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Singhal U, Hollenbeck BK, Kaffenberger SD, Salami SS, George AK, Skolarus TA, Montgomery JS, Wittmann DA, Miller DC, Wei JT, Palapattu GS, Montie JE, Dunn RL, Morgan TM. Comparing Patient-reported Functional Outcomes After Radical Prostatectomy in Historical and Contemporary Practice. J Urol 2023; 210:771-777. [PMID: 37566643 DOI: 10.1097/ju.0000000000003646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 08/01/2023] [Indexed: 08/13/2023]
Abstract
PURPOSE Modifications to surgical technique, particularly the widespread adoption of robotic surgery, have been proposed to improve functional recovery after prostate cancer surgery. However, rigorous comparison of men in historical vs contemporary practice to evaluate the cumulative effect of these changes on urinary and sexual function after radical prostatectomy is lacking. MATERIALS AND METHODS We compared prospectively collected patient-reported urinary and sexual function from historical (PROSTQA [Prostate Cancer Outcomes and Satisfaction With Treatment Quality Assessment study], n=235) and contemporary (MUSIC-PRO [Michigan Urological Surgery Improvement Collaborative Patient Reported Outcome] registry, n=1,215) cohorts at the University of Michigan to understand whether modern techniques have resulted in functional improvements for men undergoing prostate cancer surgery. RESULTS We found significant differences in baseline function, with better urinary (median [IQR]; 100 [93.8-100] vs 93.8 [85.5-100], P < .001) and sexual scores (median [IQR]; 83.3 [66.7-100] vs 74.4 [44.2-87.5], P < .001) prior to treatment in PROSTQA compared to MUSIC-PRO patients, respectively. There was no statistically significant difference in the pattern of urinary incontinence recovery after surgery from 6-24 months between groups (P = .14). However, men in the contemporary MUSIC-PRO group did have significantly better recovery of sexual function compared to men in the historical PROSTQA group (P < .0001). Further, we found that contemporary practice consists of men with more unfavorable demographic and clinical characteristics compared to historical practice. CONCLUSIONS Our results demonstrate that the widespread alterations in prostate cancer surgery over the past 2 decades have yielded improvements in sexual, but not urinary, function recovery.
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Affiliation(s)
- Udit Singhal
- Department of Urology, Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
- Department of Urology, Mayo Clinic, Rochester, Minnesota
| | - Brent K Hollenbeck
- Department of Urology, Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
| | - Samuel D Kaffenberger
- Department of Urology, Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
| | - Simpa S Salami
- Department of Urology, Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
| | - Arvin K George
- Department of Urology, Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
- James Buchanan Brady Urological Institute, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ted A Skolarus
- Department of Urology, Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
- Department of Surgery, University of Chicago, Chicago, Illinois
| | - Jeffrey S Montgomery
- Department of Urology, Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
| | - Daniela A Wittmann
- Department of Urology, Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
| | - David C Miller
- Department of Urology, Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
| | - John T Wei
- Department of Urology, Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
| | - Ganesh S Palapattu
- Department of Urology, Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
| | - James E Montie
- Department of Urology, Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
| | - Rodney L Dunn
- Department of Urology, Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
| | - Todd M Morgan
- Department of Urology, Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
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Hijazi MA, Prebay ZJ, Johnson A, Wilder S, Patel A, Mehra R, Montie JE, Noyes SL, Mirza M, Jafri M, Weizer A, Sarle R, Ghani KR, Rogers C, Lane BR. Reply by Authors. Urol Pract 2023; 10:389. [PMID: 37155952 DOI: 10.1097/upj.0000000000000399.03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 03/03/2023] [Indexed: 05/10/2023]
Affiliation(s)
- Mahmoud A Hijazi
- Oakland University William Beaumont School of Medicine, Rochester Hills, Michigan
| | - Zachary J Prebay
- Department of Urology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Anna Johnson
- Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Samantha Wilder
- Vattikuti Urology Institute, Henry Ford Health System, Detroit, Michigan
| | - Amit Patel
- Vattikuti Urology Institute, Henry Ford Health System, Detroit, Michigan
| | - Rohit Mehra
- Department of Pathology and Michigan Center for Translational Pathology, University of Michigan, Ann Arbor, Michigan
| | - James E Montie
- Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Sabrina L Noyes
- Division of Urology, Spectrum Health, Grand Rapids, Michigan
| | - Mahin Mirza
- Department of Urology, University of Michigan, Ann Arbor, Michigan
| | | | - Alon Weizer
- Department of Urology, University of Michigan, Ann Arbor, Michigan
| | | | - Khurshid R Ghani
- Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Craig Rogers
- Vattikuti Urology Institute, Henry Ford Health System, Detroit, Michigan
| | - Brian R Lane
- Division of Urology, Spectrum Health, Grand Rapids, Michigan
- Michigan State University College of Human Medicine, Grand Rapids, Michigan
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Hijazi MA, Prebay ZJ, Johnson A, Wilder S, Patel A, Mehra R, Montie JE, Noyes SL, Mirza M, Jafri M, Weizer A, Sarle R, Ghani KR, Rogers C, Lane BR. Utilization of a Virtual Tumor Board for the Care of Patients With Renal Masses: Experience From a Quality Improvement Collaborative. Urology Practice 2023:101097UPJ0000000000000399. [PMID: 37103551 DOI: 10.1097/upj.0000000000000399] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023]
Abstract
INTRODUCTION Multidisciplinary tumor board (MDTB) meetings are useful sources of insight and collaboration when establishing treatment approaches for oncologic cases. However, such meetings can be time intensive and inconvenient. We implemented a Virtual Tumor Board (VTB) within Michigan Urological Surgery Improvement Collaborative (MUSIC) to discuss and improve the management of complicated renal masses (RMs). METHODS Urologists were invited to discuss decision-making for RMs through voluntary engagement. Communication was performed exclusively through email. Case details were collected and responses were tabulated. All participants were surveyed about their perceptions of the VTB. RESULTS 50 RM cases were reviewed in a VTB that included 53 urologists. Patients ranged from 20-90 years old and 94% had localized RM. The cases generated 355 messages, ranging from 2-16 (median 7) per case; 144 responses (40.6%) were sent via smart-phone. All urologists (100%) who submitted to the VTB had their questions answered. The VTB provided suggestions to those with no stated treatment plan in 42% of cases, confirmed the physician's initial approach to their case in 36%, and offered alternative approaches in 16% of cases. 83% of survey respondents felt the experience was "Beneficial" or "Very Beneficial" and 93% stated increased confidence in their case management. CONCLUSIONS MUSIC's initial experience with a VTB showed good engagement. The format reduced barriers to multi-institutional and multi-disciplinary discussions and improved the quality of care for selected patients with complex RMs.
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Affiliation(s)
- Mahmoud A. Hijazi
- Oakland University William Beaumont School of Medicine, Rochester Hills, Michigan
| | - Zachary J. Prebay
- Department of Urology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Anna Johnson
- Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Samantha Wilder
- Vattikuti Urology Institute, Henry Ford Health System, Detroit, Michigan
| | - Amit Patel
- Vattikuti Urology Institute, Henry Ford Health System, Detroit, Michigan
| | - Rohit Mehra
- Department of Pathology and Michigan Center for Translational Pathology, University of Michigan, Ann Arbor, Michigan
| | - James E. Montie
- Department of Urology, University of Michigan, Ann Arbor, Michigan
| | | | - Mahin Mirza
- Department of Urology, University of Michigan, Ann Arbor, Michigan
| | | | - Alon Weizer
- Department of Urology, University of Michigan, Ann Arbor, Michigan
| | | | | | - Craig Rogers
- Vattikuti Urology Institute, Henry Ford Health System, Detroit, Michigan
| | - Brian R. Lane
- Division of Urology, Spectrum Health, Grand Rapids, Michigan
- Michigan State University College of Human Medicine, Grand Rapids, Michigan
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Paudel R, Ferrante S, Woodford J, Maitland C, Stockall E, Maatman T, Lane GI, Berry DL, Sales AE, Montie JE. Correction: Implementation of prostate cancer treatment decision aid in Michigan: a qualitative study. Implement Sci Commun 2023; 4:30. [PMID: 36941684 PMCID: PMC10026502 DOI: 10.1186/s43058-023-00410-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023] Open
Affiliation(s)
- Roshan Paudel
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI, USA.
| | - Stephanie Ferrante
- Michigan Urological Surgery Improvement Collaborative, University of Michigan, Ann Arbor, MI, USA
| | | | | | | | | | - Giulia I Lane
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - Donna L Berry
- Department of Biobehavioral Nursing and Health Informatics, University of Washington, Seattle, WA, USA
| | - Anne E Sales
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI, USA
| | - James E Montie
- Michigan Urological Surgery Improvement Collaborative, University of Michigan, Ann Arbor, MI, USA
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Glick H, Sarin A, Herrel LA, Ma L, Moore M, Van Wieren I, Chisolm S, O'Dell D, Duby A, Morgan TM, Montie JE, Wittmann D. Delayed urologic cancer care in the COVID-19 pandemic: Patients' experiences. Eur J Cancer Care (Engl) 2022; 31:e13677. [PMID: 35942930 PMCID: PMC9538597 DOI: 10.1111/ecc.13677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 07/11/2022] [Accepted: 07/28/2022] [Indexed: 11/30/2022]
Abstract
Objective To understand experiences of patients with genitourinary cancer who experienced delayed cancer care due to the COVID‐19 pandemic. Methods We conducted a mixed methods study with an explanatory sequential design. Qualitative findings are reported here. Patients with muscle invasive bladder, advanced prostate or kidney cancer were eligible. Participants were selected for interviews if they self‐reported low (0–3/10) or high (6–10/10) levels of distress on a previous survey. Participants were interviewed about their experiences. Interviews were transcribed, coded and categorised using thematic data analysis methodology. Results Eighteen patients were interviewed. Seven had prostate cancer, six bladder cancer and five kidney cancer. Six themes were derived from the interviews: (1) arriving at cancer diagnosis was hard enough, (2) response to treatment delay, (3) labelling cancer surgery as elective, (4) fear of COVID‐19 infection, (5) quality of patient‐provider relationship and communication and (6) what could have been done differently. Conclusion These findings offer insight into the concerns of patients with genitourinary cancers who experienced treatment delays due to COVID‐19. This information can be applied to support patients with cancers more broadly, should treatment delays occur in the future.
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Affiliation(s)
- Hannah Glick
- Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - Aashima Sarin
- Central Michigan University College of Medicine, Mount Pleasant, Michigan, USA
| | - Lindsey A Herrel
- Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - Lindsay Ma
- Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - Marissa Moore
- Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - Inga Van Wieren
- Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - Stephanie Chisolm
- Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - Diana O'Dell
- Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - Ashley Duby
- Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - Todd M Morgan
- Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - James E Montie
- Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - Daniela Wittmann
- Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
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Lane GI, Qi J, Dupati A, Ferrante S, Dunn RL, Paudel R, Wittmann D, Wallner LP, Berry DL, Ellimoottil C, Montie JE, Clemens JQ. Assessing the Impact of Decision Aid Use on Post Prostatectomy Patient Reported Outcomes. Urology 2022; 165:187-192. [PMID: 35219768 PMCID: PMC9296586 DOI: 10.1016/j.urology.2022.02.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 02/12/2022] [Accepted: 02/13/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To evaluate whether completing a decision aid, Personal Patient Profile - Prostate (P3P), prior to prostatectomy, affects self-reported bother from post-prostatectomy urinary incontinence and erectile dysfunction. MATERIALS AND METHODS This retrospective analysis included data from men with newly diagnosed clinically localized, very low to intermediate risk prostate cancer who elected for prostatectomy within the Michigan Urological Surgery Improvement Collaborative between 2018-2021. Multivariable logistic regression models were used to estimate the association between P3P use and bother from post prostatectomy erectile dysfunction and urinary incontinence as measured by the Expanded Prostate Cancer Index Composite (EPIC-26). RESULTS Among the 3987 patients included, 7% used P3P (n = 266). Men who used P3P reported significantly less bother from erectile dysfunction at 6 months vs non-users (aOR 0.42 [95% CI 0.27-0.66]). At 12 months, the effect of P3P on bother from erectile dysfunction was not statistically significant (aOR 0.62 [95% CI 0.37-1.03]). Men who used P3P did not have a statistically significant difference in bother from urinary incontinence (3-month: aOR 0.56 [95% CI 0.30-1.06]; 6-month; aOR 0.79 [95% CI 0.31-1.97]). CONCLUSION Within the stated limitations of this study, we find that use of a decision aid for localized prostate cancer was associated with decreased odds of men being bothered from sexual dysfunction but not urinary incontinence at 6 months post prostatectomy.
