br Auffenberg GB Lane BR Linsell S Cher ML Miller
21. Auffenberg GB, Lane BR, Linsell S, Cher ML, Miller DC. Practice-vs physician-level variation in use of active surveillance for men with low-risk prostate cancer: implications for collaborative quality improvement. JAMA surgery. 2017;152(10):978–980. 22. Loeb S, Curnyn C, Fagerlin A, et al. Qualitative study on decision-making by prostate cancer physicians during active surveillance. BJU Int. 2017;120:32–39.
24. Jacobs BL, Zhang Y, Skolarus TA, Hollenbeck BK. Growth of high-cost intensity-modulated radiotherapy for prostate cancer raises con-cerns about overuse. Health Aff (Millwood). 2012;31:750–759. 25. Shahinian VB, Kaufman SR, Yan P, Herrel LA, Borza T, Hollen-beck BK. Reimbursement and use of intensity-modulated radiation therapy for prostate cancer. Medicine. 2017;96:e6929. 26. Penson DF. The Power and the peril of large administrative data-bases. J Urol. 2015;194:10–11. 27. AUA Quality Registry. http://www.auanet.org/practice-resources/ aua-quality-(aqua)-registry. 28. Medicare program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) incentive under the physi-cian fee schedule, and criteria for physician-focused payment models. Final rule with comment period. Fed Regist. 2016;81:77008–77831. 29. The Patient Protection and Affordable Care Act (PPACA), (2010). similarly mirrored in a study from the Michigan Urological Surgery Improvement Collaborative.4 Although reasons for pursuing pri-mary treatment instead of AS are not captured in this study, patient preference may be driven by factors such as anxiety, need for repeat surveillance biopsies, and distance to treatment facility, among others. While older age was predictably associated with increased use of AS, the authors surprisingly did not find a signifi-cant association of race with AS, even though African Americans have a higher risk of adverse pathologic features and progression.5
Considering the impact that adherence to guidelines have on healthcare delivery and reducing financial burden, this article nicely assesses the prevalent practices and adoption of AS in pros-tate cancer management in the CP-456773 setting. The data pre-sented reflect the practices 5+ years ago, and indeed we have witnessed a considerable shift in the evaluation of prostate cancer patients since then. In our current era, reliance on multiparametric MRI, targeted biopsies, and genomic testing has largely supple-mented the traditional approach of random systematic biopsies, especially when contemplating AS in patients with presumably lower risk disease. While these approaches are increasingly becom-ing standard practice at many large hospitals and academic centers, such technology may not be readily available in community practi-ces, and an updated cohort would provide interesting insight into management trends over time in light of emerging technologies.
Undoubtedly, the decision to treat or observe prostate cancer is complex and relies on an individualized approach that involves a shared decision between the provider and the patient after considering life expectancy, underlying risk factors, com-peting comorbidities, and patient concerns. For a field that is rapidly evolving, we must do our diligence as clinicians to stay abreast the wealth of emerging knowledge, appreciate the latest guidelines, and educate our patients in order to pursue the opti-mal management strategy.
In the treatment paradigm for prostate cancer, the pendulum has swung towards increasing use of active surveillance (AS) for lower risk disease, reflected by the most recent guidelines from the American Urological Association.1 These recommendations are supported largely by level-1 evidence from the PIVOT and Pro-tecT trials, which revealed similar mortality outcomes between observation and primary treatment for patients with clinically localized disease.2,3 In the present study, the authors characterize the management patterns of a unique, sizable cohort of patients with very low, low, or intermediate risk prostate cancer diagnosed in one of several large community practices distributed geographi-cally across multiple states. Although the biopsies were conducted before the most recent American Urological Association guide-lines were released, the results encouragingly reveal that nearly three-fourths and half of community practices were adhering to current guideline recommendations regarding pursuit of AS as the initial treatment strategy for very low and low-risk disease, respec-tively. This adherence is to be applauded, as this approach theoret-ically is the least financially rewarding management strategy.