholder collaboration and targeted quality improvement initiatives. PURC is a quality improvement initiative facilitated by HCIF that brings urology practices in a physician-led data-sharing and improvement collaborative, aimed at advancing the quality of diagnosis and care for men with prostate cancer.

Tell us a little about PURC and your work to improve diagnostic accuracy in prostate cancer

HCIF established the Pennsylvania Urologic Regional Collaborative (PURC), a quality improvement initiative that brings urology practices together and aims at advancing the quality of diagnosis and care for men with prostate cancer. PURC, founded in 2015, currently comprises 11 major urology practices across Pennsylvania and New Jersey and is expanding throughout the mid-Atlantic and northeastern regions. It provides practices across the region with a mechanism for performance measurement and reporting via real-time risk-adjusted data displayed in the PURC registry. The PURC data registry consists of over 18,000 patient cases. Health Care Improvement Foundation serves as the coordinating center for PURC, providing administrative, clinical, and database support for program members.

“Our focus area is active surveillance, an early intervention used for men with low-risk prostate cancer,’” said Adam Reese. “This strategy aims to diagnose, observe, and act with the intention to cure only when essential. Patients on active surveillance are monitored for signs of disease progression, and definitive treatment only occurs in a delayed fashion in those patients with signs of progression.”

According to Reese, this strategy also allows many men to avoid the morbidities associated with more aggressive prostate cancer treatments such as surgery and radiation therapy.

You’ve stated that PURC uses active surveillance in an effort to provide early intervention for men with low-risk prostate cancer. Can you share some preliminary findings?

It is noted that a potential problem in managing patients on active surveillance is that there are no universally agreed-upon criteria to identify which men have sufficiently low-risk disease that are appropriate candidates for surveillance. Criteria typically vary among institutions and are often based on expert opinion as opposed to empirical data.

“To address this problem, we have used PURC data to develop the “PURCASE score,” a scoring system that establishes clear criteria for identifying men with newly diagnosed prostate cancer who are eligible for active surveillance,” said Reese.

The organization hopes that the “PURCASE score” will more accurately differentiate men who can be managed with surveillance from those who require definitive treatment and decrease some of the inter-institutional variability that currently exists in managing these patients.

Additionally, they have compared the PURCASE score to other widely used active surveillance eligibility criteria. Their preliminary studies suggest the PURCASE score is more accurate than existing criteria in identifying men with clinically insignificant prostate cancer who may safely be managed with active surveillance.

Has PURC uncovered any disparities when diagnosing prostate cancer? ?

“Studies have shown that African American men have a higher incidence of prostate cancer,” said Reese.  “They tend to be diagnosed at a younger age and with more advanced disease.” “Using PURC data, it suggests that early and aggressive screening from prostate cancer may significantly benefit African American men.”

“The analysis of PURC data has not shown African American men on active surveillance to be at increased risk of disease progression compared to Caucasian men,” said Reese. “Our findings suggest that the same active surveillance eligibility and monitoring criteria used in Caucasian men can also be applied to African American patients.”

AI and algorithms can be used to improve diagnosis in developing areas of inquiry for medicine. What are some key learnings so far?

“It is generally accepted that the optimal management strategy for most men diagnosed with low- risk prostate cancer is active surveillance, as opposed to aggressive treatment with surgery or radiation therapy,” said Reese. “Nonetheless, there is significant variation in how these men with low risk tumors are treated, and a significant percentage of men still undergo initial surgery or radiation therapy, as opposed to surveillance.”

One potential explanation for the relatively low utilization of active surveillance is that many providers are unsure of exactly how to manage a patient on surveillance, and therefore feel that early surgery or radiation is a safer approach.

The Michigan Urologic Surgery Improvement Collaborative (MUSIC) has developed an “active surveillance roadmap”, which is essentially an algorithm showing providers how to best manage patients on active surveillance.

PURC has trialed the roadmap and found that it increased the comfort level of both providers and patients with the practice of active surveillance.

“Algorithms such as these will decrease some of the management uncertainty among providers and patients, and allow more patients to undergo the optimal management strategy based on each individual patient’s unique disease characteristics,” said Adam Reese.

Your initiative brings urology practices together to advance the quality of diagnosis and care for men with prostate cancer through collaborative learning and the use of a shared data registry to monitor key performance metrics. What were some barriers you faced in order to advance this initiative? How did you overcome them?

“PURC was launched in 2015 with six practices from the southeastern Pennsylvania region and almost doubled the number of participating practices by 2019,” says Syed.

For PURC, a dedicated data abstractor is needed to enter longitudinal data into their registry. The collaborative requires physician leadership support to monitor overall progress and identify the region’s best practices and opportunities for continued improvement. In an effort to overcome some of these barriers, the PURC coordinating center is identifying ways to reduce abstractor burden by re-evaluating current data variables and exploring Electronic Health Record (EHR) data integration. Data integration will link practice EHRs to the PURC registry and allow for automated transfer of data versus manual entry.

As algorithms can be used to support diagnostic quality and safety, what has response been from PURC physicians?

“Our PURC physicians have been very supportive of the work that is being done within the collaborative, and really see the value of participating and using a data management tool to advance the quality of diagnosis and care for men with prostate cancer,” said Syed.

PURC’s data registry has allowed them to analyze data and compare findings to current research and evidence for diagnosing, treating, and managing patients with prostate cancer. PURC physicians are engaged in two active working groups which come together on a quarterly basis to analyze the data, evaluate research and evidence, and share findings with the larger collaborative. Through these working groups, they have developed and disseminated standardized protocols and pathways, as well as educational materials. PURC has also administered several surveys to understand current practices across the collaborative to ensure there is physician consensus.

What strategies has PURC used to get physician buy-in and were they successful?

“PURC has been modeled as a physician-led collaborative consisting of physicians in governance roles who come together to make decisions about the direction of the collaborative, strategic planning, decision-making, and financial planning,” said Syed.  “The physicians also lead the working groups and are involved in agenda setting for collaborative meetings, data analysis, and sharing of best practices.”

Each practice has identified a “physician champion” who is an active member overseeing the practice’s participation and is engaged in the collaborative meetings, working groups, and decision-making. In PURC, all participating physicians, not just those in leadership roles, are encouraged and supported in pursuing clinical research questions that are relevant to them with authorship opportunities available and shared by many.

“All of these strategies have assisted with physician buy-in but most important is the common purpose of improving care for their patients that brings this group together,” said Syed.

How has PURC involved patients or family members of patients in the design and development of the research? If it does not, has PURC considered doing that in the future?

“PURC recognizes the importance of involving patients and family members in their care and their invaluable contribution to quality and safety improvement initiatives. To that end, we have worked closely with Colonel Jim Williams, a prostate cancer survivor in co-leading the Men’s Health Workgroup as part of the Pennsylvania Prostate Cancer Coalition,” said Syed.

“We have also partnered with the Coalition by promoting and attending events intended to raise awareness, timely detection and improved treatment of prostate cancer in Pennsylvania. We would like to expand ways that PURC involves patients and family members in future programming and think SIDM can serve as an invaluable resource.”

What does being part of the Coalition mean to HCIF?

“Being part of the Coalition to Improve Diagnosis in Medicine provides our organization with the opportunity to learn from our peers and adopt best practices for how to improve diagnostic accuracy and reduce diagnostic harm,” said Syed.

“As a small non-profit organization, being part of a larger coalition also allows us to have a voice when addressing federal policies or legislation to promote diagnostic accuracy. We are stronger together and benefit from the knowledge and experience of our Coalition colleagues.”

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