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Ruchika Talwar: Hi everyone, and welcome back to UroToday's Health Policy Center of Excellence. Today I'm really excited to be joined by Dr. Udit Singhal, who's a urologic oncology fellow doing a combined fellowship at the University of Michigan and Mayo Clinic. Dr. Singhal will be presenting some important new research in the prostate cancer space. Thank you for joining us this evening, and whenever you're ready, I'll let you present your results.

Udit Singhal: Well, first and foremost, thanks so much for having me. I really appreciate you guys taking the time out of your day to have me on, and of course, I'm happy to share our study here.

So this is a study that we actually embarked upon a couple of years ago, and the title is "Comparing Patient Reported Functional Outcomes After Prostatectomy in Historical and Contemporary Practice." And this was recently published in the Journal of Urology. And so really the purpose of this study was really just to compare patient reported functional outcomes of urinary incontinence and sexual function after radical prostatectomy in historical versus contemporary practice. And the reason we embarked on this was because we just wanted to understand, have we as urological oncologists gotten better at prostate cancer surgery over time? We always feel that we're doing better, but we really wanted to answer this question in a somewhat objective manner. Are we doing prostate cancer surgery any better than we were doing it in the past?

And so to do this, we compared prospectively collected patient-reported outcomes of prostate cancer, functional outcomes from patients in historical practice and then in contemporary practice. And so we used two different cohorts for this. The first was data from the University of Michigan from a prior study that was published in the New England Journal of Medicine in 2008. This is from the PROs QA study in which we looked at patient reported functional outcomes after prostate cancer treatments at nine different institutions. And so we used Michigan data from the PROs QA study, and that was our historical cohort. And then we compared that to contemporary practice using patient-reported outcome data from the Michigan Urological Surgery Improvement Collaborative or MUSIC, which consists of a majority of the practices, both community practices and academic practices, including the University of Michigan. And this was data from the University of Michigan. And we considered this our contemporary practice.

And so really we want to understand whether there were differences in functional outcomes as reported by patients after prostate cancer surgery in historical and contemporary practice. And really what we found was that we haven't really improved as a whole, despite all the dynamic changes that have occurred in prostate cancer surgery over time. We haven't really improved in terms of preserving patient's urinary incontinence after prostate cancer surgery. But in terms of their sexual function, we have made, at least according to our data, some improvements with regards to preserving patient-reported sexual function after prostate cancer surgery in contemporary practice compared to historical practice. And so on the right you can just see some curves looking at patient-reported functional outcomes from zero baseline time all the way to 24 months. And again, urinary incontinence, really there was no improvement between historical and contemporary practice. Whereas with regards to sexual function, patients in contemporary practice reported improvement relative to their historical counterparts.

And on the left is really just our demographics of our patients. And the main point from this is that we actually saw that patients in contemporary practice actually had more unfavorable disease related characteristics as well as more unfavorable patient demographic characteristics. So those were patients that were older, that were more obese and then had more unfavorable disease related characteristics, higher NCCN risk, higher Gleason grade, higher PSA. And so this suggests that we may be more willing to operate on patients that are more unfavorable in contemporary practice compared to those in historical practice.

And so those are really our key takeaways. One is that there's really no difference in urinary incontinence recovery between historical and contemporary practice. There was a little bit of improvement with regards to sexual function as reported by patients after radical prostatectomy in contemporary practice. And then again, contemporary practice really consists of men with more unfavorable demographic and disease related characteristics.

Ruchika Talwar: Great. Thank you for that overview. I think this study is so interesting for a few reasons. First, you point out that we are operating on higher risk and more unfavorable characteristic patients. So, it's interesting to me that despite that, sexual function actually has improved over time. And there must therefore, or I should say I hypothesize, that there must be some sort of technical component to that improvement. However, we're not seeing an improvement in urinary function. And from a patient counseling perspective, I also find it interesting that incontinence is the one thing that we tend to counsel as being more predictable. We have a little better data to back up rates of improvement over time, whereas with erectile function, we really hammer home the point that it is variable and your biggest predictor of how you'll do after is how you were doing before surgery. So tell me your thoughts in the context of your findings combined with the way we counsel patients.

