Michigan’s MUSIC hitmakers' record-breaking levels for AS with favorable intermediate-risk prostate cancer
Go Blue Cross and Blue Shield.
By Howard Wolinsky
Bob “Old Time Rock & Roll” and “Against the Wind” Seger and the Silver Bullet Band aren’t the only hitmakers to come out of the Mitten State.
The Michigan Urological Surgery Improvement Collaborative (MUSIC), the pioneering group focused on improving urological care in Michigan, funded by Blue Cross Blue Shield of Michigan, has been hitting the charts with great numbers--unprecedented numbers--for active surveillance anywhere in the U.S.
Michigan is the Sweden of America as far as AS goes for low-risk and very-low risk prostate cancer.
MUSIC has the highest numbers anywhere in the U.S. for AS for low-risk prostate cancer: 90% of eligible patients with low-risk Gleason 3+3=6 (now Gleason Grade Group 1) went on AS in 2021vs. 60% nationwide.
Now, MUSIC is breaking the charts again. This time, it’s with unprecedented numbers for favorable intermediate-risk prostate cancer. A newly published report in the Journal of Urology shows Michigan has achieved 43% uptake of favorable intermediate-risk prostate cancer. The U.S. number is only 20%.
As a former Michigander, I say “Go Blue Cross/Blue Shield.” (And also go UMichigan Wolverines. I was a journalist-in-residence in what’s now known as the Mike Wallace Journalism Fellowship at UMich.)
My source in Sweden, Mats Ahlberg, MD, suggests that Michigan’s numbers for favorable intermediate-risk PCa match those for Sweden.
Ever since active surveillance became a small thing in the late 1990s, the headliner, the top banana, has been surveillance of patients with very-low risk to low-risk Gleason 6 prostate cancer.
Favorable intermediate-risk prostate cancer (FIRPC) has been a distant second banana in the Gleason game.
Kevin Ginsburg, MD, MS, of Wayne State University in Detroit, senior author on the paper, explained to me that favorable intermediate-risk disease in the study included patients in the Gleason Grade Group (GG) 1 (AKA Gleason 3+3=6) with PSAs of A 10-20 and those in GG2 (AKA Gleason 3+4=7) with PSAs less than 10.
(See following article on program featuring Ginsburg and other international leaders on AS.)
He noted: “Not all GG1 prostate cancers fall into the low-risk category. Some men with GG1 prostate cancer will have intermediate-risk disease or even high-risk disese. A man with GG1 disease and a PSA of 10-20 would fall into the favorable intermediate-risk category, while a man with GG1 and PSA <10 would fall into the low-risk category. All GG2 prostate cancers are at least favorable intermediate-risk disease, but a higher PSA can lift them into unfavorable or high-risk categories.
Many urologists have been reluctant to put their patients on AS for low-risk prostate cancer let alone favorable intermediate-risk prostate cancer (FIRPC).
A decade ago, about 20% of eligible patients with Gleason 6 went on AS. Back then, 10% of those with favorable intermediate-risk prostate cancer opted for AS to avoid surgery and radiation.
Doctors and patients worried that delay in aggressive treatment with surgery or radiation will cost patients a “window of cure.” So they often plunged in with aggressive treatment.
A new study from Roshnan Pudel, PhD, of the University of Michigan and his MUSIC colleagues in the Journal of Urology show that AS is a safe and increasingly common approach for patients with favorable intermediate-risk prostate cancer. They reviewed patients retrospectively from 2012 to 2020 in the MUSIC registry. In the MUSIC study, by practice, men with FIPRC ranged from 8% to 65% (23% to 85% for Grade Group GG 1 and 8% to 57% for GG2 disease. The 5-year treatment-free probability for those managed with AS was 63% overall and 73% for GG1 and 57% for GG2.
Researchers identified 4,275 men diagnosed with FIRPC from 2012 to 2020, of whom 1,321 (31%) were managed with AS as their primary management strategy.
There is great news for those with favorable intermediate-risk prostate cancer. The musicians concluded: “Over half of men with favorable intermediate-risk prostate cancer on active surveillance remained free of treatment 5 years after diagnosis. Most men on active surveillance will not lose their window of cure and have similar short-term oncologic outcomes as men undergoing up-front treatment. Active surveillance is an oncologically safe option for appropriately selected men with favorable intermediate-risk prostate cancer.”
In an editorial, Christopher Morash, MD, of the Division of Urology at the University of Ottawa, the fact that in 5 of the 35 practices, AS was used in 40%-50% of GG2 patients “was surprisingly high.”
“This high patient acceptance rate in GG2 FIRPC probably also requires innovative and intensive patient counseling processes. I am sure there are valuable lessons to be learned from these practices,” said Morash.
The urologist added: “With 3 years of follow-up, there was only an 8% difference in biochemical recurrence rates favoring immediate RP (22% vs 14%). This is reassuring, but perhaps not yet long enough to conclude that AS in GG2 is oncologically safe except for carefully selected patients.
“Nonetheless, these data may be useful for counseling our patients with GG2 FIRPC who are interested in AS and those facing long waiting lists. This is timely considering pandemic-related surgical backlogs.”
Moving AS to the next level
By Howard Wolinsky
The Active Surveillance Coalition, a collaboration of leading support groups for active surveillance (AS) for prostate cancer, is sponsoring a webinar at 9 a.m. Vancouver/12 p.m. New York/5 p.m. London/6 p.m. Amsterdam on Thursday, Nov. 17 to discuss how we can move the needle on AS, close monitoring of prostate cancer.
AS leaders from Sweden, Holland, the United Kingdom, and the state of Michigan’s will share their “secret sauce” for reaching AS rates of near 90% and above.
The free webinar is entitled “Moving AS to the next level: Can we help more patients?”
Register here: https://bit.ly/ASnextlevel
The United States has lagged behind other wealthy countries in AS acceptance though the approach started here and in Canada in the late 1990s. AS uptake with AS finally reached a majority of 60% in 2021. The American Urological Association in 2022 set a new goal of 80% In 2010, only 6% of patients qualified for AS opted for this approach.
Several European countries and the state of Michigan’s MUSIC (Michigan Urological Surgery Improvement Collaborative) program have reached AS uptakes of around 90% or higher.
Panel members will present their stories followed by a discussion and a Q&A involving the audience.
Time is running out—answer the survey by Nov. 15
By Howard Wolinsky
Active Surveillance Patients International, AnCan Virtual Support Group for Active Surveillance, Prostate Cancer Support Canada, and The Active Surveillor newsletter are asking you to participate in a survey on patient attitudes toward Active Surveillance,
To participate in the survey, click here: https://www.surveymonkey.com/r/W69XXDS
Please help us out. The survey closes Nov. 15. It takes five minutes and will impact how patients like us are treated.
The survey is open to patients on AS for low-risk Gleason 6 prostate cancer to favorable intermediate-risk prostate cancer as well as those who have moved on to treatment,
Data will be used to inform policymakers, guideline writers, and clinicians about the “patient voice” on key issues.
For example: Will renaming Gleason 6 lesions as noncancerous reduce mental distress and financial toxicity in patients on AS? Should U.S. guideline writers, as their European counterparts did last year? favor safer transperineal biopsies vs. transrectal biopsies that can cause sepsis and other infections?