Engaging the primary care community to encourage appropriate prostate cancer screening

Abstract

Prostate-specific antigen (PSA) screening for prostate cancer remains a controversial topic, particularly in the primary care community. Our multidisciplinary prostate screening panel at Duke University Health System, USA created a nuanced PSA screening algorithm, implemented it into the Electronic Health Record of Duke Primary Care, and conducted outreach meetings with primary care practices to support its rollout. Through this project, we identified areas of concern among primary care clinicians regarding PSA screening that we structured into two major categories: ideological opposition and logistical opposition. We outlined specific concerns in each major category and described how our team responded to those concerns. As communication between primary care clinicians and prostate specialists is vital to the success and safety of PSA screening programs, we hope that describing primary care concerns and our responses to them will help other health systems thoughtfully and efficiently implement appropriate PSA screening programs moving forward.

Introduction

Prostate cancer screening remains one of the most controversial topics in contemporary medical practice. While there is general support for prostate-specific antigen (PSA) screening in the urology and medical oncology communities, PSA screening remains controversial in the primary care community. Contemporary guidelines from both the National Comprehensive Cancer Network (NCCN) and American Urological Association (AUA) advocate appropriate PSA screening in informed men, after patient-centered informed decision-making.^1,2 In contrast, the American College of Preventive Medicine Choosing Wisely^® initiative for 2016 cited PSA screening as one of the five most overused medical tests and explicitly recommended against it. ³

The best evidence supporting PSA screening is from the European Randomized Study of Screening for Prostate Cancer (ERSPC) that has demonstrated a reduction in prostate cancer mortality, with increasing benefit being observed with progressively longer follow up.^4,5 As follow up has extended for ERSPC data, the number needed to invite to prevent one prostate cancer death has decreased from 1410 at 9 years of follow up, to 979 at 11 years of follow up, to 781 at 13 years of follow up, and is expected to continue decreasing over time.^4,6 Although the United States Preventive Services Task Force (USPSTF) recently upgraded PSA testing to ‘grade C’ in 2017 largely based on this evidence, the 2012 ‘grade D’ recommendation against PSA screening seems to have led to a significant decline in PSA testing with some evidence suggesting a higher percentage of patients now presenting with nonlocalized disease.^7,8 It is well documented that PSA screening decreased following the task forces’ initial recommendations in 2008 and their ‘grade D’ recommendation in 2012.^9,10 Furthermore, PSA testing rates have declined in primary care to a greater degree than in prostate specialists. ¹¹

To improve rates of PSA screening, several leading medical centers have recently recommended modified approaches that maintain the benefits of screening while mitigating some associated risks.^12,13 In addition, growing expertise and availability of novel diagnostic tools including multi-parametric magnetic resonance imaging (mpMRI), serum-based PSA-derivative assays, and genomic classifiers offer the promise of improved selection criteria for whom to biopsy in men presenting with an elevated PSA.^14–18 Furthermore, active surveillance has proven to be a well-tolerated management strategy and is now recommended for men with very low and low-risk disease and there have simultaneously been advances in focal therapy (partial gland treatment or image-guided ablation) for early-stage, localized disease.^19–23 Thus, while PSA testing remains a critical first step in prostate cancer screening, the subsequent evaluation and management of men with an elevated PSA is significantly more nuanced today than it was even 5 years ago.

Preliminary analysis showed that only about 50% of Duke Primary Care patients had up-to-date PSA screening. Thus, in the Duke University Health System, we initiated a primary care-focused initiative to facilitate appropriate PSA screening. First, a multidisciplinary panel of primary care, family and community medicine, urologists, radiation oncologists, and medical oncologists devised an updated prostate cancer screening algorithm incorporating a baseline PSA measurement in the fifth decade, age-based PSA thresholds, and recognition of risk factors including family history, genetic predisposition (e.g. BRCA) and African American race (Figure 1). The program was designed to encourage appropriate PSA screening within the primary care community, with subsequent referral of higher-risk men to a dedicated prostate cancer screening clinic for more comprehensive discussion and evaluation. The algorithm was developed based on current best-available evidence. Second, the algorithm was integrated into the electronic health record (EHR) in a manner that was seamless to the primary care clinician’s current workflow. PSA screening notification was housed in the same EHR area as other screening notifications (e.g. colonoscopy flag) and did not require clinicians to remember the algorithm. Third, the rollout was promoted to the primary care community through various forums over the course of 18 months, including several medical director leadership meetings, direct outreach meetings at over 10 primary care practices (PCPs), and routine administrative communications distributed to all providers.

Figure 1.

Duke Cancer Institute PSA screening algorithm.

These meetings allowed the screening initiative team to present the most recent data regarding prostate cancer screening, the clinical basis for the algorithm, and recent changes in the approach to men with an elevated PSA. One member of the screening initiative team, a fellow in urologic oncology, was designated as the point person to lead these meetings with a created Microsoft PowerPoint slide deck to facilitate discussion. At PCP sites, meetings were carried out during the lunch hour with 5–10 PCPs and physician extenders. The lunch meetings typically lasted up to 1 h, with 30 min for slide presentation and 30 min for discussion. Overall, we estimate that the various outreach vehicles engaged nearly 200 PCPs and advanced practice providers.

We found the outreach meetings to be invaluable to the adoption of the program for several reasons. First, the small group nature allowed for a more intimate, frank discussion of questions and concerns. Second, the structured presentation provided the opportunity to further educate the primary care community on newer approaches to risk stratification and both the active surveillance initiative and non-whole gland targeted therapy that can mitigate against some of the side effects of prostate cancer treatment. Finally, the repetitive sessions at multiple sites within the health system helped to identify recurrent themes of perceived barriers to screening among the primary care community, as well as targeted solutions to those barriers.