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Affiliation(s)
- Giulia I Lane
- Department of Urology, University of Michigan, Ann Arbor, MI; VA Ann Arbor Medical Center, Ann Arbor, MI.
| | - Ji Qi
- Department of Urology, University of Michigan, Ann Arbor, MI; VA Ann Arbor Medical Center, Ann Arbor, MI
| | - Ajith Dupati
- Wayne State University, School of Medicine, Detroit, MI
| | - Stephanie Ferrante
- Department of Urology, University of Michigan, Ann Arbor, MI; VA Ann Arbor Medical Center, Ann Arbor, MI
| | - Rodney L Dunn
- Department of Urology, University of Michigan, Ann Arbor, MI; VA Ann Arbor Medical Center, Ann Arbor, MI
| | - Roshan Paudel
- Health Infrastructures and Learning Systems, University of Michigan, Ann Arbor, MI
| | - Daniela Wittmann
- Department of Urology, University of Michigan, Ann Arbor, MI; VA Ann Arbor Medical Center, Ann Arbor, MI
| | - Lauren P Wallner
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Donna L Berry
- Biobehavioral Nursing and Health Informatics, University of Washington, Seattle, WA
| | - Chad Ellimoottil
- Department of Urology, University of Michigan, Ann Arbor, MI; VA Ann Arbor Medical Center, Ann Arbor, MI
| | - James E Montie
- Department of Urology, University of Michigan, Ann Arbor, MI; VA Ann Arbor Medical Center, Ann Arbor, MI
| | - J Quentin Clemens
- Department of Urology, University of Michigan, Ann Arbor, MI; VA Ann Arbor Medical Center, Ann Arbor, MI
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Wang M, Qi J, George AK, Semerjian A, Linsell SM, Montie JE, Cher ML, Ginsburg KB. The added influence of genomics and post-MRI confirmatory biopsy results to MRI results alone on medical decision making for men with favorable risk prostate cancer being considered for active surveillance. Prostate 2022; 82:1068-1074. [PMID: 35468226 DOI: 10.1002/pros.24357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 03/16/2022] [Accepted: 04/07/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND We examined how the results of genomic classifier (GC) or post-magnetic resonance imaging confirmatory biopsy (pMRI-CBx) influenced management strategy for men with an MRI considering active surveillance (AS). METHODS We reviewed the Michigan Urological Surgery Improvement Collaborative registry for men with favorable-risk prostate cancer. Among men with an MRI after the diagnostic biopsy (n = 1162) a subset also had GC (n = 126) or pMRI-CBx (n = 309). Results of MRI, GC, and pMRI-CBx were deemed reassuring (RA) or non-reassuring (Non-RA). We assess the association of the combination of test results obtained with the selection of AS. Proportions were compared with the Fisher's exact test. Multivariable logistic regression models were fit for an association of test results with the selection of AS. RESULTS The results of pMRI-CBx tended to influence management decisions greater than that of GC, especially in situation where testing results were discordant with the MRI result. Fewer men with a RA MRI and non-RA pMRI-CBx where managed with AS compared with RA MRI alone (31% vs. 86%, p < 0.001). non-RA genomics did not seem to have the same influence on management as non-RA pMRI-CBx as a similar proportion of men with RA MRI and non-RA genomics were managed with AS compared with RA MRI alone (85% vs. 86%, p = 0.753). More men with non-RA MRI and RA pMRI-CBx were managed with AS compared with non-RA MRI alone (89% vs. 40%, p < 0.001). Alternatively, a similar proportion of men with non-RA MRI and RA genomics were managed with AS compared with non-RA MRI alone (42% vs. 40%, p > 0.999). In the multivariable models, pMRI-CBx results influenced the decision for AS versus treatment. CONCLUSIONS In men with newly diagnosed prostate cancer and an MRI, the additional information provided by pMRI-CBx influenced the decision of AS versus treatment, while the addition of GC results were less influential.
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Affiliation(s)
- Michael Wang
- Department of Urology, Wayne State University, Detroit, Michigan, USA
| | - Ji Qi
- University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Arvin K George
- University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Alice Semerjian
- IHA Urology, St. Joseph Mercy Hospital, Ann Arbor, Michigan, USA
| | - Susan M Linsell
- University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - James E Montie
- University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Michael L Cher
- Department of Urology, Wayne State University, Detroit, Michigan, USA
| | - Kevin B Ginsburg
- Department of Urology, Wayne State University, Detroit, Michigan, USA
- Department of Surgical Oncology, Division of Urologic Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA
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8
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Singhal U, Qi J, Ginsberg K, Semerjian A, Maatman T, Dibianco J, Morgan TM, Montgomery JS, Nowlin M, Johnson A, Ferrante S, Montie JE, Johnston W, Jafri M, Rosenberg B, Sarle R, George AK. PD54-01 REDEFINING OPIOID USE AFTER PROSTATECTOMY: RESULTS FROM THE IMPLEMENTATION OF A STATEWIDE OPIOID-FREE PAIN OPTIMIZATION PATHWAY. J Urol 2022. [DOI: 10.1097/ju.0000000000002631.01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Arcot R, Cher ML, Qi J, Linsell SM, Dunn RL, George AK, Montie JE, Ginsburg KB. Delayed radical prostatectomy after a period of active surveillance is not associated with the use of secondary treatments compared with immediate prostatectomy. Prostate 2022; 82:323-329. [PMID: 34855239 DOI: 10.1002/pros.24277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 11/16/2021] [Indexed: 11/05/2022]
Abstract
BACKGROUND We evaluated the use of secondary treatments in men with grade group (GG) 1 PC following a period of active surveillance (AS) compared with men undergoing immediate radical prostatectomy (RP) to evaluate what is potentially lost in terms of cancer control, if a patient trials AS and transitions to treatment. METHODS We reviewed the Michigan Urological Surgery Improvement Collaborative (MUSIC) registry for men with GG1 PC undergoing RP from April 2012 to July 2018. Men were classified into groups based on time from diagnosis to RP: immediate (surgery within 1 year of diagnosis) and delayed RP (surgery >1 year after initiation of AS). Time to secondary treatment was estimated using Kaplan-Meier curves and compared using the log-rank test. A multivariable Cox proportional hazards model was fit to assess the association between timing of RP and use of secondary treatments. A chi-squared test was used to assess the association between delayed RP and adverse pathology. RESULTS We identified 1878 men that underwent an RP during the study period, of which 1489 (79%) underwent immediate RP and 389 (21%) underwent delayed RP. The incidence of adverse pathology was higher in men with delayed versus immediate RP (49% vs. 36%, p < 0.0001, respectively). However, we noted only a small absolute difference in the estimated 24-month secondary treatment-free probability between men with delayed versus immediate RP (93% and 96%, respectively). On multivariable analysis, delayed RP was associated with increased use of secondary treatments (hazard ratio = 1.94, 95% confidence interval = 1.23-3.06, p = 0.004). CONCLUSIONS The use of secondary treatment after RP in men with GG1 PC undergoing immediate or delayed prostatectomy was rare. These data suggest that the burden of treatment is near equivalent in patients who progress to treatment on AS compared with those who underwent immediate RP.
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Affiliation(s)
- Rohith Arcot
- Department of Urology, Wayne State University, Detroit, Michigan, USA
| | - Michael L Cher
- Department of Urology, Wayne State University, Detroit, Michigan, USA
| | - Ji Qi
- Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - Susan M Linsell
- Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - Rodney L Dunn
- Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - Arvin K George
- Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - James E Montie
- Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - Kevin B Ginsburg
- Department of Urology, Wayne State University, Detroit, Michigan, USA
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10
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Wittmann D, Varlamos C, Rodriguez-Galano N, Day L, Grube G, Shifferd J, Erickson K, Duby A, Morgan TM, Hollenbeck BK, Skolarus TA, Salami SS, Kaffenberger SD, Montie JE. Developing a Patient-Centered Model of Prostate Cancer Care: Patient Satisfaction With a Survivorship Program Embedded in Urologic-Oncologic Care. Urology 2021; 160:161-167. [PMID: 34896123 DOI: 10.1016/j.urology.2021.10.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 09/10/2021] [Accepted: 10/19/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate patients' and partners' satisfaction with a prostate cancer survivorship program embedded in urologic-oncologic care. As a part of quality improvement activity, we developed a patient and partner-centered, biopsychosocial support program for men and partners coping with the urinary and sexual side-effects of surgical treatment for prostate cancer. The program became a part of usual care for all prostate cancer patients. METHODS Patients who saw both an advanced practice provider and a sex therapist between August 1, 2018 and July 31, 2019 were eligible. Surveys packets were sent to 146 patients with surveys included for partners (N = 292). We used descriptive statistics to characterize participant responses. RESULTS Responses were received from 88 patients and 70 partners (56% response rate for the group). Patients and partners reported very high or fairly high satisfaction with the rehabilitation activities of the program (86-97% and 90%-100%, respectively); 91% of patients and 84% of partners thought having pre-operative education and post-operative rehabilitation was a good or fairly good idea; 83% of patients and 79% of partners would very much or somewhat recommend the program to a friend who was considering surgical treatment for prostate cancer. CONCLUSION Embedding a patient and partner-centered prostate cancer survivorship support program in oncologic care can positively impact patients' and partners' engagement in and satisfaction with post-operative rehabilitation.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - T A Skolarus
- University of Michigan; Center for Clinical Management Research, VA Ann Arbor Healthcare System
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11
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Paudel R, Ferrante S, Qi J, Dunn RL, Berry DL, Semerjian A, Brede CM, George AK, Lane BR, Ginsburg KB, Montie JE, Lane GI. Patient Preferences and Treatment Decisions for Prostate Cancer: Results From A Statewide Urological Quality Improvement Collaborative. Urology 2021; 155:55-61. [PMID: 33933504 DOI: 10.1016/j.urology.2021.04.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 04/13/2021] [Accepted: 04/15/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To examine the relationship between influential factors and treatment decisions among men with newly diagnosed prostate cancer (PCa). METHODS We identified men in the Michigan Urological Surgery Improvement Collaborative registry diagnosed with localized PCa between 2018-2020 who completed Personal Patient Profile-Prostate. We analyzed the proportion of active surveillance (AS) between men who stated future bladder, bowel, and sexual problems (termed influential factors) had "a lot of influence" on their treatment decisions versus other responses. We also assessed the relationship between influential factors, confirmatory testing results and choice of AS. RESULTS A total of 509 men completed Personal Patient Profile-Prostate. Treatment decisions aligned with influential factors for 88% of men with favorable risk and 49% with unfavorable risk PCa. A higher proportion of men who identified bladder, bowel and sexual concerns as having "a lot of influence" on their treatment decision chose AS, compared with men with other influential factors, although not statistically significant (44% vs 35%, P = .11). Similar results were also found when men were stratified based on PCa risk groups (favorable risk: 78% vs 67%; unfavorable risk: 17% vs 9%, respectively). Despite a small sample size, a higher proportion of men with non-reassuring confirmatory testing selected AS if influential factors had "a lot of influence" compared to "no influence" on their treatment decisions. CONCLUSION Men's concerns for future bladder, bowel, and sexual function problems, as elicited by a decision aid, may help explain treatment selection that differs from traditional clinical recommendation.
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Affiliation(s)
- Roshan Paudel
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI.
| | | | - Ji Qi
- Michigan Urological Surgery Improvement Collaborative, Ann Arbor, MI
| | - Rodney L Dunn
- Michigan Urological Surgery Improvement Collaborative, Ann Arbor, MI
| | - Donna L Berry
- Biobehavioral Nursing and Health Informatics, University of Washington, Seattle, WA
| | - Alice Semerjian
- Michigan Urological Surgery Improvement Collaborative, Ann Arbor, MI; IHA Urology, St. Joseph Mercy Health System, Ypsilanti, MI
| | | | - Arvin K George
- Michigan Urological Surgery Improvement Collaborative, Ann Arbor, MI; Department of Urology, University of Michigan, Ann Arbor, MI
| | | | - Kevin B Ginsburg
- Department of Urology, Wayne State University School of Medicine, Detroit, MI; Department of Surgical Oncology, Division of Urologic Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - James E Montie
- Michigan Urological Surgery Improvement Collaborative, Ann Arbor, MI; Department of Urology, University of Michigan, Ann Arbor, MI
| | - Giulia I Lane
- Department of Urology, University of Michigan, Ann Arbor, MI
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Paudel R, Ferrante S, Woodford J, Maitland C, Stockall E, Maatman T, Lane GI, Berry DL, Sales AE, Montie JE. Implementation of prostate cancer treatment decision aid in Michigan: a qualitative study. Implement Sci Commun 2021; 2:27. [PMID: 33676583 PMCID: PMC7936475 DOI: 10.1186/s43058-021-00125-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 02/05/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND The American Urological Association White Paper on Implementation of Shared Decision Making (SDM) into Urological Practice suggested SDM represents the state of the art in counseling for patients who are faced with difficult or uncertain medical decisions. The Michigan Urological Surgery Improvement Collaborative (MUSIC) implemented a decision aid, Personal Patient Profile-Prostate (P3P), in 2018 to help newly diagnosed prostate cancer patients make shared decisions with their clinicians. We conducted a qualitative study to assess statewide implementation of P3P throughout MUSIC. METHODS We recruited urologists and staff from 17 MUSIC practices (8 implementation and 9 comparator practices) to understand how practices engaged patients on treatment discussions and to assess facilitators and barriers to implementing P3P. Interview guides were developed based on the Tailored Interventions for Chronic Disease (TICD) Framework. Interviews were transcribed for analysis and coded independently by two investigators in NVivo, PRO 12. Additionally, quantitative program data were integrated into thematic analyses. RESULTS We interviewed 15 urologists and 11 staff from 16 practices. Thematic analysis of interview transcripts indicated three key themes including the following: (i) P3P is compatible as a SDM tool as over 80% of implementation urologists asked patients to complete the P3P questionnaire routinely and used P3P reports during treatment discussions; (ii) patient receptivity was demonstrated by 370 (50%) of newly diagnosed patients (n = 737) from 8 practices enrolled in P3P with 78% completion rate, which accounts for 39% of all newly diagnosed patients in these practices; and (iii) urologists' attitudes towards SDM varied. Over a third of urologists stated they did not rely on a decision aid. Comparator practices indicated habit, inertia, or concerns about clinic flow as reasons for not adopting P3P and some were unconvinced a decision aid is needed in their practice. CONCLUSION Urologists and staff affiliated with MUSIC implementation sites indicated that P3P focuses the treatment discussion on items that are important to patients. Experiences of implementation practices indicate that once initiated, there were no negative effects on clinic flow and urologists indicated P3P saves time during patient counseling, as patients were better prepared for focused discussions. Lack of awareness, personal habits, and inertia are reasons for not implementing P3P among the comparator practices.
