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Article of the Week: Decision-Making by PCa Physicians During AS

Every Week the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, it should be this one.

Qualitative study on decision-making by prostate cancer physicians during active surveillance

Stacy Loeb*,,, Caitlin Curnyn, Angela Fagerlin¶,**, Ronald Scott Braithwaite
Mark D. Schwartz, Herbert Lepor*, Herbert Ballentine Carter†† and Erica Sedlander

 

Departments of *Urology, Population Health, Laura and Isaac Perlmutter Cancer Center, New York University, §Manhattan Veterans Affairs Medical Center, New York, NY, Department of Population Health Sciences, University of Utah, Salt Lake City, UT, **Informatics, Decision Enhancement, and Surveillance (IDEAS) Center, Salt Lake City VA, UT, and ††Brady Urological Institute, Johns Hopkins Hospital, Baltimore, MD, USA

 

How to Cite

Loeb, S., Curnyn, C., Fagerlin, A., Braithwaite, R. S., Schwartz, M. D., Lepor, H., Carter, H. B. and Sedlander, E. (2017), Qualitative study on decision-making by prostate cancer physicians during active surveillance. BJU International, 120: 32–39. doi: 10.1111/bju.13651

Abstract

Objective

To explore and identify factors that influence physicians’ decisions while monitoring patients with prostate cancer on active surveillance (AS).

Subjects and Methods

A purposive sampling strategy was used to identify physicians treating prostate cancer from diverse clinical backgrounds and geographic areas across the USA. We conducted 24 in-depth interviews from July to December 2015, until thematic saturation was reached. The Applied Thematic Analysis framework was used to guide data collection and analysis. Interview transcripts were reviewed and coded independently by two researchers. Matrix analysis and NVivo software were used for organization and further analysis.

Results

Eight key themes emerged to explain variation in AS monitoring: (i) physician comfort with AS; (ii) protocol selection; (iii) beliefs about the utility and quality of testing; (iv) years of experience and exposure to AS during training; (v) concerns about inflicting ‘harm’; (vi) patient characteristics; (vii) patient preferences; and (viii) financial incentives.

Conclusion

These qualitative data reveal which factors influence physicians who manage patients on AS. There is tension between providing standardized care while also considering individual patients’ needs and health status. Additional education on AS is needed during urology training and continuing medical education. Future research is needed to empirically understand whether any specific protocol is superior to tailored, individualized care.

Editorial: AS in PCa- New Efforts, New Voices, New Hope

In January 2016, in his final State of the Union address, US President Barack Obama tasked Vice President Joseph Biden with heading up a new national mission, the Cancer Moonshot, to expedite advances in cancer prevention, diagnosis and treatment. One of the blue-ribbon panel recommendations was to minimize the side effects of cancer treatment.

There is no better target for that goal than prostate cancer, the cancer that leads all others in the toll of Americans annually diagnosed with cancer, and the fourth most common worldwide. Many men with low-risk prostate cancer undergo unnecessary treatments, including prostatectomy and radiation therapy, which are unlikely to affect their survival, even if their disease were left untreated. A case in point is the ProtecT study [1], which showed at a median of 10 years that there was no difference in prostate cancer-specific mortality between treatment with surgery or radiation therapy and no treatment [1]. Although there has been a paradigm shift in the management of low-risk prostate cancer with an increased uptake of active surveillance (AS) [2], the fact is that only ~40% of men with low-risk prostate cancer choose AS.

Because of equivalency in effectiveness of treatment options in low-risk prostate cancer, an explication of the steps involved in the clinical decision-making process were long overdue. In an innovative study in the present issue of BJUI, Loeb et al. [3] report a qualitative analysis using a purposive sampling strategy to explore the decision-making process of physicians caring for patients with prostate cancer undergoing AS. This study used qualitative interviews and investigators then analysed responses to identify factors influencing therapeutic decision-making. It is noteworthy that despite the fact that AS acceptance rates have increased and it is an established therapeutic approach, significant differences still remain with regard to when physicians enroll and how they monitor patients on AS. These findings align with those from a Surveillance Epidemiology and End Results (SEER) registry study of 12 068 men with low-risk prostate cancer whose urologists and radiation oncologists reported a spectrum of observation practices [4]. Neither study accounted for patients’ preference or perspectives.

Although there are many national guidelines for AS, no consensus on optimum AS management exists, but Movember–GAP3 (https://au.movember.com/report-cards/view/id/3372/gap3-prostate-cancer-active-surveillance), an international effort comprising 25 institutions with AS programmes, may change that. It seeks to establish standard guidelines for patient selection and monitoring and to find agreement on a trigger for treatment. The tumour heterogeneity and possible lack of linearity in early disease progression that we can glean from the next-generation sequencing studies in advanced prostate cancer [5] will not make that easy. Given the promise of precision medicine, we anticipate a decision-making process that by integrating clinical and pathological data, imaging, and biomarkers prognostic of risk of disease progression as well as patient comorbidity effectively removes guesswork from the calculation.