The success of PSA screening programs such as the one implemented is predicated on strong communication and teamwork between the primary care and prostate specialist communities. Thus, it is important to identify common areas of concern among primary care clinicians to the implementation of PSA screening and to address those concerns directly. As these barriers were identified and solutions generated, subsequent outreach meetings were structured to best target them

Concerns raised by the primary care clinicians fell into two broad groups. The first included ideological issues related to PSA screening, all with the central belief that the risks of screening outweigh the benefits (Table 1). The second encompassed logistical opposition to screening, with overall questions of the coordination and implementation of PSA screening (Table 2). As we have progressed with the prostate screening initiative, we have made efforts to address items relating to both major categories (Tables 1 and 2).

Table 1.

Ideological opposition to screening.

Specific concern	Perception of concerned primary care clinicians	Response by the Duke multidisciplinary prostate screening panel
1. Low efficacy	PSA screening detects indolent, nonlethal disease and subsequent treatment does not improve cancer-specific survival.	Presentation of recent evidence supporting PSA screening, particularly given the increased risk of prostate cancer in our served patient population (20–30% African American).
2. Side effects of screening and treatment	Screening leads to unneeded biopsies and primary treatment with more side effects, such as pain, bleeding, infection, urinary incontinence, erectile dysfunction, and rectal irritation.	Discussion of active surveillance for screen-detected, clinically indolent prostate cancer and more nuanced patient management to decrease risks.
3. Cost ineffective	Increased lab tests and cost burden to the health system without concrete benefits shown.	Presentation of evidence supporting cost-effectiveness of PSA screening. 24
4. Conflicting national guidelines	PSA screening conflicts with 2012 USPSTF guidelines and ‘grade D’ rating discouraging PSA testing.*	Discussion of controversy regarding generalizability of original USPSTF guidelines and education regarding updated guidelines.
5. Lack of autonomy of practice	A system-wide algorithm removes clinician practice autonomy and ‘expert opinion’.	Assurance to clinicians that screening was not mandatory and that this would be a continued discussion, as the algorithm is designed to be a living document, updated with latest evidence and best practice.
6. Medical-legal concerns	Unclear medical-legal ramifications of missed cancer detection or screening-related morbidity, particularly with conflicting guidelines.	Discussion with primary care leadership about the medical-legal protections for primary care clinicians.
7. Misaligned financial incentives	A system-wide algorithm leads to concerns of prostate cancer specialist over-treatment of indolent disease, particularly in fee-for-service environments.	Transparency regarding PSA screening algorithm and downstream treatment decisions of patients.

*

USPSTF guidelines for PSA screening have recently upgraded to ‘grade C’.

PSA, prostate-specific antigen; USPSTF, United States Preventive Services Task Force.

Table 2.

Logistical opposition to screening*.

Specific concern	Perception of concerned primary care clinicians	Response by the Duke multidisciplinary prostate screening panel
1. Burden to health system	Increased visit demand on already highly utilized primary care and specialty clinicians.	Streamlined screening into current primary care visits and established a separate elevated PSA referral pathway to a dedicated prostate cancer screening clinic.
2. Provider communication breakdown	Patients referred for elevated PSA will get lost in the system and primary care clinicians will not know what ultimately happens to them.	Created an in-network referral pathway for elevated PSA to improve closure of the referral loop and simplify bi-directional communication.
3. Workflow confusion	Confusion regarding the extent of PCP involvement in shared-decision-making and pre-specialist visit work-up (i.e. serum markers and imaging).	Distributed literature clearly outlining algorithm, responsibilities, and implementation into current primary care workflow.
4. EHR alert fatigue	Concerns of obtuse EHR implementation leading to alert fatigue and additional electronic requirements to already short patient visits.	Non-intrusive inclusion of PSA screening flag into EHR panel containing other screening reminders to decrease burden on clinicians.
5. Lab test confusion	Confusion about which of the >20 variations PSA lab orders was the appropriate selection.	Clear education on appropriate lab order and decrease of lab order redundancy.

*

Some of these are unique to Duke Health, but the majority can be generalized to many large health systems.

EHR, electronic health record; PCP, primary care practice; PSA, prostate-specific antigen.

Through this multidisciplinary process, we have made significant progress towards opening the lines of communication among primary care and specialty clinicians regarding thoughtful prostate cancer screening that we hope will ultimately translate to a unified, adaptable, system-wide approach to this important aspect of modern patient care. The algorithm itself is designed to be a ‘living document’ that may be amended based on the most recent best evidence. Through promotion of a culture of continual improvement, we aim to be proactive and prepared to address any unanticipated wrinkles as they arise. For example, we will regularly assess Duke Primary Care’s PSA screening rates and create a survey for primary care clinicians to more objectively identify and weigh barriers to PSA screening. While we still have far to go, we have thus far achieved rollout of our PSA screening algorithm across the Duke Health System without any IT glitches. Preliminary data suggests an increase in screening, with more concrete analyses currently underway.

Prostate cancer remains the third most common cause of cancer-related death in American men. ²⁵ Our goal is to detect life-threatening disease and offer a timely intervention to appropriate men who otherwise are destined to die from prostate cancer. We believe this approach can be implemented in other large health care systems in a similar way. As our program further develops and expands, we continue to place the patient’s interest first and maintain open lines of communication between the ‘front line’ primary care community and prostate specialists to address any ongoing concerns and appropriately modify the screening evaluation and comprehensive management of men who are ultimately diagnosed with prostate cancer.