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Affiliation(s)
- Roshan Paudel
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI USA
| | - Stephanie Ferrante
- Michigan Urological Surgery Improvement Collaborative, University of Michigan, Ann Arbor, MI USA
| | | | | | | | | | - Giulia I. Lane
- Department of Urology, University of Michigan, Ann Arbor, MI USA
| | - Donna L. Berry
- Department of Biobehavioral Nursing and Health Informatics, University of Washington, Seattle, WA USA
| | - Anne E. Sales
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI USA
| | - James E. Montie
- Michigan Urological Surgery Improvement Collaborative, University of Michigan, Ann Arbor, MI USA
| | - for the Michigan Urological Surgery Improvement Collaborative (MUSIC), Ann Arbor, Michigan, USA
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI USA
- Michigan Urological Surgery Improvement Collaborative, University of Michigan, Ann Arbor, MI USA
- University of Michigan, Ann Arbor, MI USA
- Sherwood Medical Center, Detroit, MI USA
- Capital Urological Associates, Okemos, MI USA
- Michigan Urological Clinic, Grand Rapids, MI USA
- Department of Urology, University of Michigan, Ann Arbor, MI USA
- Department of Biobehavioral Nursing and Health Informatics, University of Washington, Seattle, WA USA
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Morgan TM, Okoth LA, Spratt DE, Dunn R, Feng FY, Johnson AM, Lane BR, Linsell S, Ghani KR, Montie JE, Mehra R, Daignault-Newton S, Huang HC, Todorovic T, Davicioni E, Burks F, Rodriguez P, Sarle R, Miller DC, Cher ML. Prospective randomized trial of gene expression classifier utility following radical prostatectomy (G-MINOR). J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.6_suppl.15] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
15 Background: Decipher is a tissue-based genomic classifier (GC) developed and validated in the post-radical prostatectomy (RP) setting as a predictor of metastasis. We conducted the first prospective randomized controlled trial assessing the use of a prostate cancer GC, with a primary objective to determine the impact of test results on adjuvant treatment decisions. Methods: The Genomics in Michigan ImpactiNg Observation or Radiation (G-MINOR) randomized trial enrolled participants across 12 centers between January 2017-August 2018. Eligible patients had undergone RP within 9 months of enrollment, had pT3-4 disease and/or positive surgical margins, and a PSA < 0.1ng/mL. Patients were assigned to either the GC or Usual Care (UC) group using cluster-crossover block randomization. Patients and providers in both arms received a CAPRA-S recurrence risk score. Decipher scores were obtained on RP tissue of all patients, but patients and providers in the UC arm were blinded to the results. The primary endpoint was the impact of impact of GC test result on adjuvant treatment decisions compared to clinical factors alone within 18 months of RP. Results: 356 patients were randomized and 340 had at least 18 months of follow-up. Of these, all but 2 control (UC) patients had sufficient tissue to pass quality control for GC testing. Randomization resulted in 175 (51.5%) GC and 165 (48.5%) UC patients. There were no significant differences in clinical variables or Decipher scores between arms. At 18 months post-RP, 19 (10.9%) patients in the GC group and 12 (7.3%) patients in the UC group had received adjuvant treatment. In the primary analysis, availability of the GC score in the GC arm was significantly associated with adjuvant treatment in GC high-risk patients after controlling for CAPRA-S risk (OR 7.6, 95%CI 1.95-29.6, p = 0.009). In the GC arm, both GC score (OR 8.8, 95%CI 1.9-39.7, p = 0.005) and CAPRA-S score (OR 3.8, 95%CI 1.09-12.9, p = 0.04) were independently associated with adjuvant treatment in a multivariable logistic regression model. Conclusions: In the first ever randomized trial testing the impact of a prostate cancer genomic classifier on treatment decisions, the use of a GC post-RP impacted post-operative treatment in a manner concordant with classifier risk. Further follow-up will be necessary to assess the impact of GC testing on oncologic outcomes. Clinical trial information: NCT02783950. [Table: see text]
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Affiliation(s)
| | | | | | | | - Felix Y Feng
- University of California, San Francisco, Helen Diller Family Comprehensive Cancer Center, San Francisco, CA
| | | | | | | | | | | | | | | | | | | | | | | | - Paul Rodriguez
- Urology Associates of Grand Rapids P.C., Grand Rapids, MI
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Singhal U, Tosoian JJ, Qi J, Miller DC, Linsell SM, Cher M, Lane B, Cotant M, Montie JE, Bazzi W, Jafri M, Rosenberg B, George AK. Overtreatment and Underutilization of Watchful Waiting in Men With Limited Life Expectancy: An Analysis of the Michigan Urological Surgery Improvement Collaborative Registry. Urology 2020; 145:190-196. [DOI: 10.1016/j.urology.2020.07.047] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 07/06/2020] [Accepted: 07/20/2020] [Indexed: 10/23/2022]
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15
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Ginsburg KB, Jacobs JC, Qi J, Kaye DR, Eggly SS, Linsell SM, Auffenberg GB, George AK, Montie JE, Cher ML. Impact of Early Confirmatory Tests on Upgrading and Conversion to Treatment in Prostate Cancer Patients on Active Surveillance. Urology 2020; 147:213-222. [PMID: 32946908 DOI: 10.1016/j.urology.2020.07.067] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 07/06/2020] [Accepted: 07/27/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To assess the impact of confirmatory tests on active surveillance (AS) biopsy disease reclassification and progression to treatment in men with favorable risk prostate cancer (FRPC). METHODS We searched the MUSIC registry for men with FRPC managed with AS without or with a confirmatory test. Confirmatory tests included (1) repeat prostate biopsy, (2) genomic tests, (3) prostate magnetic resonance imaging (MRI), or (4) MRI followed by a post-MRI biopsy. Confirmatory test results were deemed reassuring (RA) or nonreassuring (nonRA) according to predefined criteria. Kaplan-Meier curves and multivariable Cox regression models were used to compare surveillance biopsy disease reclassification-free survival and treatment-free survival. RESULTS Of the 2,514 men with FRPC who were managed on AS, 1211 (48%) men obtained a confirmatory test. We noted differences in the 12-month unadjusted surveillance biopsy disease reclassification-free probability (68%, 83%, and 90%, P < .0001) and 24-month unadjusted treatment-free probability (55%, 81%, and 79%, P < .0001), for men with nonRA confirmatory tests, no confirmatory test, and RA confirmatory tests, respectively. Excluding patients with genomic confirmatory tests, men with RA confirmatory tests were associated with a lower hazard (hazard ratio [HR] 0.57, 95% confidence interval [CI] 0.38-0.84, P = .005) and men with nonRA confirmatory tests had an increased hazard (HR 1.97, 95% CI 1.22-3.19, P = .006) of surveillance disease reclassification compared with men without confirmatory tests in the multivariable model. CONCLUSION These data suggest men with RA confirmatory tests have less surveillance biopsy reclassification and remain on AS longer than men with nonRA test results. Confirmatory tests may help risk stratify men considering active surveillance.
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Affiliation(s)
| | - Jesse C Jacobs
- Department of Urology, Wayne State University, Detroit, MI
| | - Ji Qi
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - Deborah R Kaye
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI; Department of Urology, University of Michigan, Ann Arbor, MI
| | - Susan S Eggly
- Department of Oncology, Wayne State University/Karmanos Cancer Institute, Detroit, MI
| | - Susan M Linsell
- Department of Urology, University of Michigan, Ann Arbor, MI
| | - Gregory B Auffenberg
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Arvin K George
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI; Department of Urology, University of Michigan, Ann Arbor, MI
| | - James E Montie
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI; Department of Urology, University of Michigan, Ann Arbor, MI
| | - Michael L Cher
- Department of Urology, Wayne State University, Detroit, MI
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Peabody H, Lane BR, Qi J, Kim T, Montie JE, Moriarity A, Brede CM, Montgomery J. Limitations of abdominopelvic CT and multiparametric MR imaging for detection of lymph node metastases prior to radical prostatectomy. World J Urol 2020; 39:779-785. [PMID: 32361876 DOI: 10.1007/s00345-020-03227-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 04/24/2020] [Indexed: 01/03/2023] Open
Abstract
PURPOSE To investigate the performance of pre-surgery CT and multiparametric MRI (mpMRI) to identify lymph node (LN) metastases in the Michigan Urological Surgery Improvement Collaborative (MUSIC). Abdominopelvic CT and mpMRI are commonly used for intermediate- and high-risk prostate cancer (PCa) staging. METHODS Retrospective analysis of the MUSIC registry identified patients undergoing robot-assisted radical prostatectomy (RP) between 3/2012 and 7/2018. Patients were classified according to pre-surgery imaging modality. Primary outcomes were operating characteristics of CT and mpMRI for detection of pathologic LN involvement (pN1). RESULTS A total of 10,250 patients underwent RP and 3924 patients (38.3%) underwent CT and/or mpMRI prior to surgery. Suspicion for LN involvement was identified on 2.3% CT and 1.9% mpMRI. Overall, 391 patients were pN1(3.8%), including 0.1% low-, 2.1% intermediate-, and 10.9% high-risk PCa patients. Of 235 pN1 patients that underwent CT prior, far more had negative (91.1%) than positive (8.9%) findings, yielding sensitivity: 8.9%, specificity: 98.3%, negative predictive value (NPV): 92.1%, and positive predictive value (PPV): 32.3% for CT with regard to LN metastases. Similarly, more patients with pN1 disease had negative mpMRI (81.0%) then suspicious or indeterminate MRI (19.0%), yielding sensitivity: 19.0%, specificity: 97.3%, NPV: 95.9%, and PPV: 26.7%. CONCLUSIONS Abdominopelvic CT and mpMRI have clear limitations in identifying LN metastases. Additional clinicopathologic features should be considered when making management decisions, as 2.1% and 10.9% with intermediate-and high-risk cancer had metastatic LNs. The majority of pN1 patients had a negative CT or a negative/indeterminate mpMRI prior to RP. Pelvic LN dissection should be performed in RP patients with intermediate- or high-risk PCa, independent of preoperative imaging results.
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Affiliation(s)
- Henry Peabody
- Spectrum Health, 145 Michigan Street NE, Grand Rapids, MI, USA
| | - Brian R Lane
- Spectrum Health, 145 Michigan Street NE, Grand Rapids, MI, USA.
- Michigan State University College of Human Medicine, Grand Rapids, MI, USA.
| | - Ji Qi
- Michigan Medicine, Ann Arbor, MI, USA
| | - Tae Kim
- Michigan Medicine, Ann Arbor, MI, USA
| | | | - Andrew Moriarity
- Spectrum Health, 145 Michigan Street NE, Grand Rapids, MI, USA
- Advanced Radiology Services, PC, Grand Rapids, MI, USA
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17
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Eyrich NW, Tosoian JJ, Drobish J, Montie JE, Qi J, Kim T, Noyes SL, Moriarity AK, Lane BR. Do patients who undergo multiparametric MRI for prostate cancer benefit from additional staging imaging? Results from a statewide collaborative. Urol Oncol 2020; 38:636.e13-636.e19. [PMID: 32067844 DOI: 10.1016/j.urolonc.2020.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 01/16/2020] [Accepted: 01/21/2020] [Indexed: 10/25/2022]
Abstract
OBJECTIVES Prostate cancer (CaP) staging traditionally includes computed tomography (CT) and technetium-99m bone scintigraphy (BS) for assessment of lymph node (LN) and bone metastases, respectively. In recent years, multiparametric magnetic resonance imaging (mpMRI) has been used in diagnostic assessment of CaP. We sought to compare the accuracy of mpMRI to CT and BS for pretreatment staging. MATERIALS AND METHODS Using the Michigan Urological Surgery Improvement Collaborative registry, we identified men undergoing pretreatment mpMRI in addition to CT and/or BS in 2012 to 2018. Imaging reports were classified as positive, negative, or equivocal for detection of LN and bone metastases. A best value comparator (BVC) was used to adjudicate metastatic status in the absence of pathologic data. mpMRI accuracy was calculated using pessimistic (equivocal=positive) and optimistic (equivocal = negative) interpretations. We compared the diagnostic performance of mpMRI, CT, and BS in detecting metastases. RESULTS In total, 364 men underwent CT and mpMRI, and 646 underwent BS and mpMRI. Based on the BVC, 52 men (14%) harbored LN metastases and 38 (5.9%) harbored bone metastases. Sensitivity of mpMRI for LN metastases was significantly higher than CT (65-73% vs 38%, P < 0.005), and specificity of mpMRI and CT were 97% to 99% and 99% (P = 0.2-0.4), respectively. For bone metastases, BS sensitivity was 68% as compared to 42% to 71% (P = 0.02-0.83) for mpMRI. Specificity for bone metastases was 95% to 99% across all modalities. CONCLUSIONS Using statewide data, mpMRI appears superior to CT and comparable to BS for detection of LN and bone metastases, respectively. Pretreatment mpMRI may obviate the need for additional staging imaging.
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Affiliation(s)
| | | | - Justin Drobish
- Michigan State University College of Human Medicine, Grand Rapids, MI
| | | | - Ji Qi
- Department of Urology, Michigan Medicine, Ann Arbor, MI
| | - Tae Kim
- Department of Urology, Michigan Medicine, Ann Arbor, MI
| | | | | | - Brian R Lane
- Department of Urology, Michigan Medicine, Ann Arbor, MI; Michigan State University College of Human Medicine, Grand Rapids, MI; Spectrum Health Hospital System, Grand Rapids, MI.
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18
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Agochukwu NQ, Wittmann D, Boileau NR, Dunn RL, Montie JE, Kim T, Miller DC, Peabody J, Carlozzi NE. Validity of the Patient-Reported Outcome Measurement Information System (PROMIS) Sexual Interest and Satisfaction Measures in Men Following Radical Prostatectomy. J Clin Oncol 2019; 37:2017-2027. [PMID: 31232671 DOI: 10.1200/jco.18.01782] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
PURPOSE Patient-reported outcomes after radical prostatectomy have focused on erectile function. To date, no studies have validated the Patient-Reported Outcome Measurement Information System (PROMIS) Sexual Interest and Satisfaction single item measures in patients with prostate cancer, nor have studies examined how these measures relate to erectile function. In addition, data are lacking with regard to the clinical responsiveness of these measures to treatment. We sought to validate and examine the clinical utility of these measures in men after radical prostatectomy. PATIENTS AND METHODS We identified men who underwent a robotic radical prostatectomy from May 2014 to January 2016 in the Michigan Urological Surgery Improvement Collaborative. A single item from the PROMIS Global Satisfaction With Sex Life subdomain and a single item from the PROMIS Interest in Sexual Activity subdomain were administered. Erectile function was also assessed. Differences between baseline and 24-month T-scores for both PROMIS interest and satisfaction were examined. Multilevel models were constructed to examine change over time. RESULTS A total of 1,604 patients were included in the analysis. Convergent and discriminant validity of the PROMIS measures was supported. The mean PROMIS interest T-score decreased significantly from baseline to 3 months (P = .001) and significantly increased from 3 months to 24 months in this cohort, with 24-month scores exceeding baseline scores (P < .001). The mean PROMIS satisfaction T-score declined from baseline to 3 months and increased from 3 months to 24 months (P < .002). CONCLUSION PROMIS Global Satisfaction With Sex Life and Interest in Sexual Activity single-item measures are fundamental measures in prostate cancer survivorship. Patients are interested in sex despite functional losses and can salvage satisfaction, thereby giving insight into attainable patient-centered survivorship goals for sexual recovery after radical prostatectomy.
