Trends in Surveillance for Localized Prostate Cancer and Barriers to its Use

描述(申请人提供)：观察局限性前列腺癌通常是立即确定治疗的合理替代方案，因为许多前列腺癌是非致命性的，并且有长期的自然病史。在前瞻性队列研究中，主动监测(AS)与低风险临床局限性前列腺癌治疗中近100%的疾病特异性生存率有关，近年来已被推广为阻止低风险疾病过度治疗的一种手段。然而，在前列腺癌的管理中，这似乎是一种未得到充分利用的策略，部分原因可能是它与被称为守望等待(WW)的被动观察策略有关，在过去的几十年里，这种策略更常被推荐给老年和虚弱的男性。AS寻求识别疾病进展的迹象并提供最终的治疗(放射或手术)，如果发现进展，WW旨在允许前列腺癌进展，假设患者更有可能死于其他原因，并且只提供姑息干预来缓解症状。观察 前列腺癌在欧洲和加拿大得到了更广泛的接受，而在美国，低风险患者的使用率保持在10%或更低。为了扩大对低风险临床局限性前列腺癌治疗的接受和坚持，可能有必要将其与普通临床实践中的WW区分开来，并确定影响选择AS的决定的患者水平因素和医生沟通方式。我们建议使用两项具有类似研究设计的大型、基于社区的前瞻性队列研究(前列腺癌结果研究[PCOS]和手术和放射治疗的比较有效性分析[Ceasar])的数据，来比较两个时代(1990年代的PCOS和2010年代的Ceasar)监测的使用情况。我们的目的是确定证明AS是积极治疗的安全替代方案的证据是否导致低风险疾病男性使用AS的增加，以及两个时代更年轻、更健康的男性使用AS的增加(表明从WW过渡到AS)。其次，我们将使用Ceasar基线问卷来确定医生的沟通方式在多大程度上影响AS的选择，支持目前可用的其他治疗方法。拟议的研究结果将为计划在泌尿外科质量协作中利用AS的研究提供基础，该协作是一个由美国中西部、大西洋中部和东南部的7个泌尿外科诊所组成的多机构小组。使用已建立的质量评估和质量改进模型，我们的目标是前瞻性地评估AS的医生和患者层面的障碍；然后与医生一起进行教育干预，以努力在适当的临床场景中增加AS的使用；然后重新评估以评估干预的有效性。由于前列腺癌是男性中最常见的诊断癌症，随着使用量的增加，潜在的公共健康影响是巨大的。

DESCRIPTION (provided by applicant): Observation of localized prostate cancer is often a reasonable alternative to immediate definitive treatment because many prostate cancers are non-lethal and have a protracted natural history. Active surveillance (AS) is associated with nearly 100% disease-specific survival in the management of low-risk clinically localized prostate cancer in prospective cohort studies and has been promoted in recent years as a means of stemming over-treatment of low-risk disease. However, AS seems to be an underutilized strategy in the management of prostate cancer, perhaps in part because of its association with the passive observation strategy known as watchful waiting (WW), which was more commonly recommended in elderly and infirmed men in past decades. Whereas AS seeks to identify signs of disease progression and offers definitive therapy (radiation or surgery) if progression is found WW is designed to allow prostate cancer to progress, assuming that the patient is more likely to die of other causes, and only palliative intervention is offered for symptom relief. Observation of prostate cancer has gained wider acceptance in Europe and Canada than it has in the US, where utilization remains at 10% or less among low-risk patients. In order to expand the acceptance of and adherence to AS for management of low-risk clinically localized prostate cancer, it may be necessary to distinguish it from WW in common clinical practice and to identify patient-level factors and physician communication styles that impact the decision to select AS. We propose using data from two large, community-based prospective cohort studies of men with localized prostate cancer with similar study designs (Prostate Cancer Outcomes Study [PCOS] and Comparative Effectiveness Analysis of Surgery And Radiation [CEASAR]), to compare the use of surveillance between two eras (1990s for PCOS and 2010s for CEASAR). Our aim is to determine whether the evidence demonstrating that AS is a safe alternative to active treatment has led to an increase in its use among men with low-risk disease and to increased use among younger, healthier men across the two eras (suggesting a transition from WW to AS). Secondly, we will use the CEASAR baseline questionnaire to determine the extent to which physician communication style influences the selection of AS in favor of other currently available treatments. The results of the proposed study will provide the foundation for a planned study of AS utilization within the Urological Surgery Quality Collaborative, a multi-institutional group of 7 urology practices throughout the Mid- West, Mid-Atlantic and Southeastern United States. Using an established quality assessment, quality improvement model, we aim to assess prospectively the physician and patient level barriers to AS; then perform an educational intervention with physicians in an effort to increase use of AS in appropriate clinical scenarios; then reassess to evaluate the effectiveness of the intervention. Because prostate cancer is the most commonly diagnosed cancer among men, the potential public health impact of increasing AS use is enormous.