A light at the end of the tunnel for low-risk prostate cancer?


At the American Urological Association (AUA) meeting in New Orleans in May, there was apparently a “light at the end of the tunnel” moment.

Matthew Cooperberg, MD, MPH, a leading proponent of active surveillance (AS) at the University of California, San Francisco, reported that the AAU’s own data from its AQUA registry showed that for the first time, the majority of low-risk prostate cancer patients (slightly less than 60%) opted for AS rather than rushing to the operating room or radiotherapy room. AS had finally broken with academic practices and gone mainstream.

Victory in our time? Not yet. Not really. A not insignificant 40% of American AS candidates still opt for radiation therapy or surgery.

The AAU committee has called for greater adoption of AS, with a target of 80% within a vague time frame.

Then someone at the meeting spoke up, a voice from Michigan, which is proving to be a hotbed of urology reform, especially for AS for low-risk prostate cancer. Kevin Ginsburg, MD, a urological oncologist from Wayne State University in Detroit, stepped on the microphone and said 80% just wasn’t good enough as a goal and called for a more aggressive migration to AS.

Ginsburg is one of the leaders in MUSIC (Michigan Urological Surgery Improvement Collaborative), an innovative physician-led quality program collaborative improvement founded in 2012, comprising a consortium of 46 urology practices across the state of Michigan and supported by Blue Cross Blue Shield of Michigan.

Kevin Ginsburg, MD

He told the meeting: “My name is Kevin Ginsburg and I work with MUSIC. At MUSIC, we have been able to drive our rates even higher, to over 90% in 2021. Why aim for 80%? In my mind, the only reason to treat someone with grade 1 (GG1) prostate cancer right away is that they will suffer damage and metastasize or die from prostate cancer by delaying the treatment of his disease with AS. I’m not sure that 20% of men with GG1 disease fall into this category.”

Of course, this is not the case with this type of lazy cancer.

Ginsburg said one of MUSIC’s early goals was to scale up SA throughout Mitten State, including college practices, but also large private practices and small practices. Virtually every practice in Michigan is part of MUSIC’s efforts to combine and share data to improve patient care and reduce costs.

“It’s not just university ships, such as Wayne State and the University of Michigan, that are saying, ‘Hey, let’s use active surveillance. It’s everyone agreeing and saying we absolutely can use more active surveillance for men with low-risk prostate cancer,” Ginsburg said.

Michigan has become the AS Sweden in America, largely through the efforts of MUSIC. MUSIC helps physicians monitor their own practices and encourages adoption of SA. Through concerted quality improvement efforts, the state has achieved a rate of over 90% low-risk patients on AS, rivaling the rates of AS in Sweden.

According to the American Cancer Society, more than 268,000 American men will be diagnosed with prostate cancer in 2022. Of these men, 35% (about 94,000) will have low or very low risk Gleason scores. Of these low- or very-low-risk men, approximately 60% (56,400) will opt for AS in the US

As an AS defender, this is MUSIC to my ears. There will never be 100% adoption of AS, Cooperberg and Ginsburg noted. AS is not for everyone due to anxiety and other factors, but MUSIC shows there is the possibility of a much higher acceptance rate for AS.

MUSIC leads the way with A model which should be adopted everywhere in the United States. It is more than voluntary monitoring to improve rates through medical peer support. MUSIC studied what could be changed in practice to improve outcomes in several areas of prostate cancer care. MUSIC’s collaborative model also produces a newsletter for each practitioner and globally.

“Everyone knows their own and MUSIC’s data as a whole, but they don’t know each other’s individual data. Otherwise, it’s too easy to talk about generalities and think you’re doing the right thing (like using a lot of AS) without knowledge if you do the right thing. Knowing your data is the first step to improvement,” Ginsburg said.

“One of the founding principles of MUSIC was that as a band we would be ‘collegiate, not competitive.’ Although it sounds cliché, we have a strong mentality that ‘a rising tide lifts all boats.’ wouldn’t say we had to use peer pressure, because MUSIC urologists are there voluntarily. MUSIC is a coalition of volunteers. Urologists participate in MUSIC because they want to provide the best possible care to their patients,” said he continued.

In addition to newsletters, MUSIC meets three times a year to discuss quality improvement topics related to prostate cancer, kidney cancer and kidney stone care.

This brings us to “swish” – a biopsy disinfection technique.

Ginsburg said MUSIC looked at ways to improve the 1% rate of sepsis in biopsies leading to hospitalization.

“We got together and asked what are the things we could do to make it safer. We actually found lower rates of sepsis in urologists who swish the biopsy needle directly in formalin – it decontaminates the needle – then they swirl saline or water and then do the next biopsy. We found that these people had the lowest incidence of infection,” he explained.

Doctors with higher rates of sepsis among patients simply rubbed needles on gauze, which would be used to transfer the tissue into the container sent to the pathologist. MUSIC published his discoveries in BJU International. After adjusting for confounders, the study results were not statistically significant.

“It was one of those variants of medicine. Do you tie your shoe starting with your left foot or your right foot? It’s something no one has ever thought of. We thought it was without But really, you’re able to take a deep dive into that and figure out that’s one of the techniques that we’ve found to help reduce the incidence of infection after prostate biopsy,” he said. declared.

“Although the rustling study did not reach statistical significance, I still find it valuable. For me, reducing infectious hospitalizations by 0.3% or 0.5% with a simple maneuver, even if this change is not statistically significant, I still find it clinically significant,” he added.

Ginsburg said the success of the rustle led to other priorities within MUSIC, such as encourage transperineal biopsies (TP). According to MUSIC data not yet published, the rate of hospitalizations for infections is 0.6% after transrectal ultrasound (TRUS) and 0.3% after TP.

“I’m a swisher. I mostly do a TP biopsy now, but when I do TRUS, I swish,” Ginsburg noted.

MUSIC is currently exploring more appropriate use of imaging, improving the quality of MRI, fusion imaging, as well as several factors to improve prostatectomies.

What is missing ?

In my opinion, MUSIC and other researchers need to examine the psychology of AS, the impact of anxiety and depression on the decision-making process, what can be done to improve these adoption rates and how to keep more patients on SA longer. MUSIC needs to generate data on race and ethnicity, especially within the black population, which is hard hit by prostate cancer but too often alienated from AS.

Could the MUSIC model spread across the United States to try to improve the quality of life for patients with low-risk cancers and prevent harm from prostate cancer overtreatment and even move to PT procedures safer?

“We are currently, and very selectively, exploring how we might expand the MUSIC model outside of Michigan,” Ginsburg said.

Howard Wolinsky is a Chicago-based medical writer. He wrote the blog “A Patient’s Journey” for MedPage today since 2016. He is the editor of the Substack newsletter, TheActiveSurveillor.com.

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