JOURNAL BRIEFS Urology Practice: Primary Care Physicians: an Untapped Resource for Improving Active Surveillance
By: Archana Radhakrishnan, MD, MHS; Lauren P. Wallner, PhD, MPH; Ted A. Skolarus, MD, MPH, FACS; Vahakn B. Shahinian, MD; Paul H. Abrahamse, MA; Michael D. Fetters, MD, MPH, MA; Sarah T. Hawley, PhD, MPH | Posted on: 01 Nov 2021
Radhakrishnan A, Wallner LP, Skolarus TA et al: Primary care physician perspectives on low risk prostate cancer management: results of a national survey. Urol Pract 2021; 8: 515.
The number of men with favorable-risk prostate cancer on active surveillance is rapidly growing. Ensuring that these men receive high-quality active surveillance care—including guideline recommended testing and maximizing adherence—presents challenges for urologists who traditionally manage these patients. For example, in a cohort of men with favorable-risk prostate cancer in Michigan, only 31% of men received guideline-concordant surveillance testing.1 Other studies have shown that up to a third of men leave active surveillance to get definitive treatment without evidence of their cancer progressing.2,3
Primary care providers (PCPs) could work with urologists to deliver high-quality active surveillance care (shared-care model). After all, active surveillance management is similar to other chronic diseases and, increasingly, national organizations are calling for including PCPs in cancer care to meet the needs of a growing cancer population.4 But PCP perspectives on active surveillance as a management strategy and their beliefs about their potential roles, both critically important to understand prior to implementing a shared-care model for low-risk prostate cancer and active surveillance, is not known. We conducted a national survey of PCPs to answer these questions.5
We found that half of PCPs (49.5%) supported active surveillance for all men, with over two-thirds (69.4%) doing so for older men (>70 years). While many PCPs (81.0%) agreed that active surveillance allows men to avoid the side effects of surgery or radiation, over half (57.4%) were also concerned that active surveillance causes worry for their patient and nearly a third (31.5%) were concerned that it could miss a lethal cancer. We also found that support for active surveillance was linked to beliefs about the consequences about being on active surveillance. For example, PCPs who supported active surveillance for all men with low-risk prostate cancer were less likely to be concerned that active surveillance causes worry or that it could miss a lethal cancer. These beliefs are important to acknowledge as PCPs may be more likely to support active surveillance as a management strategy (and then promote patient adherence to it) if they themselves believe in it. This also matters given how important provider recommendations are for cancer treatment decision making and patients increasingly involving their PCPs in them.6,7 While advances in low-risk prostate cancer management, such as the use of confirmatory testing to ensure appropriateness of active surveillance and robust active surveillance protocols to monitor for progression, are helpful in addressing these concerns, it will be important to appropriately broadcast these to the PCP community to build further confidence in this approach.
About half of PCPs believed they had the skills necessary to monitor for progression (57.2%) and provide cancer-related care (50.0%), and are better able than cancer specialists to provide psychosocial support (51.5%). Nearly two-thirds of PCPs also preferred a shared-care model to evaluate for adverse psychological effects (66.0%) and order prostate specific antigen tests (60.1%; see figure). Not surprisingly, PCP preferences for their role in low-risk prostate cancer management varied by their beliefs in their skills. For example, PCPs who agreed that they have the skills necessary to provide cancer-related care were more likely to prefer a PCP-led or shared-care model for ordering prostate specific antigen tests and a PCP-led model to evaluate for adverse psychological effects. The potential for PCP involvement in low-risk prostate cancer management is important to recognize. PCPs often have longitudinal and trusting relationships with their patients, and leveraging primary care visits presents a promising opportunity to improve active surveillance care. For men who transition off active surveillance to receive surgery or radiation without evidence of their cancer progressing, it is plausible that ongoing or unmanaged worry contributes to this decision.8 PCPs may be especially well-positioned to work with urologists in providing this aspect of care. It is important, though, to recognize that there were a considerable number of PCPs who did not believe they had the skills to deliver active surveillance care. So while national organizations have called for increased PCP involvement, it is imperative we ensure that PCPs not only have the skills and knowledge necessary but also have the support to actively engage in delivering low-risk prostate cancer care.9 Broadly, strategies to achieve this could include PCP-specific guidelines or recommendations for how to manage low-risk prostate cancer care (including active surveillance) while more practical approaches would be for urologists to provide clear communication through treatment plans or office documentation regarding prostate specific antigen testing frequency and triggers for referral, and assign responsibility for each component of active surveillance care as part of a shared-care approach.
The growing number of men on active surveillance and pending urologist workforce shortages has generated interest in shared-care for low-risk prostate cancer management.10 We found that PCPs supported active surveillance for men with low-risk prostate cancer and saw themselves being able to participate in the care delivery. Engaging PCPs in this context holds promise for improving the delivery of high-quality active surveillance care while maintaining and expanding patient-centered care within primary care practice.
- Luckenbaugh AN, Auffenberg GB, Hawken SR, et al: Variation in guideline concordant active surveillance followup in diverse urology practices. J Urol 2017; 197: 621.
- Loeb S, Folkvaljon Y, Makarov DV et al: Five-year nationwide follow-up study of active surveillance for prostate cancer. Eur Urol 2015; 67: 233.
- Newcomb LF, Thompson IM Jr, Boyer HD et al: Outcomes of active surveillance for clinically localized prostate cancer in the prospective, multi-institutional Canary PASS cohort. J Urol 2016; 195: 313.
- Institute of Medicine, National Research Council: From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: The National Academies Press 2006.
- Radhakrishnan A, Wallner LP, Skolarus TA et al: Primary care physician perspectives on low risk prostate cancer management: results of a national survey. Urol Pract 2021; 8: 515.
- Radhakrishnan A, Grande D, Ross M et al: When primary care providers (PCPs) help patients choose prostate cancer treatment. J Am Board Fam Me 2017; 30: 298.
- Scherr KA, Fagerlin A, Hofer T et al: Physician recommendations trump patient preferences in prostate cancer treatment decisions. Med Decis Making 2017; 37: 56.
- Lang MF, Tyson M, Alvarez JR et al: The influence of psychosocial constructs on the adherence to active surveillance for localized prostate cancer in a prospective, population-based cohort. Urology 2017; 103: 173.
- Kosty MP, Hanley A, Chollette V et al: National Cancer Institute–American Society of Clinical Oncology Teams in Cancer Care Project. J Oncol Pract 2016; 12: 955.
- American Urological Association: The State of the Urological Workforce and Practice in the United States. Linthicum, Maryland 2018.