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Affiliation(s)
- Nnenaya Q Agochukwu
- 1University of Michigan Health System, Ann Arbor, MI.,2University of Michigan, Ann Arbor, MI
| | - Daniela Wittmann
- 1University of Michigan Health System, Ann Arbor, MI.,2University of Michigan, Ann Arbor, MI
| | | | - Rodney L Dunn
- 1University of Michigan Health System, Ann Arbor, MI.,2University of Michigan, Ann Arbor, MI
| | - James E Montie
- 1University of Michigan Health System, Ann Arbor, MI.,2University of Michigan, Ann Arbor, MI
| | - Tae Kim
- 1University of Michigan Health System, Ann Arbor, MI.,2University of Michigan, Ann Arbor, MI
| | - David C Miller
- 1University of Michigan Health System, Ann Arbor, MI.,2University of Michigan, Ann Arbor, MI
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Kirmiz S, Qi J, Babitz SK, Linsell S, Denton B, Singh K, Auffenberg G, Montie JE, Lane BR. Grade Groups Provide Improved Predictions of Pathological and Early Oncologic Outcomes Compared with Gleason Score Risk Groups. J Urol 2019; 201:278-283. [PMID: 30195846 DOI: 10.1016/j.juro.2018.08.081] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
PURPOSE The GG (Grade Group) system was introduced in 2013. Data from academic centers suggest that GG better distinguishes between prostate cancer risk groups than the Gleason score (GS) risk groups. We compared the performance of the 2 systems to predict pathological/recurrence outcomes using data from the MUSIC (Michigan Urological Surgery Improvement Collaborative). MATERIALS AND METHODS Patients who underwent biopsy and radical prostatectomy in the MUSIC from March 2012 to June 2017 were classified according to GG and GS. Outcomes included the presence or absence of extraprostatic extension, seminal vesical invasion, positive lymph nodes, positive surgical margins and time to cancer recurrence (defined as postoperative prostate specific antigen 0.2 ng/ml or greater). Logistic and Cox regression models were used to compare the difference in outcomes. RESULTS A total of 8,052 patients were identified. When controlling for patient characteristics, significantly higher risks of extraprostatic extension, seminal vesical invasion and positive lymph nodes were observed for biopsy GG 3 vs 2 and for GG 5 vs 4 (p <0.001). Biopsy GGs 3, 4 and 5 also showed shorter time to biochemical recurrence than GGs 2, 3 and 4, respectively (p <0.001). GGs 3, 4 and 5 at radical prostatectomy were each associated with a greater probability of recurrence compared to the next lower GG (p <0.001). GG (vs GS) had better predictive power for extraprostatic extension, seminal vesical invasion, positive lymph nodes and biochemical recurrence. CONCLUSIONS GG at biopsy and radical prostatectomy allows for better discrimination of recurrence-free survival between individual risk groups than GS risk groups with GGs 2, 3, 4 and 5 each incrementally associated with increased risk.
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Affiliation(s)
- Samer Kirmiz
- College of Human Medicine, Michigan State University, University of Michigan Medical School, Ann Arbor, Michigan
| | - Ji Qi
- Departments of Urology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Stephen K Babitz
- Spectrum Health Hospital System, University of Michigan Medical School, Ann Arbor, Michigan
| | - Susan Linsell
- Departments of Urology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Brian Denton
- Departments of Urology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Karandeep Singh
- Learning Health Sciences, University of Michigan Medical School, Ann Arbor, Michigan
| | - Gregory Auffenberg
- Departments of Urology, University of Michigan Medical School, Ann Arbor, Michigan
| | - James E Montie
- Departments of Urology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Brian R Lane
- Grand Rapids, University of Michigan Medical School, Ann Arbor, Michigan
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Hawken SR, Spratt DE, Qi J, Linsell SM, Cher ML, Ghani KR, Miller DC, Montie JE, Morgan TM. Utilization of Salvage Radiation Therapy for Biochemical Recurrence After Radical Prostatectomy. Int J Radiat Oncol Biol Phys 2019; 104:1030-1034. [PMID: 30682490 DOI: 10.1016/j.ijrobp.2019.01.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 12/26/2019] [Accepted: 01/06/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE For men with biochemical recurrence after radical prostatectomy (RP), salvage radiation therapy (SRT), especially "early" SRT (PSA level ≤0.5 ng/mL), is a potentially curative option; however, its utilization is not well defined. We sought to determine factors associated with SRT utilization as well as variation in its administration. MATERIALS AND METHODS Patients with localized prostate cancer undergoing RP at 33 practices participating in the statewide Michigan Urological Surgery Improvement Collaborative between 2012 and 2016 were prospectively followed. Eligible patients had at least 1 post-RP PSA level ≥0.1 ng/mL with ≥6 months of follow-up after the first detectable PSA level. Patients undergoing adjuvant radiation therapy were excluded. SRT utilization and clinical and pathologic patient characteristics were examined. RESULTS Of 1010 eligible patients with a detectable PSA level, 29.5% underwent SRT. Of patients who received SRT, 46.9% either reached a PSA ≥0.2 ng/mL or were treated before reaching that PSA level. A total of 30.6% of patients had a PSA level ≥0.5 ng/mL without undergoing prior SRT; of this group, 42.1% later received SRT. After adjusting for patient and practice level factors, positive surgical margins, higher T stage, and higher grade group were all associated with receipt of SRT (P < .05). Even after adjusting for patient and tumor characteristics, significant variation remained in the adjusted rate of SRT utilization across practices sites, ranging from 7% (95% confidence interval, 3%-17%) to 73% (95% confidence interval, 45%-90%, P < .001). Practices were grouped into tertiles based on SRT utilization, and those practices that used SRT more frequently overall were more likely to administer SRT across all patient-based predictors of SRT utilization. CONCLUSIONS SRT utilization is low among men with a detectable post-RP PSA level, with significant variation in practice-level SRT utilization that cannot be explained by patient factors alone. Factors suggesting higher-risk disease were predictors of SRT administration. These data support the potential to expand the use of SRT, particularly among sites with low utilization.
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Affiliation(s)
- Scott R Hawken
- Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Daniel E Spratt
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Ji Qi
- Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Susan M Linsell
- Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Michael L Cher
- Department of Urology, Wayne State University, Detroit, Michigan
| | - Khurshid R Ghani
- Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - David C Miller
- Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - James E Montie
- Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Todd M Morgan
- Department of Urology, University of Michigan, Ann Arbor, Michigan.
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Hu JC, Tosoian JJ, Qi J, Kaye D, Johnson A, Linsell S, Montie JE, Ghani KR, Miller DC, Wojno K, Burks FN, Spratt DE, Morgan TM. Clinical Utility of Gene Expression Classifiers in Men With Newly Diagnosed Prostate Cancer. JCO Precis Oncol 2018; 2:PO.18.00163. [PMID: 32832833 PMCID: PMC7440129 DOI: 10.1200/po.18.00163] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
PURPOSE Tissue-based gene expression classifiers (GECs) may assist with management decisions in patients with newly diagnosed prostate cancer. We sought to assess the current use of GEC tests and determine how the test results are associated with primary disease management. METHODS In this observational study, patients diagnosed with localized prostate cancer were tracked through the Michigan Urological Surgery Improvement Collaborative registry. The utilization and results of three GECs (Decipher Prostate Biopsy, Oncotype DX Prostate, and Prolaris) were prospectively collected. Practice patterns, predictors of GEC use, and effect of GEC results on disease management were investigated. RESULTS Of 3,966 newly diagnosed patients, 747 (18.8%) underwent GEC testing. The rate of GEC use in individual practices ranged from 0% to 93%, and patients undergoing GEC testing were more likely to have a lower prostate-specific antigen level, lower Gleason score, lower clinical T stage, and fewer positive cores (all P < .05). Among patients with clinical favorable risk of cancer, the rate of active surveillance (AS) differed significantly among patients with a GEC result above the threshold (46.2%), those with a GEC result below the threshold (75.9%), and those who did not undergo GEC (57.9%; P < .001 for comparison of the three groups). This results in an estimate that, for every nine men with favorable risk of cancer who undergo GEC testing, one additional patient may have their disease initially managed with AS. On multivariable analysis, patients with favorable-risk prostate cancer who were classified as GEC low risk were more likely to be managed on AS than those without testing (odds ratio, 1.84; P = .006). CONCLUSION There is large variability in practice-level use and GEC tests ordered in patients with newly diagnosed, localized prostate cancer. In patients with clinical favorable risk of cancer, GEC testing significantly increased the use of AS. Additional follow-up will help determine whether incorporation of GEC testing into initial patient care favorably affects clinical outcomes.
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Affiliation(s)
- Jonathan C. Hu
- Jonathan C. Hu and Frank N. Burks, Oakland University William Beaumont School of Medicine, Rochester; Jeffrey J. Tosoian, Ji Qi, Deborah Kaye, Anna Johnson, Susan Linsell, James E. Montie, Khurshid R. Ghani, David C. Miller, Daniel E. Spratt, and Todd M. Morgan, University of Michigan, Ann Arbor; and Kirk Wojno, Comprehensive Urology, Royal Oak, MI
| | - Jeffrey J. Tosoian
- Jonathan C. Hu and Frank N. Burks, Oakland University William Beaumont School of Medicine, Rochester; Jeffrey J. Tosoian, Ji Qi, Deborah Kaye, Anna Johnson, Susan Linsell, James E. Montie, Khurshid R. Ghani, David C. Miller, Daniel E. Spratt, and Todd M. Morgan, University of Michigan, Ann Arbor; and Kirk Wojno, Comprehensive Urology, Royal Oak, MI
| | - Ji Qi
- Jonathan C. Hu and Frank N. Burks, Oakland University William Beaumont School of Medicine, Rochester; Jeffrey J. Tosoian, Ji Qi, Deborah Kaye, Anna Johnson, Susan Linsell, James E. Montie, Khurshid R. Ghani, David C. Miller, Daniel E. Spratt, and Todd M. Morgan, University of Michigan, Ann Arbor; and Kirk Wojno, Comprehensive Urology, Royal Oak, MI
| | - Deborah Kaye
- Jonathan C. Hu and Frank N. Burks, Oakland University William Beaumont School of Medicine, Rochester; Jeffrey J. Tosoian, Ji Qi, Deborah Kaye, Anna Johnson, Susan Linsell, James E. Montie, Khurshid R. Ghani, David C. Miller, Daniel E. Spratt, and Todd M. Morgan, University of Michigan, Ann Arbor; and Kirk Wojno, Comprehensive Urology, Royal Oak, MI
| | - Anna Johnson
- Jonathan C. Hu and Frank N. Burks, Oakland University William Beaumont School of Medicine, Rochester; Jeffrey J. Tosoian, Ji Qi, Deborah Kaye, Anna Johnson, Susan Linsell, James E. Montie, Khurshid R. Ghani, David C. Miller, Daniel E. Spratt, and Todd M. Morgan, University of Michigan, Ann Arbor; and Kirk Wojno, Comprehensive Urology, Royal Oak, MI
| | - Susan Linsell
- Jonathan C. Hu and Frank N. Burks, Oakland University William Beaumont School of Medicine, Rochester; Jeffrey J. Tosoian, Ji Qi, Deborah Kaye, Anna Johnson, Susan Linsell, James E. Montie, Khurshid R. Ghani, David C. Miller, Daniel E. Spratt, and Todd M. Morgan, University of Michigan, Ann Arbor; and Kirk Wojno, Comprehensive Urology, Royal Oak, MI
| | - James E. Montie
- Jonathan C. Hu and Frank N. Burks, Oakland University William Beaumont School of Medicine, Rochester; Jeffrey J. Tosoian, Ji Qi, Deborah Kaye, Anna Johnson, Susan Linsell, James E. Montie, Khurshid R. Ghani, David C. Miller, Daniel E. Spratt, and Todd M. Morgan, University of Michigan, Ann Arbor; and Kirk Wojno, Comprehensive Urology, Royal Oak, MI
| | - Khurshid R. Ghani
- Jonathan C. Hu and Frank N. Burks, Oakland University William Beaumont School of Medicine, Rochester; Jeffrey J. Tosoian, Ji Qi, Deborah Kaye, Anna Johnson, Susan Linsell, James E. Montie, Khurshid R. Ghani, David C. Miller, Daniel E. Spratt, and Todd M. Morgan, University of Michigan, Ann Arbor; and Kirk Wojno, Comprehensive Urology, Royal Oak, MI
| | - David C. Miller
- Jonathan C. Hu and Frank N. Burks, Oakland University William Beaumont School of Medicine, Rochester; Jeffrey J. Tosoian, Ji Qi, Deborah Kaye, Anna Johnson, Susan Linsell, James E. Montie, Khurshid R. Ghani, David C. Miller, Daniel E. Spratt, and Todd M. Morgan, University of Michigan, Ann Arbor; and Kirk Wojno, Comprehensive Urology, Royal Oak, MI
| | - Kirk Wojno
- Jonathan C. Hu and Frank N. Burks, Oakland University William Beaumont School of Medicine, Rochester; Jeffrey J. Tosoian, Ji Qi, Deborah Kaye, Anna Johnson, Susan Linsell, James E. Montie, Khurshid R. Ghani, David C. Miller, Daniel E. Spratt, and Todd M. Morgan, University of Michigan, Ann Arbor; and Kirk Wojno, Comprehensive Urology, Royal Oak, MI
| | - Frank N. Burks
- Jonathan C. Hu and Frank N. Burks, Oakland University William Beaumont School of Medicine, Rochester; Jeffrey J. Tosoian, Ji Qi, Deborah Kaye, Anna Johnson, Susan Linsell, James E. Montie, Khurshid R. Ghani, David C. Miller, Daniel E. Spratt, and Todd M. Morgan, University of Michigan, Ann Arbor; and Kirk Wojno, Comprehensive Urology, Royal Oak, MI
| | - Daniel E. Spratt
- Jonathan C. Hu and Frank N. Burks, Oakland University William Beaumont School of Medicine, Rochester; Jeffrey J. Tosoian, Ji Qi, Deborah Kaye, Anna Johnson, Susan Linsell, James E. Montie, Khurshid R. Ghani, David C. Miller, Daniel E. Spratt, and Todd M. Morgan, University of Michigan, Ann Arbor; and Kirk Wojno, Comprehensive Urology, Royal Oak, MI
| | - Todd M. Morgan
- Jonathan C. Hu and Frank N. Burks, Oakland University William Beaumont School of Medicine, Rochester; Jeffrey J. Tosoian, Ji Qi, Deborah Kaye, Anna Johnson, Susan Linsell, James E. Montie, Khurshid R. Ghani, David C. Miller, Daniel E. Spratt, and Todd M. Morgan, University of Michigan, Ann Arbor; and Kirk Wojno, Comprehensive Urology, Royal Oak, MI
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22
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Kaye DR, Qi J, Morgan TM, Linsell S, Ginsburg KB, Lane BR, Montie JE, Cher ML, Miller DC. Pathological upgrading at radical prostatectomy for patients with Grade Group 1 prostate cancer: implications of confirmatory testing for patients considering active surveillance. BJU Int 2018; 123:846-853. [PMID: 30248225 DOI: 10.1111/bju.14554] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine the association between National Comprehensive Cancer Network (NCCN) risk, number of positive biopsy cores, age, and early confirmatory test results on pathological upgrading at radical prostatectomy (RP), in order to better understand whether early confirmatory testing and better risk stratification are necessary for all men with Grade Group (GG) 1 cancers who are considering active surveillance (AS). PATIENTS AND METHODS We identified men in Michigan initially diagnosed with GG1 prostate cancer, from January 2012 to November 2017, who had a RP within 1 year of diagnosis. Our endpoints were: (i) ≥GG2 cancer at RP and (ii) adverse pathology (≥GG3 and/or ≥pT3a). We compared upgrading according to NCCN risk, number of positive biopsy cores, and age. Last, we examined if confirmatory test results were associated with upgrading or adverse pathology at RP. RESULTS Amongst 1966 patients with GG1 cancer at diagnosis, the rates of upgrading to ≥GG2 and adverse pathology were 40% and 59% (P < 0.001), and 10% and 17% (P = 0.003) for patients with very-low- and low-risk cancers, respectively. Upgrading by volume ranged from 49% to 67% for ≥GG2, and 16% to 23% for adverse pathology. Generally, more patients aged ≥70 vs <70 years had adverse pathology. Unreassuring confirmatory test results had a higher likelihood of adverse pathology than reassuring tests (35% vs 18%, P = 0.017). CONCLUSIONS Upgrading and adverse pathology are common amongst patients initially diagnosed with GG1 prostate cancer. Early use of confirmatory testing may facilitate the identification of patients with more aggressive disease ensuring improved risk classification and safer selection of patients for AS.