As this international effort and the vice president’s work proceed, we urge all to listen to the voices of patients and ensure they are heard as clearly as those of the experts. We know the paternalistic model of medicine, in which physicians are the exclusive decision-makers, has long been outmoded [6]. With so much at stake, let us now act like it.

Spyridon P. Basourakos* Karen Hoffman† and Jeri Kim*

 

*Department of Genitourinary Medical Oncology, and Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, US

 

 

References

 

1 Hamdy F, Donovan J, Lane J et al. 10-year outcomes after monitoring, surgery, or radiotherapy for localized prostate cancer. N Engl J Med 2016; 375: 141524

 

 

3 Loeb S, Curnyn C, Fagerlin A et al. Qualitative study on decision- making by prostate cancer physicians during active surveillance. BJU Int 2017; 120: 329

 

4 Hoffman K, Niu J, Shen Y et al. Physician variation in management of low-risk prostate cancer: a population-based cohort study. JAMA Intern Med 2014; 174: 14509

 

5 Robinson D, Van Allen E, Wu Y et al. Integrative clinical genomics of advanced prostate cancer. Cell 2015; 161: 121528

 

 

Video: Decision-Making by PCa Physicians During AS

Qualitative study on decision-making by prostate cancer physicians during active surveillance

 

Abstract

Objective

To explore and identify factors that influence physicians’ decisions while monitoring patients with prostate cancer on active surveillance (AS).

Subjects and Methods

A purposive sampling strategy was used to identify physicians treating prostate cancer from diverse clinical backgrounds and geographic areas across the USA. We conducted 24 in-depth interviews from July to December 2015, until thematic saturation was reached. The Applied Thematic Analysis framework was used to guide data collection and analysis. Interview transcripts were reviewed and coded independently by two researchers. Matrix analysis and NVivo software were used for organization and further analysis.

Results

Eight key themes emerged to explain variation in AS monitoring: (i) physician comfort with AS; (ii) protocol selection; (iii) beliefs about the utility and quality of testing; (iv) years of experience and exposure to AS during training; (v) concerns about inflicting ‘harm’; (vi) patient characteristics; (vii) patient preferences; and (viii) financial incentives.

Conclusion

These qualitative data reveal which factors influence physicians who manage patients on AS. There is tension between providing standardized care while also considering individual patients’ needs and health status. Additional education on AS is needed during urology training and continuing medical education. Future research is needed to empirically understand whether any specific protocol is superior to tailored, individualized care.

Article of the week: The survey says: surgeon preferences during robot-assisted radical prostatectomy

Every week the Editor-in-Chief selects the Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, it should be this one.

The European Association of Urology Robotic Urology Section (ERUS) survey of robot-assisted radical prostatectomy (RARP)

Vincenzo Ficarra1, Peter N. Wiklund2, Charles Henry Rochat3, Prokar Dasgupta4, Benjamin J. Challacombe4, Prasanna Sooriakumaran5, Stefan Siemer6, Nazareno Suardi7, Giacomo Novara1 and Alexandre Mottrie8

1Oncological and Surgical Sciences, Urology Clinic, University of Padua, Padua, Italy; 2Urology Laboratory, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; 3Multidisciplinary Centre of Robot-Assisted Laparoscopic Surgery, Générale-Beaulieu Clinic, Geneva, Switzerland; 4Department of Urology, Guy’s Hospital, London, UK; 5Department of Urology, Royal Surrey County Hospital, Guildford, UK; 6Department of Urology, Universitätsklinikum des Saarlandes, Homburg/Saar, Germany; 7Department of Urology, Vita-Salute University San Raffaele, Milan, Italy; and 8Department of Urology O.L.V. Clinic Aalst, Aalst, Belgium; EAU Robotic Urologic Section (ERUS) Scientific Working Group

OBJECTIVE

• To evaluate surgeons adherence to current clinical practice, with the available evidence, for robot-assisted radical prostatectomy (RARP) and offer a baseline assessment to measure the impact of the Pasadena recommendations. Recently, the European Association of Urology Robotic Urology Section (ERUS) supported the Pasadena Consensus Conference on best practices in RARP.

SUBJECTS AND METHODS

• This survey was performed in January 2012. A specific questionnaire was sent, by e-mail, to 145 robotic surgeons who were included in the mailing-list of ERUS members and working in different urological institutions.

• Participating surgeons were invited to answer a multiple-choice questionnaire including 24-items evaluating the main RARP surgical steps.

RESULTS

• In all, 116 (79.4%) invited surgeons answered the questionnaire and accepted to participate to the ERUS survey.

• In all, 47 (40.5%) surgeons performed >100 RARPs; 41 (35.3%) between 50 and 100, and 28 (24.1%) <50 yearly.

