At the American Urological Association (AUA) meeting in New Orleans in May, there was seemingly a "light at the end of the tunnel" moment.
Matthew Cooperberg, MD, MPH, a leading advocate for active surveillance (AS) from the University of California San Francisco, announced that the AUA's own data from its AQUA registry showed that, for the first time, the majority of patients with low-risk prostate cancer (just under 60%) opted for AS rather than a rush into the OR or the radiotherapy suite. AS had finally broken out of academic practices and become mainstream.
Victory in our time? Not yet. Not really. A not insignificant 40% of U.S. candidates for AS still opt for radiation or surgery.
The AUA's committee called for greater adoption of AS, with a goal of 80% within some vague timeframe.
Then, someone at the meeting spoke up, a voice from Michigan, which turns out to be a hotbed for urological reform, especially for AS for low-risk prostate cancer. Kevin Ginsburg, MD, a urologic oncologist from Wayne State University in Detroit, stepped up to the mic and said 80% simply was not good enough as a goal and called for a more aggressive migration to AS.
Ginsburg is one of the leaders in (Michigan Urological Surgery Improvement Collaborative), an innovative physician-led quality founded in 2012, comprising a consortium of 46 urology practices in the state of Michigan and supported through Blue Cross Blue Shield of Michigan.
He told the assembly: "I'm Kevin Ginsburg and I work with MUSIC. At MUSIC we've been able to get our rates even higher, up to above 90% in 2021. Why shoot for 80%? In my mind, the only reason to treat someone upfront with Grade Group 1 (GG1) prostate cancer is that they will be harmed and develop metastasis or death from prostate cancer by delaying treatment of their disease with AS. I'm not sure 20% of men with GG1 disease fall into that category."
Of course, that isn't the case with this lazy kind of cancer.
Ginsburg said one of MUSIC's first goals was to step up AS throughout the Mitten State, including academic practices but also large private practices and small practices. Virtually all practices in Michigan are part of MUSIC's efforts to combine and share data to drive improvements in patient care and reductions in cost.
"This isn't just the academic ships, such as Wayne State and the University of Michigan, saying, 'Hey, let's use active surveillance.' This is everyone buying in and saying we can absolutely use more active surveillance for men with low-risk prostate cancer," Ginsburg said.
Michigan has become the in America, largely due to the efforts of MUSIC. MUSIC helps physicians monitor their own practices and encourages the adoption of AS. Through concerted quality improvement efforts, the state has achieved a rate of more than 90% of low-risk patients going on AS, rivaling AS rates in Sweden.
According to the American Cancer Society, more than will be diagnosed with prostate cancer in 2022. Of these men, 35% (approximately 94,000) will have low-risk or very-low-risk Gleason scores. Among these low- or very-low-risk men, approximately 60% (56,400) will opt for AS in the U.S.
As an advocate for AS, this is MUSIC to my ears. There will never be 100% uptake of AS, Cooperberg and Ginsburg noted. AS isn't for everybody because of anxiety and other factors, but MUSIC shows there is the possibility of a much higher AS acceptance rate.
MUSIC is showing the way with that should be adopted throughout the U.S. It's more than voluntary monitoring to improve rates through medical peer support. MUSIC has studied what could be changed in practice to improve outcomes in multiple areas of prostate cancer care. MUSIC's collaborative model also produces a report card for each practitioner and overall.
"Everyone knows their own and the data of MUSIC as a whole, but they don't know everyone else's individual data. Otherwise, it's too easy to speak in generalities and think you are doing the right thing (like using a lot of AS) without knowing if you are doing the right thing. Knowing your data is the first step in improvement," Ginsburg said.
"One of the founding principles of MUSIC was that as a group we would be 'collegial and non-competitive.' Although it sounds cliche, we have a strong mentality of 'a rising tide lifts all boats.' I wouldn't say we have had to use peer pressure, as urologists in MUSIC are there voluntarily. MUSIC is a coalition of the willing. Urologists participate in MUSIC because they want to deliver the best possible care to their patients," he continued.
In addition to report cards, MUSIC convenes three times per year to discuss quality improvement topics pertaining to prostate cancer care, kidney cancer care, and kidney stone care.
This brings us to "the swish" -- a biopsy disinfectant technique.
Ginsburg said MUSIC examined ways of improving the 1% rate for sepsis in biopsies that lead to hospitalization.
"We got together and asked what are some things we could do to make it safer? We actually found lower rates of sepsis in urologists that swish the biopsy needle directly in formalin -- it decontaminates the needle -- and then they swish in some saline or water and then take the next biopsy. We found that those people had the lowest incidence of infection," he explained.
The docs with higher sepsis rates among patients just rubbed needles on gauze, which would be used to transfer the tissue to the container sent to the pathologist. MUSIC published in BJU International. After adjusting for confounders, the study findings weren't statistically significant.
"It was one of these variation things in medicine. Do you tie your shoe starting with your left foot or your right foot? It's something no one ever thought about. We thought it was inconsequential. But really, you're able to take a deep dive into this and determine that this is one of the techniques that we found to help reduce the incidence of infection after prostate biopsy," he said.
"Although the swishing study didn't meet statistical significance, I still find it valuable. To me, decreasing infectious hospitalizations by 0.3% or 0.5% with a simple maneuver, even if that change is not statistically significant, I still find it clinically significant," he added.
Ginsburg said the success with swishing led to other priorities within MUSIC, such as . According to MUSIC data that have not yet been published, the rate of hospitalizations for infections is 0.6% following transrectal ultrasound (TRUS) and 0.3% following TP.
"I am a swisher. I mostly do TP biopsy now but when I do TRUS, I swish," Ginsburg noted.
MUSIC currently is exploring more appropriate use of imaging, improving the quality of MRI, fusion imaging, and also several factors to improve prostatectomies.
What's missing?
In my view, MUSIC and other researchers need to look at the psychology of AS, how anxiety and depression impact the decision-making process, what can be done to improve those uptake rates, and how to keep more patients on AS longer. MUSIC needs to generate data on race and ethnicity, especially within the Black population, which is hard hit by prostate cancer but is too often steered away from AS.
Could the MUSIC model spread throughout the U.S. to try to improve the quality of life in patients with low-risk cancers and prevent the damage of overtreatment of prostate cancer and even to switch to safer TP procedures?
"We are currently, and very selectively, investigating how we could expand the MUSIC model outside of Michigan," said Ginsburg.
Howard Wolinsky is a Chicago-based medical writer. He has written the blog, "A Patient's Journey," for 鶹ý since 2016. He is the editor of the Substack newsletter, .