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Affiliation(s)
- Deborah R Kaye
- Dow Division of Health Services Research, University of Michigan, Ann Arbor, MI, USA.,University of Michigan, Ann Arbor, MI, USA
| | - Ji Qi
- Dow Division of Health Services Research, University of Michigan, Ann Arbor, MI, USA
| | | | - Susan Linsell
- Dow Division of Health Services Research, University of Michigan, Ann Arbor, MI, USA
| | | | | | - James E Montie
- Dow Division of Health Services Research, University of Michigan, Ann Arbor, MI, USA.,University of Michigan, Ann Arbor, MI, USA
| | - Michael L Cher
- Department of Urology, Wayne State University, Detroit, MI, USA
| | - David C Miller
- Dow Division of Health Services Research, University of Michigan, Ann Arbor, MI, USA.,University of Michigan, Ann Arbor, MI, USA
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23
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Ginsburg KB, Auffenberg GB, Qi J, Powell IJ, Linsell SM, Montie JE, Miller DC, Cher ML. Risk of Becoming Lost to Follow-up During Active Surveillance for Prostate Cancer. Eur Urol 2018; 74:704-707. [PMID: 30177290 DOI: 10.1016/j.eururo.2018.08.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Accepted: 08/09/2018] [Indexed: 11/26/2022]
Abstract
Active surveillance (AS) has emerged as the preferred management strategy for many men with prostate cancer (PC); however, insufficient longitudinal monitoring may increase the risk of poor outcomes. We sought to determine rates of patients becoming lost to follow-up (LTFU) and associated risk factors in a large AS cohort. The Michigan Urologic Surgery Improvement Collaborative (MUSIC) maintains a prospective registry of PC patients from 44 academic and community urology practices. Over a 6-yr period (2011-2017), we identified patients managed with AS. LTFU was defined as any 18-mo period where no pertinent surveillance testing was entered in the registry. With a median surveillance period of 32 mo, the estimated 2-yr LTFU-free probability calculated by Kaplan-Meier method was 90% (95% confidence interval [CI]=89-92%). Both African American race (hazard ratio [HR]: 2.77, 95% CI=1.81-4.24) and Charlson comorbidity index ≥1 (HR: 1.55, 95% CI=1.08-2.23) were independently associated with increased risk of LTFU. There was variability in rates of estimated 2-yr LTFU-free survival across MUSIC practices, ranging from 52% (95% CI=21-100%) to 99% (95% CI=97-100%), with a median of 96% (interquartile range: 94-98%), although this did not reach statistical significance (p=0.076). These data reveal opportunities for urology practices to identify systems to reduce rates of LTFU and improve the long-term safety of AS. PATIENT SUMMARY: With a median observation period of 32 mo, an estimated 10% of patients will be lost to follow-up at the 2 yr time point while on AS. African American men and generally unhealthy patients were at increased risk, and there was variability from one urology practice to another. There is ample opportunity to improve the quality of the performance of AS.
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Affiliation(s)
- Kevin B Ginsburg
- Department of Urology, Wayne State University, School of Medicine, Detroit, MI, USA
| | - Gregory B Auffenberg
- Department of Urology, University of Michigan, School of Medicine, Ann Arbor, MI, USA; Department of Urology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Ji Qi
- Department of Urology, University of Michigan, School of Medicine, Ann Arbor, MI, USA
| | - Isaac J Powell
- Department of Urology, Wayne State University, School of Medicine, Detroit, MI, USA
| | - Susan M Linsell
- Department of Urology, University of Michigan, School of Medicine, Ann Arbor, MI, USA
| | - James E Montie
- Department of Urology, University of Michigan, School of Medicine, Ann Arbor, MI, USA
| | - David C Miller
- Department of Urology, University of Michigan, School of Medicine, Ann Arbor, MI, USA
| | - Michael L Cher
- Department of Urology, Wayne State University, School of Medicine, Detroit, MI, USA.
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24
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Curci NE, Lane BR, Shankar PR, Noyes SL, Moriarity AK, Kubat A, Brede C, Montgomery JS, Auffenberg GB, Miller DC, Montie JE, George AK, Davenport MS. Integration and Diagnostic Accuracy of 3T Nonendorectal coil Prostate Magnetic Resonance Imaging in the Context of Active Surveillance. Urology 2018; 116:137-143. [PMID: 29653121 DOI: 10.1016/j.urology.2018.02.043] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 02/12/2018] [Accepted: 02/17/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the integration of 3T nonendorectal coil multiparametric prostate magnetic resonance imaging (mpMRI) at 2 high-volume practices that routinely use mpMRI in the setting of active surveillance. MATERIALS AND METHODS This was an institutional review board-approved, Health Insurance Portability and Accountability Act-compliant, and dual-institution retrospective cohort study. Subjects undergoing 3T mpMRI without endorectal coil at either study institution over a 13-month period (August 1, 2015-August 31, 2016) were selected based on predefined criteria: clinical T1/T2 Gleason 6 prostate cancer, prostate-specific antigen <15 ng/mL, ≥40 years old, mpMRI within 2 years of prostate biopsy, and Prostate Imaging Reporting and Data System (PI-RADS) v2 score assigned. Subjects surveilled for Gleason ≥3 + 4 prostate cancer were excluded. The primary outcome was detection of Gleason ≥3 + 4 prostate cancer on magnetic resonance-ultrasound fusion biopsy, standard biopsy, or prostatectomy within 6 months following mpMRI. Positive predictive values (PPVs) were calculated. RESULTS A total of 286 subjects (N = 193 from institution 1, N = 93 from institution 2) met the criteria. Most (87% [90 of 104]) with maximum PI-RADS v2 scores of 1-2 did not receive immediate biopsy or treatment and remained on active surveillance. Incidence and PPVs for PI-RADS v2 scores of ≥3 were the following: PI-RADS 3 (n = 57 [20%], PPV 21% [6 of 29]), PI-RADS 4 (n = 96 [34%], PPV 51% [39 of 77]), and PI-RADS 5 (n = 29 [13%], PPV 71% [20 of 28]). No Gleason ≥4 + 3 prostate cancer was identified for PI-RADS v2 scores of 1-3 (0 of 43 with histology). Following mpMRI and subsequent biopsy, 21% (61 of 286) of subjects were removed from active surveillance and underwent definitive therapy. CONCLUSION The 3T nonendorectal coil mpMRI has been integrated into the care of patients on active surveillance and effectively stratifies risk of Gleason ≥3 + 4 prostate cancer in this population.
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Affiliation(s)
- Nicole E Curci
- Department of Radiology, Michigan Medicine, Ann Arbor, MI
| | - Brian R Lane
- Department of Urology, Spectrum Health Medical Group, Grand Rapids, MI
| | | | - Sabrina L Noyes
- Department of Urology, Spectrum Health Medical Group, Grand Rapids, MI
| | - Andrew K Moriarity
- Advanced Radiology Services, Spectrum Health Medical Group, Grand Rapids, MI
| | - Anthony Kubat
- Department of Pathology, Spectrum Health Medical Group, Grand Rapids, MI
| | - Chris Brede
- Department of Urology, Spectrum Health Medical Group, Grand Rapids, MI
| | | | | | | | | | | | - Matthew S Davenport
- Department of Radiology, Michigan Medicine, Ann Arbor, MI; Department of Urology, Michigan Medicine, Ann Arbor, MI; Michigan Radiology Quality Collaborative, Ann Arbor, MI.
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25
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Hawken S, Spratt DE, Qi J, Linsell SM, Cher ML, Ghani KR, Miller DC, Montie JE, Morgan TM, Surgery Improvement Collaborative FTMU. MP22-03 UTILIZATION OF SALVAGE RADIATION THERAPY FOR BIOCHEMICAL RECURRENCE AFTER RADICAL PROSTATECTOMY. J Urol 2018. [DOI: 10.1016/j.juro.2018.02.714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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26
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Barnett CL, Davenport MS, Montgomery JS, Wei JT, Montie JE, Denton BT. Cost‐effectiveness of magnetic resonance imaging and targeted fusion biopsy for early detection of prostate cancer. BJU Int 2018; 122:50-58. [DOI: 10.1111/bju.14151] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Christine L. Barnett
- Department of Industrial and Operations Engineering University of Michigan Ann Arbor MI USA
| | | | | | - John T. Wei
- Department ofUrology University of Michigan Ann Arbor MI USA
| | - James E. Montie
- Department ofUrology University of Michigan Ann Arbor MI USA
| | - Brian T. Denton
- Department of Industrial and Operations Engineering University of Michigan Ann Arbor MI USA
- Department ofUrology University of Michigan Ann Arbor MI USA
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27
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Morgan TM, Miller DC, Dunn R, Susan L, Okoth L, Johnson A, Feng FY, Khurshid G, Davicioni E, Du Plessis M, Montie JE, Cher ML. Prospective randomized trial of genomic classifier impact on treatment decisions in patients at high risk of recurrence following radical prostatectomy (G-MINOR). J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.6_suppl.tps154] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
TPS154 Background: Approximately 30% of patients will have ≥pT3 disease and/or positive surgical margins at radical prostatectomy (RP), indicating a high risk of local recurrence. While current guidelines recommend consideration of adjuvant radiotherapy (aRT) in this setting, < 10% undergo aRT. The Decipher assay is a novel, tissue-based genomic classifier (GC) developed and validated in the post-RP setting as a predictor of metastasis. Current retrospective evidence suggests that patients with a high GC score may benefit from aRT, while observation may be safe for those with a lower GC score. However, there are no randomized prospective data evaluating the clinical utility of biomarkers in men with adverse features after RP. Here we see to determine the impact of GC test results on adjuvant treatment decisions for high-risk post-RP patients vs. clinical factors alone. Methods: Genomics in Michigan ImpactiNg Observation or Radiation (G-MINOR) is a 4-year (12-month enrollment, 3-year follow-up) prospective, cluster-crossover, unblinded, study of 350 subjects from twelve Urology practices in the Michigan Urological Surgery Improvement Collaborative (MUSIC). MUSIC is a physician-led quality improvement consortium nearly all academic and community urology practices within the state of Michigan. Each clinical center participating in this trial will be randomly assigned to either a Genomic Classifier (GC)-based strategy or control arm for a period of 3 months. Patients in both arms will receive a predicted risk of recurrence based on a validated clinical nomogram, the CAPRA-S score, enabling a head-to-head comparison of the Decipher assay with a freely-available validated prognostic tool. Random assignments will be generated centrally by a study statistician and provided to centers immediately before commencing enrollment in each 3-month period. Each center will have two GC and two UC enrollment periods, maintaining study-wide balance and blinding of assignments in subsequent periods. Patients will be followed for receipt of adjuvant therapy as well as oncologic (recurrence, metastasis, and death) and patient-reported quality of life. Clinical trial information: NCT02783950.
