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Ruchika Talwar: Hi everyone. Welcome back to UroToday's Health Policy Center of Excellence. As always, my name is Ruchika Talwar, and I'm a urologic oncologist in Nashville, Tennessee. Today I'm so excited to be joined by my good friend Dr. Adam Weiner, who is a urologic oncologist at Cedars-Sinai Medical Center. He's here with us today discussing some important work he recently published on international variations in adherence to quality metrics for prostate cancer. Thanks for being here with us, Dr. Weiner. We're excited to hear about your work.

Adam Weiner: Yeah, thanks for having me, Dr. Talwar. So first off, I'll just do a brief introduction here, and then I'm going to share my screen, put some slides up as well. But I think that one important question that we have with prostate cancer, because it is such a common cancer, is that it can be difficult to homogenize or uniform what everyone's approach is to managing some of these patients. It's sort of upfront when you first meet a patient with prostate cancer, and there's clearly some variation within countries and things that don't exactly align with guidelines or what's recommended by guidelines. So we wanted to take this opportunity to do the first analysis that combined one multinational cohort into one, and at the same time evaluate how countries vary in their approach to that initial management of patients with prostate cancer and how they align with guidelines.

Here we go. I'm going to briefly introduce the cohort. So this cohort was derived from the TrueNTH Global Registry. This is again a multinational registry that's hosted by the Movember Foundation, funded by the Movember Foundation, and led by the principal investigators at these various sites. And it's an international cohort that really sets out to define quality when it comes to outcomes for patients with localized prostate cancer. And a lot of the things that they look at actually tend to be related to patient-reported outcomes, so like incontinence or erectile dysfunction following a treatment. But you could also use this data set to see, well, what did the doctors initially do to help these patients? What were their initial management approaches?

So in total, there were 10 countries that participated in this study, with over 60,000 patients with a new diagnosis of localized prostate cancer. Again, we hypothesized that there were big variations from one country to another or one region to another in terms of some of these quality metrics, which I'll define for you. Most of these quality metrics we derived from a combination of probably the two most common guidelines in terms of prostate cancer. That was from the U.S., the NCCN guidelines, and then from Europe—and actually many places outside of Europe follow the European Association of Urology guidelines on localized prostate cancer. So we derived four quality metrics, and to assess those metrics, we used multivariable regressions.

The first assessment that we looked at was the use of surveillance for patients with low-risk prostate cancer. So as many of us know who are taking care of these patients, it's become very clear in the past 10, 15 years that treating patients with low-risk prostate cancer doesn't actually derive a major benefit for them in terms of survival or freedom from metastatic disease. And so those patients are largely recommended to undergo at least a period of surveillance at first.

And so we wanted to look at, well, that's clearly an indicator of good quality—how many patients get that in these various countries? And you can see that there was substantial heterogeneity in the use of surveillance for low-risk prostate cancer. In Central Europe, only about 14% of patients, at least in this data set, who were low-risk, got surveillance at first. And that's in contrast to when you look at Australia and New Zealand, when as high as 85% of patients got that. And that value in the U.S. was somewhere closer to more like 80%.

In terms of initial treatment for patients with unfavorable-risk prostate cancer. So these are patients with grade group three disease or high-risk disease, high-grade disease. These patients would typically have a recommendation to get a form of definitive treatment as their initial management, and typically it'd be recommended that they get that in a timely manner. And what that timely manner is, it varies from one person, from one patient to another. But certainly most people would agree getting that treatment within 12 months of a diagnosis would certainly be an indicator of good quality care.

And there was less variation, as you can imagine, in this one. Central Europe did extremely well within the cohort that came from Central Europe. Those patients—98% of them with unfavorable-risk prostate cancer—received radiation or radical prostatectomy within 12 months of their diagnosis. The U.S. was actually the country with the lowest proportion of timely treatment, with about two-thirds getting treatment within 12 months of diagnosis.

So moving on. The second part of the study focused on imaging, which I think we all know is certainly a measure of quality and certainly a measure of using our healthcare dollars wisely. So as many of us know, most guidelines, including NCCN and those from Europe, would recommend against imaging for the initial staging of patients with favorable-risk prostate cancer—so those with favorable intermediate-risk or low-risk prostate cancer.

