Moving the Needle on AS. Michigan Shows a Path to a 90%+ AS Rate
MUSIC to my ears
By Howard Wolinsky
Urologists were slapping high fives and backslaps when news was released at the American Urological Association’s annual meeting in May: For the first time, the majority (60%) of patients with low-risk prostate cancer opted for Active Surveillance (AS).
This has been an uphill struggle. AS, close monitoring of low-risk Gleason 6 lesions, was accepted by only 6% of these patients when I joined the AS Club in 2010. AS had finally broken out of academic practices and become mainstream.
What is next? The AUA committee announced a seemingly reasonable goal of 80% sometime in the future.
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.
Michigan is the Sweden of America. Like Sweden, Michigan’s AS uptake tops 90%. This includes small and large practices in the Mitten State.
Ginsburg is one of the leaders in MUSIC (Michigan Urological Surgery Improvement Collaborative), an innovative physician-led quality improvement collaborative 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: "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) (Gleason 6) 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."
And Michigan doesn’t achieve AS success only for patients with low-risk Gleason 6 (Grade Group 1). It has also doubled the AS uptake for patients with favorable intermediate Gleason 3+4 (GG 2).
MUSIC could serve as a model in other states to spare more men from unnecessary surgery and radiation and their side effects.
A moderator of a support group mainly of men who had been treated for prostate cancer recently told me I was maybe too much of a cheerleader for AS.
It’s true. In general, I tend to root for the underdog. And men on AS used to be in that position. We were the Rodney Dangerfields of prostate cancer. No respect. Down so long, it looked like up to me.
Now we are on the upside and gaining.
The acceptance rate for AS is on the rise, reaching a slim majority (60 %) amongst men diagnosed with Gleason 6, per the AUA’s AQUA database.
AS is a hard concept for many men to accept. Some insist on surgery or radiation. They want the cancer out—out, out damned spot—even when they are assured that a “pure” Gleason 6 will never spread, never will kill.
Some patients are too anxious to go on or stay on AS. (I will be writing about that soon.) They should be able to choose their treatment path—active surveillance or active treatment.
Still, high AS rates can be achieved. Not 100%. But into the 90%. or high 80%s. It’s happened in Sweden, the United Kingdom, and Holland. And of course in Michigan and in some individual urology practices in the United States.
(Some practices achieve 100% AS rates as some men seek out AS-friendly docs. I know a German urologist who was injured in a skiing accident. He had to give up surgery so he is now an AS specialist. Meanwhile, urology practices have 0% AS rates as urologists focus on surgery.)
I am helping to organize a webinar in November on how MUSIC, Sweden, U.K. and Holland have achieved high rates for AS. I tentatively am calling it “Moving the Needle on Active Surveillance: Global Success Stories.” Details to come.
More MUSIC on favorable intermediate prostate cancer
By Howard Wolinsky
Since Active Surveillance became a strategy in the late 1990s to monitor prostate lesions and avoid active radical treatment, the focus has been on patients with low-risk cancers.
It makes sense. Prostate gurus assure us that “pure” Gleason 3+3=6 cancers (Grade Group 1) will never be a threat. We live with cancer; we don’t die from it.
60% of American men in this scenario follow AS—90% do in Michigan.
The Mitten State is home of MUSIC (Michigan Urological Surgery Improvement Collaborative), an innovative physician-led quality improvement collaborative founded in 2012, comprising a consortium of 46 urology practices in the state of Michigan and supported through Blue Cross Blue Shield of Michigan.
Michigan also has amazing numbers for patients with Gleason 3+4-7 Gleason 7 (Gleason Group 2).
GG 2 is a tougher call. Biologically, Gleason Grade 1 lesions are inert, lazy, while Gleason 2 tumors have a much greater chance to develop serious problems though these patients can be monitored with AS.
Recent figures nationally show that uptake of AS in the Gleason Group 2 patients had grown from to about 20% in 2021 from 10% in 2015.
The MUSIC program in Michigan, where doctors use peer data to improve their practices, is a different story.
Kevin Ginsburg, MD, a urologic oncologist at Wayne State in Detroit and a MUSIC leader, told me 45% of patients with intermediate-risk prostate cancer in 2021 in Michigan choose active surveillance compared with 13% in 2013.
Michigan urologists must be some sort of prostate whisperers.
Again, Michigan is showing the way with a model that could be emulated around the country.
There will never be 100% uptake of AS in those of us with low-risk let alone those with favorable intermediate-risk prostate cancer.
The fear factor is far too strong for many patients, partners, and physicians to accept AS. Each patient has to make his own choice in consultation with his partner, family, and physician.
Ginsburg and his colleagues presented a paper on the MUSIC experience at the August regional meeting in Chicago of the American Urological Association.
First author Raghav Madan, MD, a resident at Wayne State, said in Urology Today, “Active surveillance has been used for grade group 1, or Gleason 6 prostate cancer, for quite some time with remarkable success. Those cancers are very slow growing; in relative terms, they don't advance quickly, so it's safe to actively (surveil) them and then operate when necessary. There's been recent interest in expanding [active surveillance] to men with favorable intermediate-risk prostate cancer and examine whether that is a safe approach.”
For the study, the investigators identified 4,291 men in the MUSIC prostate cancer registry with favorable intermediate-risk disease.“
The investigators examined oncologic outcomes. Madan noted that approximately 50% to 60% of patients were able to delay treatment by five years. The risk of biochemical recurrence was similar when comparing men who underwent immediate vs delayed treatment.
Ginsburg said researchers observed wide variation by practice in the use of active surveillance in this patient population.
“When we look at this from a practice standpoint, we see some practices have 50% to 60% of their men with favorable intermediate-risk prostate cancer selecting active surveillance, and we see other practices [where the number is] very low—closer to 5% to 10%. And then [there are] a lot of practices in the middle, around the 20% to 40% range. So there's still quite a remarkable amount of variability in there,” said Ginsburg.
He told me to stay tuned. More data was published in the Journal of Urology.
The way to increase active surveillance rates in this country is for urologist to tell potential AS patients that this is the best treatment path to take. This change would have to be initiated from the American Urological Society and other professional groups. Would urologist see a decrease in their income, if they push AS over surgery? Perhaps not. Patients on AS require multiple office visits yearly and this never ends.
In my own experience the path to AS was not an easy one to find. When my urologist told me that I had prostate cancer he said I did not need surgery. He did recommend radiation and sent me to a radiation oncologist that he works with. (Possible referral fee?) He also briefly mentioned AS , didn't really explain it, and said that most men drop out. Then he told me my path was my mine to choose, not his, and he wouldn't not let me make a wrong decision. I was totally perplexed as to what to do. I went to my trusted internist and explained everything to him. He simply said that if he had gleason 6 he would do active surveillance. This simple statement was a game changer for me. Next, I traveled 4 hours by car during the pandemic to Moffitt Cancer Center in Tampa Florida. The urologist in Tampa made it so easy for me. He told me to go on AS, and took the time to explain to me. I am really felt relieved.
I am still using the same urologist. He does support AS and my next office visits to be this coming Wednesday. It would have been better if he told me in the beginning to do AS rather than having me run around like a crazy man for 6 months.
Thanks for sharing Steve. FYI, urologists actually make more money over time with AS than they do with a quick cash infusion from surgical fees and follow-up. As the doctors told you, each of us needs to make his own decision with discussion with partners, family and docs. Only 60% of American men go this route vs. 90%+ in Sweden and in the state of Michigan. Urologists need to present all the options in a balanced way. Glad things worked out for you--albeit the hard way. Howard