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Affiliation(s)
| | | | | | | | | | | | - Felix Y Feng
- University of California San Francisco, San Francisco, CA
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28
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Kaye DR, Syrjamaki J, Ellimoottil C, Schervish EW, Solomon MH, Linsell S, Montie JE, Miller DC, Dupree JM. Use of Routine Home Health Care and Deviations From an Uncomplicated Recovery Pathway After Radical Prostatectomy. Urology 2017; 112:74-79. [PMID: 29155190 DOI: 10.1016/j.urology.2017.11.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 11/02/2017] [Accepted: 11/03/2017] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To evaluate the statistical association between routine home health use after prostatectomy, short-term surgical outcomes, and payments. METHODS We identified all men who underwent a robotic radical prostatectomy from April 1, 2014, to October 31, 2015, in the Michigan Urological Surgery Improvement Collaborative (MUSIC) with insurance from Medicare or a large commercial payer. We calculated rates of "routine" home care use after prostatectomy by urology practice. We defined "routine" home care as home care initiated within 4 days of discharge among patients discharged without a pelvic drain. We then compared emergency department (ED) visits, readmissions, prolonged catheter use, catheter reinsertion rates, and 90-day episode payments, in unadjusted and using a propensity-adjusted analysis, for those who did and did not receive home care. RESULTS We identified 647 patients, of whom 13% received routine home health care. At the practice level, the use of routine home care after prostatectomy varied from 0% to 53% (P = .05) (mean: 3.6%, median: 0%). Unadjusted, patients with routine home care had increased ED visits within 16 days (15.5% vs 6.9%, P <.01), similar rates of catheter duration for >16 days (3.6% vs 3.0%, P = .79) and need for catheter replacement (1.2% vs 2.5%, P = .46), and a trend toward decreased readmissions (0% vs 4.1%, P = .06). Only the increased ED visits remained significant in adjusted analyses (P <.01). Home health had an average payment of $1000 per episode. CONCLUSION Thirteen percent of patients received routine home health care after prostatectomy, without improved outcomes. These findings suggest that patients do not routinely require home health care to improve short-term outcomes following radical prostatectomy, however, the appropriate use of home health care should be evaluated further.
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Affiliation(s)
- Deborah R Kaye
- Michigan Urological Surgery Improvement Collaborative, Ann Arbor, MI; Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI; Michigan Value Collaborative, Ann Arbor, MI.
| | - John Syrjamaki
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI; Michigan Value Collaborative, Ann Arbor, MI
| | - Chad Ellimoottil
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI; Michigan Value Collaborative, Ann Arbor, MI
| | - Edward W Schervish
- Michigan Urological Surgery Improvement Collaborative, Ann Arbor, MI; Michigan Institute of Urology, Detroit, MI
| | - M Hugh Solomon
- Michigan Urological Surgery Improvement Collaborative, Ann Arbor, MI
| | - Susan Linsell
- Michigan Urological Surgery Improvement Collaborative, Ann Arbor, MI; Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - James E Montie
- Michigan Urological Surgery Improvement Collaborative, Ann Arbor, MI; Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - David C Miller
- Michigan Urological Surgery Improvement Collaborative, Ann Arbor, MI; Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI; Michigan Value Collaborative, Ann Arbor, MI
| | - James M Dupree
- Michigan Urological Surgery Improvement Collaborative, Ann Arbor, MI; Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI; Michigan Value Collaborative, Ann Arbor, MI
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29
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Barnett CL, Auffenberg GB, Cheng Z, Yang F, Wang J, Wei JT, Miller DC, Montie JE, Mamawala M, Denton BT. Optimizing active surveillance strategies to balance the competing goals of early detection of grade progression and minimizing harm from biopsies. Cancer 2017; 124:698-705. [DOI: 10.1002/cncr.31101] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Revised: 09/26/2017] [Accepted: 10/02/2017] [Indexed: 11/11/2022]
Affiliation(s)
| | | | - Zian Cheng
- University of MichiganAnn Arbor Michigan
| | - Fan Yang
- University of MichiganAnn Arbor Michigan
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30
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Auffenberg GB, Qi J, Gao Y, Miller DC, Ye Z, Brachulis A, Linsell S, Gandhi TN, Kraklau D, Montie JE, Ghani KR. Evaluation of a needle disinfectant technique to reduce infection-related hospitalisation after transrectal prostate biopsy. BJU Int 2017; 121:232-238. [PMID: 28796919 DOI: 10.1111/bju.13982] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To determine whether a needle disinfectant step during transrectal ultrasonography (TRUS)-guided prostate biopsy is associated with lower rates of infection-related hospitalisation. PATIENTS AND METHODS We conducted a retrospective analysis of all TRUS-guided prostate biopsies taken across the Michigan Urological Surgery Improvement Collaborative (MUSIC) from January 2012 to March 2015. Natural variation in technique allowed us to evaluate for differences in infection-related hospitalisations based on whether or not a needle disinfectant technique was used. The disinfectant technique was an intra-procedural step to cleanse the biopsy needle with antibacterial solution after each core was sampled (i.e., 10% formalin or 70% isopropyl alcohol). After grouping biopsies according to whether or not the procedure included a needle disinfectant step, we compared the rate of infection-related hospitalisations within 30 days of biopsy. Generalised estimating equation models were fit to adjust for potential confounders. RESULTS During the evaluated period, 17 954 TRUS-guided prostate biopsies were taken with 5 321 (29.6%) including a disinfectant step. The observed rate of infection-related hospitalisation was lower when a disinfectant technique was used during biopsy (0.60% vs 0.90%; P = 0.04). After accounting for differences between groups the adjusted hospitalisation rate in the disinfectant group was 0.85% vs 1.12% in the no disinfectant group (adjusted odds ratio 0.76, 95% confidence interval 0.50-1.15; P = 0.19). CONCLUSIONS In this observational analysis, hospitalisations for infectious complications were less common when the TRUS-guided prostate biopsy included a needle disinfection step. However, after adjusting for potential confounders the effect of needle disinfection was not statistically significant. Prospective evaluation is warranted to determine if this step provides a scalable and effective method to minimise infectious complications.
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Affiliation(s)
| | - Ji Qi
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - Yuqing Gao
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - David C Miller
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - Zaojun Ye
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - Andrew Brachulis
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - Susan Linsell
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - Tejal N Gandhi
- Division of Infectious Diseases, Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| | | | - James E Montie
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - Khurshid R Ghani
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
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31
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Burks FN, Hu JC, Telang D, Liu A, Hawken S, Montgomery Z, Linsell S, Montie JE, Miller DC, Ghani KR. Repeat Prostate Biopsy Practice Patterns in a Statewide Quality Improvement Collaborative. J Urol 2017; 198:322-328. [DOI: 10.1016/j.juro.2017.02.3338] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2017] [Indexed: 12/29/2022]
Affiliation(s)
- Frank N. Burks
- Department of Urology, Oakland University William Beaumont School of Medicine, Royal Oak, Michigan
- Department of Urology, University of Michigan (AL, SH, ZM, SL, JEM, DCM, KRG), Ann Arbor, Michigan
| | - Jonathan C. Hu
- Department of Urology, Oakland University William Beaumont School of Medicine, Royal Oak, Michigan
- Department of Urology, University of Michigan (AL, SH, ZM, SL, JEM, DCM, KRG), Ann Arbor, Michigan
| | - Dinesh Telang
- Department of Urology, Oakland University William Beaumont School of Medicine, Royal Oak, Michigan
- Department of Urology, University of Michigan (AL, SH, ZM, SL, JEM, DCM, KRG), Ann Arbor, Michigan
| | - Alice Liu
- Department of Urology, Oakland University William Beaumont School of Medicine, Royal Oak, Michigan
- Department of Urology, University of Michigan (AL, SH, ZM, SL, JEM, DCM, KRG), Ann Arbor, Michigan
| | - Scott Hawken
- Department of Urology, Oakland University William Beaumont School of Medicine, Royal Oak, Michigan
- Department of Urology, University of Michigan (AL, SH, ZM, SL, JEM, DCM, KRG), Ann Arbor, Michigan
| | - Zack Montgomery
- Department of Urology, Oakland University William Beaumont School of Medicine, Royal Oak, Michigan
- Department of Urology, University of Michigan (AL, SH, ZM, SL, JEM, DCM, KRG), Ann Arbor, Michigan
| | - Susan Linsell
- Department of Urology, Oakland University William Beaumont School of Medicine, Royal Oak, Michigan
- Department of Urology, University of Michigan (AL, SH, ZM, SL, JEM, DCM, KRG), Ann Arbor, Michigan
| | - James E. Montie
- Department of Urology, Oakland University William Beaumont School of Medicine, Royal Oak, Michigan
- Department of Urology, University of Michigan (AL, SH, ZM, SL, JEM, DCM, KRG), Ann Arbor, Michigan
| | - David C. Miller
- Department of Urology, Oakland University William Beaumont School of Medicine, Royal Oak, Michigan
- Department of Urology, University of Michigan (AL, SH, ZM, SL, JEM, DCM, KRG), Ann Arbor, Michigan
| | - Khurshid R. Ghani
- Department of Urology, Oakland University William Beaumont School of Medicine, Royal Oak, Michigan
- Department of Urology, University of Michigan (AL, SH, ZM, SL, JEM, DCM, KRG), Ann Arbor, Michigan
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Hu JC, Ghani KR, Telang D, Liu A, Hawken S, Montgomery Z, Linsell S, Montie JE, Miller DC, Burks FN. PD43-10 REPEAT PROSTATE BIOPSY PRACTICE PATTERNS IN A STATEWIDE QUALITY IMPROVEMENT COLLABORATIVE. J Urol 2017. [DOI: 10.1016/j.juro.2017.02.1915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Barnett CL, Tomlins SA, Underwood DJ, Wei JT, Morgan TM, Montie JE, Denton BT. Two-Stage Biomarker Protocols for Improving the Precision of Early Detection of Prostate Cancer. Med Decis Making 2017; 37:815-826. [DOI: 10.1177/0272989x17696996] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background. New cancer biomarkers are being discovered at a rapid pace; however, these tests vary in their predictive performance characteristics, and it is unclear how best to use them. Methods. We investigated 2-stage biomarker-based screening strategies in the context of prostate cancer using a partially observable Markov model to simulate patients’ progression through prostate cancer states to mortality from prostate cancer or other causes. Patients were screened every 2 years from ages 55 to 69. If the patient’s serum prostate-specific antigen (PSA) was over a specified threshold in the first stage, a second stage biomarker test was administered. We evaluated design characteristics for these 2-stage strategies using 7 newly discovered biomarkers as examples. Monte Carlo simulation was used to estimate the number of screening biopsies, prostate cancer deaths, and quality-adjusted life-years (QALYs) per 1000 men. Results. The all-cancer biomarkers significantly underperformed the high-grade cancer biomarkers in terms of QALYs. The screening strategy that used a PSA threshold of 2 ng/mL and a second biomarker test with high-grade sensitivity and specificity of 0.86 and 0.62, respectively, maximized QALYs. This strategy resulted in a prostate cancer death rate within 1% of using PSA alone with a threshold of 2 ng/mL, while reducing the number of biopsies by 20%. Sensitivity analysis suggests that the results are robust with respect to variation in model parameters. Conclusions. Two-stage biomarker screening strategies using new biomarkers with risk thresholds optimized for high-grade cancer detection may increase quality-adjusted survival and reduce unnecessary biopsies.
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Affiliation(s)
- Christine L. Barnett
- Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, MI (CLB, BTD)
- Department of Urology, University of Michigan, Ann Arbor, MI (SAT, JTW, TMM, JEM, BTD)
- Department of Pathology, University of Michigan, Ann Arbor, MI (SAT)
- Department of Industrial & Systems Engineering, North Carolina State University, Raleigh, NC (DJU)
| | - Scott A. Tomlins
- Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, MI (CLB, BTD)
- Department of Urology, University of Michigan, Ann Arbor, MI (SAT, JTW, TMM, JEM, BTD)
- Department of Pathology, University of Michigan, Ann Arbor, MI (SAT)
- Department of Industrial & Systems Engineering, North Carolina State University, Raleigh, NC (DJU)
| | - Daniel J. Underwood
- Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, MI (CLB, BTD)
- Department of Urology, University of Michigan, Ann Arbor, MI (SAT, JTW, TMM, JEM, BTD)
- Department of Pathology, University of Michigan, Ann Arbor, MI (SAT)
- Department of Industrial & Systems Engineering, North Carolina State University, Raleigh, NC (DJU)
| | - John T. Wei
- Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, MI (CLB, BTD)
- Department of Urology, University of Michigan, Ann Arbor, MI (SAT, JTW, TMM, JEM, BTD)
- Department of Pathology, University of Michigan, Ann Arbor, MI (SAT)
- Department of Industrial & Systems Engineering, North Carolina State University, Raleigh, NC (DJU)
| | - Todd M. Morgan
- Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, MI (CLB, BTD)
- Department of Urology, University of Michigan, Ann Arbor, MI (SAT, JTW, TMM, JEM, BTD)
- Department of Pathology, University of Michigan, Ann Arbor, MI (SAT)
- Department of Industrial & Systems Engineering, North Carolina State University, Raleigh, NC (DJU)
| | - James E. Montie
- Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, MI (CLB, BTD)
- Department of Urology, University of Michigan, Ann Arbor, MI (SAT, JTW, TMM, JEM, BTD)
- Department of Pathology, University of Michigan, Ann Arbor, MI (SAT)
- Department of Industrial & Systems Engineering, North Carolina State University, Raleigh, NC (DJU)
| | - Brian T. Denton
- Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, MI (CLB, BTD)
- Department of Urology, University of Michigan, Ann Arbor, MI (SAT, JTW, TMM, JEM, BTD)
- Department of Pathology, University of Michigan, Ann Arbor, MI (SAT)
- Department of Industrial & Systems Engineering, North Carolina State University, Raleigh, NC (DJU)
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Auffenberg G, Barnett C, Cheng Z, Yang F, Wang J, Miller DC, Montie JE, Mamawala M, Denton B. Can frequency of prostate biopsy on active surveillance be reduced without significantly increasing risk? J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.6_suppl.e546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e546 Background: The goal of this investigation is to use longitudinal Active Surveillance (AS) data to identify whether biopsies could be eliminated from a 10-year AS plan calling for annual biopsy without substantially prolonging the time to detection of prostate cancer (CaP) grade progression. Methods: With data from 1,500 men with very-low or low-risk CaP enrolled in AS at Johns Hopkins, we developed a hidden Markov model to estimate probabilities of progression to Gleason 7 or higher. We then simulated all potential AS biopsy strategies where it was assumed biopsy would be performed no more often than annually and either would or would not be performed each year after diagnosis. For every strategy the model was used to predict the average time from occurrence to the detection of grade progression. Potential alternatives to annual biopsy were identified. Results: The estimated 10 year probability of grade progression was 40.0% and the annual probability was 4.0%. Simulation of an annual biopsy strategy estimated that for men who experience grade progression the mean time from occurrence to detection would be 14.1 months. Alternative strategies that reduced the number of biopsies received over 10 years increased the time to detecting grade progression; however several strategies eliminated biopsies with only small increases in the time to detecting grade progression (Table). For instance, a strategy calling for 6 biopsies over 10 years (biopsies in years 1-3,5,7, and 8) would only increase the average time to detecting grade progression by 4.6 months while eliminating 4 biopsies. Conclusions: While annual biopsy was associated with the shortest interval to detecting grade progression, several alternative strategies may allow for less frequent biopsy without sizable increases in time to detecting grade progression. [Table: see text]
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Affiliation(s)
| | | | | | - Fan Yang
- University of Michigan, Ann Arbor, MI
| | | | | | - James E. Montie
- Department of Urology, University of Michigan, Ann Arbor, MI
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Hurley P, Dhir A, Gao Y, Drabik B, Lim K, Curry J, Womble PR, Linsell SM, Brachulis A, Sexton DW, Ghani KR, Denton BT, Miller DC, Montie JE. A Statewide Intervention Improves Appropriate Imaging in Localized Prostate Cancer. J Urol 2016; 197:1222-1228. [PMID: 27889418 DOI: 10.1016/j.juro.2016.11.098] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/28/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE We implemented a statewide intervention to improve imaging utilization for the staging of patients with newly diagnosed prostate cancer. MATERIALS AND METHODS MUSIC (Michigan Urological Surgery Improvement Collaborative) is a quality improvement collaborative comprising 42 diverse practices representing approximately 85% of the urologists in Michigan. MUSIC has developed imaging appropriateness criteria (prostate specific antigen greater than 20 ng/ml, Gleason score 7 or higher and clinical stage T3 or higher) which minimize unnecessary imaging with bone scan and computerized tomography. After baseline rates of radiographic staging were established in 2012 and 2013, we used multidimensional interventions to deploy these criteria in 2014. Imaging utilization was then remeasured in 2015 to evaluate for changes in practice patterns. RESULTS A total of 10,554 newly diagnosed patients with prostate cancer were entered into the MUSIC registry from January 1, 2012 through December 31, 2013 and January 1, 2015 through December 31, 2015. Of these patients 7,442 (79%) and 7,312 (78%) met our criteria to avoid bone scan and computerized tomography imaging, respectively. The use of bone scan imaging when not indicated decreased from 11.0% at baseline to 6.5% after interventions (p <0.0001). The use of computerized tomography when not indicated decreased from 14.7% at baseline to 7.7% after interventions (p <0.0001). Variability among practices decreased substantially after the interventions as well. The use of recommended imaging remained stable during these periods. CONCLUSIONS An intervention aimed at appropriate use of imaging was associated with decreased use of bone scans and computerized tomography among men at low risk for metastases.