• The transperitoneal, antegrade technique was the preferred approach.

• Minimising bladder neck dissection and the use of athermal dissection of the neurovascular bundles (NVBs) were also popular.

• There was more heterogeneity in the use of energy for seminal vesicle dissection, the preservation of the tips of the seminal vesicle and the choice between intra- and interfascial planes during the antero-lateral dissection of the NVBs. There was also large variability in the posterior and/or anterior reconstruction steps.

CONCLUSIONS

• The present study is the first international survey evaluating surgeon preferences during RARP.

• Considering that the results were collected before the publication of the Pasadena recommendations, the data might be considered an important baseline evaluation to test the dissemination and effects of the Pasadena recommendations in subsequent years.

 

Read Previous Articles of the Week

Editorial: Robot-assisted radical prostatectomy: getting your ducks in a row!

Robot-assisted radical prostatectomy (RARP) has become the technique of choice for clinically localised prostate cancer. However, marked inter-surgeon heterogeneity and an obvious lack of standardisation exist for the indications and technique of the procedure. In this issue of the BJUI, Ficarra et al. conducted a multinational survey seeking opinion from 145 robotic surgeons about individual practices during RARP. These opinions can be compared against the benchmark set by the Pasadena Consensus and can help gauge the impact of its recommendations.

Responses from 116 (79.4%) invited surgeons were analysed. The authors acknowledge the limited participation of non-European surgeons (17.1%), which may limit validity and application of its results at a global level. Most surgeons were in consensus with the Pasadena recommendations for transperitoneal access (88%), antegrade approach (76%) and bladder neck preservation (77%). The opinions on cautery use for the seminal vesicle/vas deferens dissection (51% athermal; 21% bipolar), athermal nerve-sparing approach (90%) and the use of the running suture technique for urethrovesical anastomosis (96.6%) were also in agreement.

Despite wide surgeon and institutional variability regarding the definition of bladder neck preservation and its role in the return of urinary continence, most preferred to preserve the bladder neck. This may pose difficulty in the interpretation of the results in view of the ambiguity about the definition and technique adopted under the term ‘bladder neck preservation’ (Eur Urol, BJU Int).

Most of the participating surgeons were using anterolateral prostatic fascia dissection (Veil of Aphrodite) towards preserving the cavernous nerves by using an athermal approach. Over the last decade the evolution of robot-assisted surgery, with excellent three-dimensional visualisation, depth perception, and EndoWrist® technology has made working in the confines of the pelvis both ubiquitous and a desired skill.

The present study found that 33% of surgeons omitted the internal iliac lymph nodes (LNs) and removed only obturator, with or without the external iliac LNs. The Pasadena Consensus recommends a template that includes the internal iliac, external iliac and obturator LNs. Mattei et al. in an attempt to map primary prostatic lymphatic ‘landing’ zones found that after performing a standard limited LN dissection (dorsal to and along the external iliac vein; medially along the obturator nerve) only 38% of LNs were removed. They recommended a template that retrieves LNs extending up to the ureteric crossing of the common iliac vessels. Meanwhile, Menon et al. evaluated the role of only internal iliac LN dissection (limited) in patients with a low probability of nodal disease (Partin table prediction 0–1%), and surprisingly found positive LNs in the internal iliac/obturator region 13.7 times more often than in the external iliac/obturator region. One of the issues that could be addressed in future surveys would be to evaluate how surgeons view and adapt to changes in the proposed LN template. The Pasadena Consensus further recommends considering performing LN dissection for the low-risk category based on the D’Amico risk stratification. The surgeon’s indications for pelvic LN dissection were not addressed in this survey.

Despite significant studies, including two randomised controlled trials (RCTs), published in the peer-reviewed literature reporting minimal advantage for early recovery of urinary continence with posterior reconstruction, a significant number of the surveyed surgeons still preferred to perform it. Responses to other questions about the posterior/anterior reconstruction also showed marked variability reflecting the controversial opinion about the value of these surgical steps.

On the other hand, future surveys should gather opinions about the role of RARP for high-risk disease, standardised evaluation of surgical complications; while addressing continence and potency status along with methods of their measurement. These topics were already addressed in the Pasadena Consensus and obtaining opinions of surgeons will further provide insight as to how surgeons adapt to the ever-changing advances in this field.

Over the last decade RARP has gained acceptance despite the absence of high-quality RCTs in robot-assisted surgery. The Pasadena Consensus was meant to meet the need for uniformity and this study educates us on how the surgeons really perform ‘in the trenches’. Until further evidence is available, surgeon experience and institutional volume will remain the main force driving the use of these surgical techniques and their outcomes.

Ahmed A. Aboumohamed and Khurshid A. Guru
Department of Urology, Roswell Park Cancer Institute, Buffalo, NY, USA

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