And so the countries that did the best in that, by far and away, the U.S. actually did extraordinarily well. Ninety-four percent of patients with favorable risk did not get imaging for their initial staging, but Italy was kind of on the other side of the spectrum with 30% not getting any imaging.

And then in contrast to that objective, we looked at imaging for people with unfavorable-risk prostate cancer. So these would be patients that would certainly be recommended to get staging imaging because their chance of having metastatic disease would be much higher. So the percentage of patients getting staging imaging was very high in Hong Kong with 83%, and then very low in the U.S. at 39%, which of course is an interesting contrast to the no imaging finding.

So I lay out some of the statistics here, but the main conclusion that I think we can derive from, again, sort of the first-of-its-kind, single international data set, is that these quality metrics—which I think most people who take care of patients with prostate cancer would say are pretty conservative and well-accepted metrics—they vary quite a lot from one region to the other. Now, we can't exactly get at the reasons why they vary so much in this cohort, but you can pretty easily discern that these are probably reflections of either differences in regional culture or healthcare policies between these different countries.

Of course, this sort of study and studies like it should really be benchmarks to motivate and drive other quality improvement efforts when it comes to making sure that our patients with localized prostate cancer do get high-quality care. So that's my presentation, and let's take some time to discuss it.

Ruchika Talwar: Yeah, absolutely. Really interesting study, and I think that this study really underscores the need for improved collaboration between nations, particularly when we're talking about cancer guidelines. So tell me, based on all of everything you just presented, all of these findings, what do you think we can all do better as a global urologic community?

Adam Weiner: Well, I think that it's important that we decide what defines high quality. Even within this data set, our countries—you imagine trying to design a study like this—you want to make sure that you're looking at quality metrics that are generally accepted by these countries. Otherwise, what's the point? And there were a few countries that stood out. When you go back and see, okay, what are those people following in terms of their guidelines? And you could actually be quite surprised—whole countries that don't put, for instance, quite the emphasis on the preferred initial management for those patients with low-risk prostate cancer.

There were a number even within this data set that said, well, even for low-risk prostate cancer, radical prostatectomy or radiation are options. And they're kind of on the same level as active surveillance. That was a bit of a surprise to me. Again, these could still be reflections of regional cultural differences. So for instance, perhaps those countries, it's just regionally a little bit less acceptable to surveil a cancer. And I can't really speak to that, but I could say that it warrants dialogue, as you suggest.

Ruchika Talwar: Absolutely. And I think there's no right or wrong here; it's just coming to a consensus. So I think that dialogue and that mutual understanding is important. We know that variations do overall reduce the quality of care that we provide. So we want to try to address those and ensure there's equity globally. And so let's talk about the implications of this study to our audience of global urologists from a—on a one-to-one scale, when a specific urologist is talking to a specific patient, regardless of what country they're in, what is your suggestion on how this study modifies our practice?

Adam Weiner: Right. So I think what motivated me a lot by this study is really that these quality metrics that we look at or looked at, they have evidence behind them. We know that patients with low-risk prostate cancer don't derive a benefit in terms of overall survival or metastatic disease with an initial treatment. We know that, and we know active surveillance is safe. We know that imaging people with low or favorable intermediate-risk prostate cancer is very low yield, and thus it's going to be wasteful in terms of healthcare dollars. And I don't care if the out-of-pocket costs for a PSMA PET in your country is very cheap. It's getting paid for somehow, whether or not it's going to the payer or the patient or taxpayer dollars—it doesn't really make a difference. We know that imaging those patients is just low yield.

So if I am in a conversation with someone from a different country and they're talking to me about their practice with regards to prostate cancer, and we're coming to a consensus or discussion, I'm still just holding the highest level of evidence as what's important, what's come out of prospective trials, what do we know actually benefits these patients?

Ruchika Talwar: Yeah. And I think the onus is on us to share that evidence with patients because sometimes a lot of the things people cite as motivators do end up being patient preference, anxiety, concerns regarding a new cancer diagnosis. But I think that that's part of our job as healthcare professionals is to distill what's out in the literature in a way that patients can understand what's motivating us to make a shared decision. So really good points. I'm super excited to have read this exciting work, and we really appreciate your time and sharing this information with the UroToday audience.

Adam Weiner: Well, and thank you so much for having me. This was an absolute pleasure. Thank you.

Ruchika Talwar: Great. And to our audience, thanks again for joining. We'll see you next time.