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Crowley SA, Foley SM, Wittmann D, Jagielski CH, Dunn RL, Clark PM, Griggs JJ, Peterson C, Leonard M, An LC, Wei JT, Montie JE, Janz NK. Sexual Health Concerns Among Cancer Survivors: Testing a Novel Information-Need Measure Among Breast and Prostate Cancer Patients. J Cancer Educ 2016; 31:588-94. [PMID: 26076657 DOI: 10.1007/s13187-015-0865-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
While it is recognized that cancer treatment can contribute to problems in sexual function, much less is currently known about the specific sexual health concerns and information needs of cancer survivors. This study tested a new instrument to measure cancer survivors' sexual health concerns and needs for sexual information after cancer treatment. The Information on Sexual Health: Your Needs after Cancer (InSYNC), developed by a multidisciplinary team of experts, is a novel 12-item questionnaire to measure sexual health concerns and information needs of cancer survivors. We tested the measure with a sample of breast and prostate cancer survivors. A convenience sample of 114 cancer survivors (58 breast, 56 prostate) was enrolled. Results of the InSYNC questionnaire showed high levels of sexual concern among cancer survivors. Areas of concern differed by cancer type. Prostate cancer survivors were most concerned about being able to satisfy their partners (57 %) while breast cancer survivors were most concerned with changes in how their bodies worked sexually (46 %). Approximately 35 % of all cancer survivors wanted more information about sexual health. Sexual health concerns and unmet information needs are common among breast and prostate cancer survivors, varying in some aspects by type of cancer. Routine screening for sexual health concerns should be included in comprehensive cancer survivorship care to appropriately address health care needs. The InSYNC questionnaire is one tool that may help clinicians identify concerns facing their patients.
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Affiliation(s)
- Sheila A Crowley
- Comprehensive Cancer Center, University of Michigan, Ann Arbor, MI, USA
| | - Sallie M Foley
- School of Social Work, University of Michigan, Ann Arbor, MI, USA.
| | | | | | - Rodney L Dunn
- School of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Patricia M Clark
- Comprehensive Cancer Center, University of Michigan, Ann Arbor, MI, USA
| | - Jennifer J Griggs
- School of Medicine, University of Michigan, Ann Arbor, MI, USA
- School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | | | - Marcia Leonard
- Comprehensive Cancer Center, University of Michigan, Ann Arbor, MI, USA
| | - Lawrence C An
- School of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - John T Wei
- School of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - James E Montie
- School of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Nancy K Janz
- School of Public Health, University of Michigan, Ann Arbor, MI, USA
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Cher ML, Dhir A, Auffenberg GB, Linsell S, Gao Y, Rosenberg B, Jafri SM, Klotz L, Miller DC, Ghani KR, Bernstein SJ, Montie JE, Lane BR. Appropriateness Criteria for Active Surveillance of Prostate Cancer. J Urol 2016; 197:67-74. [PMID: 27422298 DOI: 10.1016/j.juro.2016.07.005] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/06/2016] [Indexed: 11/25/2022]
Abstract
PURPOSE The adoption of active surveillance varies widely across urological communities, which suggests a need for more consistency in the counseling of patients. To address this need we used the RAND/UCLA Appropriateness Method to develop appropriateness criteria and counseling statements for active surveillance. MATERIALS AND METHODS Panelists were recruited from MUSIC urology practices. Combinations of parameters thought to influence decision making were used to create and score 160 theoretical clinical scenarios for appropriateness of active surveillance. Recent rates of active surveillance among real patients across the state were assessed using the MUSIC registry. RESULTS Low volume Gleason 6 was deemed highly appropriate for active surveillance whereas high volume Gleason 6 and low volume Gleason 3+4 were deemed appropriate to uncertain. No scenario was deemed inappropriate or highly inappropriate. Prostate specific antigen density, race and life expectancy impacted scores for intermediate and high volume Gleason 6 and low volume Gleason 3+4. The greatest degree of score dispersion (disagreement) occurred in scenarios with long life expectancy, high volume Gleason 6 and low volume Gleason 3+4. Recent rates of active surveillance use among real patients ranged from 0% to 100% at the provider level for low or intermediate biopsy volume Gleason 6, demonstrating a clear opportunity for quality improvement. CONCLUSIONS By virtue of this work urologists have the opportunity to present specific recommendations from the panel to their individual patients. Community-wide efforts aimed at increasing rates of active surveillance and reducing practice and physician level variation in the choice of active surveillance vs treatment are warranted.
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Affiliation(s)
- Michael L Cher
- Department of Urology, Wayne State University, Detroit, Michigan.
| | - Apoorv Dhir
- Department of Urology, University of Michigan, Ann Arbor, Michigan
| | | | - Susan Linsell
- Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Yuqing Gao
- Department of Urology, University of Michigan, Ann Arbor, Michigan
| | | | | | - Laurence Klotz
- Division of Urology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - David C Miller
- Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Khurshid R Ghani
- Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Steven J Bernstein
- Department of Medicine, University of Michigan, Ann Arbor, Michigan; Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - James E Montie
- Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Brian R Lane
- Division of Urology, Spectrum Health, Grand Rapids, Michigan
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Ahmadi H, Montie JE, Weizer AZ, Morgan T, Montgomery JS, Lee CT. Patient Psoas Muscle Mass as a Predictor of Complications and Survival After Radical Cystectomy. Curr Urol Rep 2016; 16:79. [PMID: 26403157 DOI: 10.1007/s11934-015-0548-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
As a treatment for high-risk bladder cancer, radical cystectomy (RC) remains a highly morbid operation with complication rates of 40-60% and mortality rates as high as 9% in the first 90 days after surgery (Aziz et al., Eur Urol 66(1):156-163, 2014; Shabsigh et al., Eur Urol 55(1):164-174, 2009). Many patients suffer from a failure-to-thrive syndrome associated with anorexia, weight loss, dehydration, and immobility. In elderly patients, failure-to-thrive may result in loss of independence and a cascade of events that increases the risk of perioperative morbidity and mortality, ultimately resulting in impaired survival. Psoas muscle mass has been used to predict morbidity and mortality after major surgical procedures in vulnerable populations with substantial comorbidities. Increasingly, psoas muscle mass is also being used to predict outcomes after RC. If patients with a high risk of impaired survival are identified preoperatively, prehabilitative interventions can be integrated into their preparation for surgical treatment (Porserud et al., Clin Rehab 28(5):451-459, 2014; Friedman et al., Nutr Clin Pract: Off Publ Am Soc Parenter Enter Nutr 30(2):175-179, 2015). This chapter discusses the role of psoas muscle mass as a predictor of negative surgical outcomes after cystectomy.
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Affiliation(s)
- Hamed Ahmadi
- Oregon Health and Science University, Portland, OR, USA.
| | - James E Montie
- University of Michigan, 7303 CCGC, 1500 E. Medical Center Dr, Ann Arbor, MI, 48109-5946, USA.
| | - Alon Z Weizer
- University of Michigan, 7303 CCGC, 1500 E. Medical Center Dr, Ann Arbor, MI, 48109-5946, USA.
| | - Todd Morgan
- University of Michigan, 7303 CCGC, 1500 E. Medical Center Dr, Ann Arbor, MI, 48109-5946, USA.
| | - Jeffrey S Montgomery
- University of Michigan, 7303 CCGC, 1500 E. Medical Center Dr, Ann Arbor, MI, 48109-5946, USA.
| | - Cheryl T Lee
- University of Michigan, 7303 CCGC, 1500 E. Medical Center Dr, Ann Arbor, MI, 48109-5946, USA.
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Morgan TM, Hawken SR, Ghani KR, Miller DC, Feng FY, Linsell SM, Salisz JA, Gao Y, Montie JE, Cher ML. Variation in the use of postoperative radiotherapy among high-risk patients following radical prostatectomy. Prostate Cancer Prostatic Dis 2016; 19:216-21. [PMID: 26951715 DOI: 10.1038/pcan.2016.9] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 12/29/2015] [Accepted: 01/26/2015] [Indexed: 11/09/2022]
Abstract
BACKGROUND We used data from the Michigan Urological Surgery Improvement Collaborative (MUSIC) to investigate the use of adjuvant and salvage radiotherapy (ART, SRT) among patients with high-risk pathology following radical prostatectomy (RP). METHODS For patients with pT3a disease or higher and/or positive surgical margins, we examined post-RP radiotherapy administration across MUSIC practices. We excluded patients with <6 months follow-up, and those that failed to achieve a postoperative PSA nadir ⩽0.1. ART was defined as radiation administered within 1 year post RP, with all post-nadir PSA levels <0.1 ng ml(-1). Radiation administered >1 year post RP and/or after a post-nadir PSA ⩾0.1 ng ml(-1) was defined as SRT. We used claims data to externally validate radiation administration. RESULTS Among 2337 patients undergoing RP, 668 (28.6%) were at high risk of recurrence. Of these, 52 (7.8%) received ART and 56 (8.4%) underwent SRT. Patients receiving ART were younger (P=0.027), more likely to have a greater surgical Gleason sum (P=0.009), higher pathologic stage (P<0.001) and received treatment at the smallest and largest size practices (P=0.011). Utilization of both ART and SRT varied widely across MUSIC practices (P<0.001 and P=0.046, respectively), but practice-level rates of ART and SRT administration were positively correlated (P=0.003) with lower ART practices also utilizing SRT less frequently. Of the 88 patients not receiving ART and experiencing a PSA recurrence ⩾0.2 ng ml(-1), 38 (43.2%) progressed to a PSA ⩾0.5 ng ml(-1) and 20 (22.7%) to a PSA ⩾1.0 ng ml(-1) without receiving prior SRT. There was excellent concordance between registry and claims data κ=0.98 (95% CI: 0.94-1.0). CONCLUSIONS Utilization of ART and SRT is infrequent and variable across urology practices in Michigan. Although early SRT is an alternative to ART, it is not consistently utilized in the setting of post-RP biochemical recurrence. Quality improvement initiatives focused on current postoperative radiotherapy administration guidelines may yield significant gains for this high-risk population.
