VA & Low-Risk PCa Treatment.

[pjoshea13]

New paper in JAMA raised my hackles somewhat. [1]

What is low-risk PCa? It's cancer that doesn't progress to high-risk by the time of a subsequent active surveillance [AS] biopsy.

With 25-30% low-risk Gleason score 3+3 cases ultimately progressing, it's no wonder that there is some resistance to AS, as currently practiced.

Seems that the VA has found a solution: "the US Department of Veterans Affairs (VA), an integrated health care system providing equal access for patients without financial incentives for physicians to provide high-volume care."

Some oncologists suggest that urologists recommend surgery because of the profit motive. Oncologists don't have a profit motive? These days, many have a stake in the companies that perform radiation.

Fixed salaries often come with tight budgets & a financial disincentive for preemptive treatment.

No doubt the U.S. Preventive Services Task Force [USPSTF] applauds the success of the VA.

-Patrick

[1] jamanetwork.com/journals/ja...

May 15, 2018

Use of Conservative Management for Low-Risk Prostate Cancer in the Veterans Affairs Integrated Health Care System From 2005-2015

Stacy Loeb, MD, MSc1; Nataliya Byrne, BA2; Danil V. Makarov, MD, MHS1; et al Herbert Lepor, MD2; Dawn Walter, MPH3

Author Affiliations Article Information

1Manhattan Veterans Affairs Medical Center, New York, New York

2Department of Urology, New York University, New York

3Department of Population Health, New York University, New York

JAMA. Published online May 15, 2018. doi:10.1001/jama.2018.5616

Low-risk prostate cancer has a favorable prognosis without treatment. Current guidelines recommend conservative management or deferring upfront treatment as the preferred approach,1 but previous studies reported underutilization in the United States2,3 compared with other countries.4 Qualitative data suggest that financial incentives and medicolegal concerns are barriers to uptake by US physicians.5 We examined utilization of conservative management in the US Department of Veterans Affairs (VA), an integrated health care system providing equal access for patients without financial incentives for physicians to provide high-volume care.

Methods

The study was approved by the VA New York Harbor institutional review board with a waiver of informed consent. Using VA’s Central Data Warehouse, we examined treatment patterns for veterans diagnosed with low-risk prostate cancer (prostate-specific antigen [PSA] <10 ng/mL, Gleason ≤6, and stage cT1/T2a) from January 2005 through November 2015. Our dependent variable was receipt of curative therapy within 1 year of diagnosis (including androgen deprivation monotherapy), determined by administrative codes. Linkage to Medicare was performed to identify tests or treatment performed outside the VA for men 65 years or older. Men with PSA less than 1 ng/mL during follow-up were also classified as likely having received curative treatment outside the VA. Untreated veterans were classified as receiving conservative management, subdivided into active surveillance (≥2 PSAs and 1 biopsy within 2 years after diagnosis) or watchful waiting. The final date of follow-up was November 16, 2017.

We explored use of conservative management over time, stratified by age. The Cochran-Armitage test was used to examine trends over time, and logistic regression was used to identify the association between year of diagnosis and conservative management, adjusting for age, race, marital status, PSA, comorbidity, and region. Men without a PSA, biopsy, or treatment recorded within 2 years were excluded. Analysis was performed using SAS Enterprise Guide (SAS Institute), version 7.1, and tests were 2-sided at an α of .05.

Results

Among 125 083 veterans with low-risk prostate cancer, mean age was 64 years (SD, 7) and mean PSA was 5.4 ng/mL (SD, 2.1). Of the 65 142 (52%) who were treated, 65% were identified through VA claims, 25% by PSA less than 1 ng/mL, and 10% through Medicare claims. Of 59 941 veterans (48%) who received conservative management, 37 717 (30%) received watchful waiting and 22 224 (18%) received active surveillance. Utilization of conservative management increased among men younger than 65 years (27% in 2005 to 72% in 2015) and 65 years or older (35% in 2005 to 79% in 2015); both P for trend <.001 (Figure). The increase was primarily due to greater use of active surveillance (4% in 2005 to 39% in 2015 in men <65 y; 3% in 2005 to 41% in 2015 in men ≥65 y).

On multivariable analysis, more recent years were associated with greater odds of conservative management, as were increasing age, black race, unmarried status, higher PSA, increasing comorbidity, and geographic region (Table). Men older than 75 years, higher PSA, and greater comorbidity were more likely to receive watchful waiting than active surveillance.

Discussion

Utilization of conservative management has increased significantly among US veterans with low-risk prostate cancer, suggesting a substantial reduction in overtreatment during the past decade. These rates are higher than prior US studies in different health care settings. In the Surveillance, Epidemiology, and End Results (SEER)–Medicare–linked database from 2010-2011, only 32% of suitable patients received conservative management.3 In another registry of 45 US community-based urology practices, 40% of low-risk patients received conservative management from 2010-2013.2 Within a Michigan quality improvement collaborative (2012-2016), the proportion of low-risk patients managed by active surveillance varied significantly across practices (range, 30.2%-72.6%).6 By contrast, international rates of conservative management are considerably higher. For example, in Sweden, 74% of low-risk patients underwent active surveillance in 2014.4

Limitations of this study include possible nondetection and misclassification of treatment outside the VA that was not captured, difficulty distinguishing active surveillance vs watchful waiting using administrative codes, and inability to determine participation in shared decision making. Strengths include a large, racially diverse population of US veterans, providing comprehensive nationwide data on treatment trends.

Despite some regional variation suggesting additional room for improvement in the VA, these data suggest that an integrated health care system with equitable access for patients and without volume-based incentives for physicians may overcome many barriers to guideline-recommended conservative management.

[Shooter1]

VA--High normal PSA. Don't put much faith in that test. 18mo. later stage 4 aggressive, fast growing, metastasized, incurable, going to kill you Pca. Let's hear it for VA.

Doug

[Hidden in reply to Shooter1]

I for one deeply appreciate EVERYTHING the VA does for veterans. Did anyone force you to get care at a VA facility?

[Shooter1 in reply to Hidden]

No. I was getting ready to retire and was shifting stuff to them. Guess I started a year to early. They have been treating my thumb for years for an injury sustained while I was serving. All other surgeries and chemo. have been covered by health insurance at work. AZ VA has had lots of problems for years and are just starting to get them fixed. Still waiting for podiatry appt. after 6 mo. but did got x-rays last week, so maybe not too much longer to wait for that problem. At least local clinic is now responsive to calls.

Doug