Udit Singhal: Yeah, I mean, I think this is just another piece of data and another study that we can potentially look to, to help counsel patients like you're saying. I think one of the limitations of our study is that we are not able to answer the question of why. Why is it that we are better now maybe at preserving sexual function? And why are we not potentially better at preserving urinary function over time? And so potentially I would say that would be one of our limitations: that we're not able to answer the question of why. But really we wanted to understand over time, despite all the dynamic changes that have occurred, there are changes that have occurred with regards to penile rehabilitation, regards to pelvic floor physical therapy and other adjunctive things that we do for prostate cancer patients after surgery. We perhaps have gotten better at those things and maybe those things have contributed as well in addition to potentially some technical improvements that we've made with regards to our surgical ability.

And so all of those things combined, potentially have provided us with some improvements, but we don't really know why. And so I think our study allows us to potentially counsel patients and say that, "Hey, look, we do robotic surgery now for the most part when it comes to prostate cancer surgery, and we've potentially made some improvements with regards to preserving your sexual function." And that could be a result of doing a better nerve sparing procedure or could be a result of some other technical improvements that we've made. But really with regards to our urinary function, we at least in our study, have not been able to show that we've really improved over time.

And so in some ways that's good because we were probably pretty good at prostate cancer surgery in the past, but in some ways we still have a lot of ways to go, at least with regards to patient-reported outcomes. And so I think it's just another data point for us to be able to use to counsel patients. And I think it's important for that reason. But why is still important. We still need to figure out why these findings are the way that they are.

Ruchika Talwar: Yeah, I couldn't agree more. And looking at this from a health policy lens, we're always looking to improve the quality of care that we deliver. The question arises, what does quality mean to us versus what does quality mean to patients? And we know that patient-reported outcomes are often the central focus point for people actually having the surgery. So I think this is important that when we have these quality consortiums such as MUSIC, and I know in Pennsylvania they have the PERC and there's the AQUA Registry, I think that the fact that you all did this sort of quality control analysis to see how we are doing from the perspective that truly matters, the one of the patient, operative time, maybe not as important to them, EBL, transfusion rate, of course important, but maybe that's not their number one or number two priority. So I commend you all on this important finding that you identified. And what is your advice to other urologists out there who treat prostate cancer patients and also participate in these sort of quality collaboratives?

Udit Singhal: Yeah, I would say I think it's important. It's important to participate because identifying these types of things is what allows us to get better as a group, as a field altogether. And so I think MUSIC has in some ways been a leader in that and we're very proud of that here. But we've been really able to show that you can look at individual surgeon outcomes and then use that in some ways to not only better individual surgeons, but then also surgeons as a community as a whole.

Because if you're able to identify certain practices within specific surgeons who are high performing surgeons, and especially in the era of robotic surgery, these surgeries can be recorded. And so that's a huge benefit potentially in something like prostate cancer surgery. And so you're able to then identify those high performing surgeons, identify maybe specific surgical techniques that they're using through video review, and then kind of roll those out to the rest of the collaborative, to the other participating surgeons to help them improve, to help raise the bar overall of the care that we're delivering or the surgical care that we're delivering to patients. So I would say my piece of advice would be, participate. Participate and make sure that you're a part of these types of collaboratives. None of this is to call out surgeons who are not performing well. It's really to raise the bar as a whole for our field.

Ruchika Talwar: Absolutely. And I think performance measurement is the key component here. Even if you don't have access to one of these collaboratives, I do think that there's value in retrospectively looking back and seeing trends in this sort of data that really matters to patients. So again, I totally agree with you. Thank you so much for spending time with us tonight. Congratulations on publishing this in the Journal of Urology, and we appreciate your important insights.

Udit Singhal: Yeah, thanks so much for having me. I really appreciate being here.

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