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Affiliation(s)
- T M Morgan
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - S R Hawken
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - K R Ghani
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - D C Miller
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - F Y Feng
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - S M Linsell
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | | | - Y Gao
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - J E Montie
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - M L Cher
- Department of Urology, Wayne State University, Detroit, MI, USA
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Affiliation(s)
- James E Montie
- Department of Urology, University of Michigan, Ann Arbor, Michigan
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Myers SN, Ghani KR, Dunn RL, Lane BR, Schervish EW, Gao Y, Linsell SM, Miller DC, Montie JE, Dupree JM. Notable Outcomes and Trackable Events after Surgery: Evaluating an Uncomplicated Recovery after Radical Prostatectomy. J Urol 2016; 196:399-404. [PMID: 26916722 DOI: 10.1016/j.juro.2016.02.083] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/11/2016] [Indexed: 11/16/2022]
Abstract
PURPOSE A priority of MUSIC (Michigan Urological Surgery Improvement Collaborative) is to improve patient outcomes after radical prostatectomy. As part of these efforts we developed a novel system that uses unambiguous events to define an uncomplicated 30-day postoperative recovery and compares these outcomes across diverse urology practices. MATERIALS AND METHODS MUSIC used a consensus approach to develop an uncomplicated recovery pathway comprising a set of precise perioperative events that are reliably measured and collectively reflect resource utilization, technical complications and coordination of care. Events that occurred outside the uncomplicated recovery pathway were considered deviations, including rectal injury, high blood loss, extended length of stay, prolonged drain or catheter placement, catheter replacement, hospital readmission or mortality. For men undergoing radical prostatectomy trained abstractors prospectively recorded clinical and perioperative data in an electronic registry. When a deviation from the NOTES (Notable Outcomes and Trackable Events after Surgery) pathway occurred, precipitating events were described by abstractors and we analyzed the events. RESULTS From April 2014 through July 2015 a total of 2,245 radical prostatectomies were performed by 100 surgeons in a total of 37 diverse participating MUSIC practices. In the 29 practices in which 10 or more radical prostatectomies were performed during the interval analyzed the risk adjusted deviation rate ranged from 0.0% to 46.1% (p <0.0001). Anastomotic and gastrointestinal events were contributing factors in 50.2% of deviated cases. CONCLUSIONS The novel NOTES system provides comparative data on unambiguous and actionable short-term outcomes after radical prostatectomy. The observed variation in outcomes across practices suggests opportunities for quality improvement initiatives. Decreasing anastomotic and gastrointestinal events represents a high impact opportunity for initial quality improvement efforts.
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Affiliation(s)
- Stacie N Myers
- Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Khurshid R Ghani
- Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Rodney L Dunn
- Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Brian R Lane
- Spectrum Health Medical Group, Grand Rapids, Michigan
| | | | - Yuqing Gao
- Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Susan M Linsell
- Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - David C Miller
- Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - James E Montie
- Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - James M Dupree
- Department of Urology, University of Michigan, Ann Arbor, Michigan.
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Hawken SR, Womble PR, Herrel LA, Ye Z, Linsell SM, Hurley PM, Montie JE, Miller DC. Understanding the Performance of Active Surveillance Selection Criteria in Diverse Urology Practices. J Urol 2015; 194:1253-7. [DOI: 10.1016/j.juro.2015.05.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2015] [Indexed: 10/23/2022]
Affiliation(s)
- Scott R. Hawken
- Department of Urology, University of Michigan, Ann Arbor and Providence Hospital (PMH), Southfield, Michigan
| | - Paul R. Womble
- Department of Urology, University of Michigan, Ann Arbor and Providence Hospital (PMH), Southfield, Michigan
| | - Lindsey A. Herrel
- Department of Urology, University of Michigan, Ann Arbor and Providence Hospital (PMH), Southfield, Michigan
| | - Zaojun Ye
- Department of Urology, University of Michigan, Ann Arbor and Providence Hospital (PMH), Southfield, Michigan
| | - Susan M. Linsell
- Department of Urology, University of Michigan, Ann Arbor and Providence Hospital (PMH), Southfield, Michigan
| | - Patrick M. Hurley
- Department of Urology, University of Michigan, Ann Arbor and Providence Hospital (PMH), Southfield, Michigan
| | - James E. Montie
- Department of Urology, University of Michigan, Ann Arbor and Providence Hospital (PMH), Southfield, Michigan
| | - David C. Miller
- Department of Urology, University of Michigan, Ann Arbor and Providence Hospital (PMH), Southfield, Michigan
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Myers SN, Dupree JM, Dunn RL, Gao Y, Linsell SM, Lane BR, Ghani KR, Miller DC, Montie JE. Gastrointestinal and Urinary Events: Key Deviation Drivers from an Uncomplicated Radical Prostatectomy Recovery Pathway. J Am Coll Surg 2015. [DOI: 10.1016/j.jamcollsurg.2015.07.295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Wibowo E, Schellhammer PF, Montie JE, Lange PH, Goldenberg SL, Wassersug RJ. ‘Should I get a PSA test?’ - the question is not that simple. Trends Urology & Men Health 2015. [DOI: 10.1002/tre.484] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Erik Wibowo
- Vancouver Prostate Centre; Vancouver Coastal Health Research Institute; Vancouver Canada
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Liu J, Womble PR, Merdan S, Miller DC, Montie JE, Denton BT. Factors Influencing Selection of Active Surveillance for Localized Prostate Cancer. Urology 2015; 86:901-5. [PMID: 26358397 DOI: 10.1016/j.urology.2015.08.024] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2015] [Revised: 08/17/2015] [Accepted: 08/28/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To determine how well demographic and clinical factors predict the initiation of Active Surveillance (AS). METHODS AS has been suggested as a way to reduce overtreatment of men who have prostate cancer; however, factors associated with the decision to choose AS are poorly quantified. Using the Michigan Urological Surgery Improvement Collaborative registry, we identified 2977 men with prostate cancer who made treatment decisions from January 1, 2012, through December 31, 2013. We used chi-square and Wilcoxon tests to examine the association between factors and initiation of AS. Logistic regression models were fit for D'Amico risk categories. Measures of model discrimination and calibration were estimated, including area under the curve (AUC) and Brier score (BS). RESULTS Patient age, Gleason score, clinical T-stage, urology practice, and tumor volume (greatest percent of a core involved with cancer and proportion of positive cores) were associated with the decision to choose AS in the intermediate-risk cohort (AUC = 0.875, BS = 0.07) and the complete cohort (AUC = 0.89, BS = 0.10). Patient age, urology practice, and tumor volume were significant in the low-risk cohort (AUC = 0.71, BS = 0.22). The addition of urology practice increased AUC in the low-risk cohort from 0.71 to 0.76 and reduced BS from 0.22 to 0.21. CONCLUSION The urology practice at which a patient is seen is an important predictor for whether patients will initiate AS. Predictions were least accurate for low-risk patients, suggesting that factors such as patient preference play a role in treatment decisions.
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Affiliation(s)
- Jianyu Liu
- Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, MI
| | - Paul R Womble
- Department of Urology, University of Michigan, Ann Arbor, MI
| | - Selin Merdan
- Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, MI
| | - David C Miller
- Department of Urology, University of Michigan, Ann Arbor, MI
| | - James E Montie
- Department of Urology, University of Michigan, Ann Arbor, MI
| | - Brian T Denton
- Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, MI; Department of Urology, University of Michigan, Ann Arbor, MI.
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Affiliation(s)
- James E Montie
- Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan
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48
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Singla N, Montie JE, Lee CT, Wolf JS, Faerber GJ. Experience with 45 Consecutive Patients with Neobladders Undergoing Retrograde Ureteroscopy for Upper Tract Abnormalities. Urol Pract 2015; 2:244-249. [PMID: 31930163 DOI: 10.1016/j.urpr.2014.12.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Introduction In this study we reviewed the feasibility, technique, complications and outcomes of retrograde ureteroscopy in patients with orthotopic neobladders. Methods We retrospectively reviewed our retrograde ureteroscopic experience in patients with orthotopic ileal neobladder diversions. Data were collected and analyzed regarding patient characteristics, indications, technique, success and complications of the procedure. Results Between 1995 and 2013, 45 patients with neobladders underwent 77 retrograde ureteroscopy sessions on 97 renal units for filling defects (47 cases), urothelial thickening (9), calculi (4), positive cytology (27) and/or positive fluorescence in situ hybridization (15) on followup. The ureter and renal pelvis were successfully instrumented in 78 of 97 units (80.4%), with 85.3% success in Hautmann-type neobladders (75 renal units attempted), 50% in Studer-type neobladders (8 renal units attempted) and 71.4% in unascertained-type neobladders (14 renal units attempted). Causes of failure involved the inability to locate the ureteral orifice (8 cases), to cannulate the orifice (6 cases) or to advance the ureteroscope due to tortuosity (5 cases). Among the successful attempts with appropriately documented findings 35.9% of cases with filling defects (39) were confirmed malignant and 61.5% were confirmed benign by ureteroscopy. All cases with a positive cytology (23) and 85.7% of cases with positive fluorescence in situ hybridization (14) were confirmed malignant by retrograde ureteroscopy, and 2 of the 4 cases of calculi were successfully managed retrogradely. Conclusions Retrograde ureteroscopic evaluation of upper tract abnormalities is feasible and practical in patients with orthotopic neobladders. Identification and cannulation of the ureteral orifice are challenging, particularly in tortuous situations, but difficulties can be overcome with fluoroscopic techniques. Retrograde ureteroscopy avoids the morbidity of percutaneous access with minimal complications.
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Affiliation(s)
- Nirmish Singla
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas (NS), and Department of Urology, University of Michigan, Ann Arbor, Michigan (JEM, CTL, JSW, GJF)
| | - James E Montie
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas (NS), and Department of Urology, University of Michigan, Ann Arbor, Michigan (JEM, CTL, JSW, GJF)
| | - Cheryl T Lee
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas (NS), and Department of Urology, University of Michigan, Ann Arbor, Michigan (JEM, CTL, JSW, GJF)
| | - J Stuart Wolf
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas (NS), and Department of Urology, University of Michigan, Ann Arbor, Michigan (JEM, CTL, JSW, GJF)
| | - Gary J Faerber
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas (NS), and Department of Urology, University of Michigan, Ann Arbor, Michigan (JEM, CTL, JSW, GJF)
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Merdan S, Tomlins SA, Barnett CL, Morgan TM, Montie JE, Wei JT, Denton BT. Assessment of long-term outcomes associated with urinary prostate cancer antigen 3 and TMPRSS2:ERG gene fusion at repeat biopsy. Cancer 2015; 121:4071-9. [PMID: 26280815 DOI: 10.1002/cncr.29611] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 07/01/2015] [Accepted: 07/06/2015] [Indexed: 11/09/2022]
Abstract
BACKGROUND In men with clinically localized prostate cancer who have undergone at least 1 previous negative biopsy and have elevated serum prostate-specific antigen (PSA) levels, long-term health outcomes associated with the assessment of urinary prostate cancer antigen 3 (PCA3) and the transmembrane protease, serine 2 (TMPRSS2):v-ets erythroblastosis virus E26 oncogene homolog (avian) (ERG) gene fusion (T2:ERG) have not been investigated previously in relation to the decision to recommend a repeat biopsy. METHODS The authors performed a decision analysis using a decision tree for men with elevated PSA levels. The probability of cancer was estimated using the Prostate Cancer Prevention Trial Risk Calculator (version 2.0). The use of PSA alone was compared with the use of PCA3 and T2:ERG scores, with each evaluated independently, in combination with PSA to trigger a repeat biopsy. When PCA3 and T2:ERG score evaluations were used, predefined thresholds were established to determine whether the patient should undergo a repeat biopsy. Biopsy outcomes were defined as either positive (with a Gleason score of <7, 7, or >7) or negative. Probabilities and estimates of 10-year overall survival and 15-year cancer-specific survival were derived from previous studies and a literature review. Outcomes were defined as age-dependent and Gleason score-dependent 10-year overall and 15-year cancer-specific survival rates and the percentage of biopsies avoided. RESULTS Incorporating the PCA3 score (biopsy threshold, 25; generated based on the urine PCA3 level normalized to the amount of PSA messenger RNA) or the T2:ERG score (biopsy threshold, 10; based on the urine T2:ERG level normalized to the amount of PSA messenger RNA) into the decision to recommend repeat biopsy would have avoided 55.4% or 64.7% of repeat biopsies for the base-case patient, respectively, and changes in the 10-year survival rate were only 0.93% or 1.41%, respectively. Multi-way sensitivity analyses suggested that these results were robust with respect to the model parameters. CONCLUSIONS The use of PCA3 or T2:ERG testing for repeat biopsy decisions can substantially reduce the number of biopsies without significantly affecting 10-year survival.
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Affiliation(s)
- Selin Merdan
- Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, Michigan
| | - Scott A Tomlins
- Michigan Center for Translational Pathology, Department of Pathology, University of Michigan Medical School, Ann Arbor, Michigan.,Department of Urology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Christine L Barnett
- Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, Michigan
| | - Todd M Morgan
- Department of Urology, University of Michigan Medical School, Ann Arbor, Michigan
| | - James E Montie
- Department of Urology, University of Michigan Medical School, Ann Arbor, Michigan
| | - John T Wei
- Department of Urology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Brian T Denton
- Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, Michigan.,Department of Urology, University of Michigan Medical School, Ann Arbor, Michigan
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Zhang Y, Lee SYD, Gilleskie DB, Sun Y, Padakandla A, Jacobs BL, Montgomery JS, Montie JE, Wei JT, Hollenbeck BK. A Generalized Assessment of the Impact of Regionalization and Provider Learning on Patient Outcomes. Med Decis Making 2015; 36:990-8. [PMID: 26169752 DOI: 10.1177/0272989x15593282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Accepted: 05/30/2015] [Indexed: 11/16/2022]
Abstract
We present a generalized model to assess the impact of regionalization on patient care outcomes in the presence of heterogeneity in provider learning. The model characterizes best regionalization policies as optimal allocations of patients across providers with heterogeneous learning abilities. We explore issues that arise when solving for best regionalization, which depends on statistically estimated provider learning curves. We explain how to maintain the problem's tractability and reformulate it into a binary integer program problem to improve solvability. Using our model, best regionalization solutions can be computed within reasonable time using current-day computers. We apply the model to minimally invasive radical prostatectomy and estimate that, in comparison to current care delivery, within-state regionalization can shorten length of stay by at least 40.8%.
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Affiliation(s)
- Yun Zhang
- University of Michigan Health System, Ann Arbor, MI (YZ)
| | - Shoou-Yih D Lee
- University of Michigan School of Public Health, Ann Arbor, MI (S-YDL)
| | - Donna B Gilleskie
- University of Michigan Health System, Ann Arbor, MI (YZ),University of North Carolina at Chapel Hill, Chapel Hill, NC (DBG)
| | | | - Arun Padakandla
- University of Michigan, Ann Arbor, MI (AP, JSM, JEM, JTW, BKH)
| | | | | | - James E Montie
- University of Michigan, Ann Arbor, MI (AP, JSM, JEM, JTW, BKH)
| | - John T Wei
- University of Michigan Health System, Ann Arbor, MI (YZ),University of Michigan, Ann Arbor, MI (AP, JSM, JEM, JTW, BKH)
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