Clinical Topics

A Systems Engineering and Decision-Support Tool to Enhance Care of Veterans Diagnosed With Prostate Cancer

A prostate-specific antigen tracking system identifies patients who require intervention before they present with clinical problems, ensuring that testing occurs at appropriate intervals.

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In the U.S. in 2015, there were more than 220,800 new cases of prostate cancer and about 27,000 deaths due to prostate cancer. Across the VHA, prostate cancer is the most common nonskin cancer malignancy, and more than 25,000 patients are diagnosed yearly.1 Patients who receive treatment for prostate cancer have excellent rates of disease-specific survival: nearly 100% at 5 years, 99% at 10 years, and 94% at 15 years.

Prostate cancer is one of several cancers that can be treated successfully with radiotherapy alone, and its success or failure is defined by a discrete numerical value from the prostate specific antigen (PSA) blood test. Failure occurs when the PSA is 2.0 ng/mL greater than the lowest PSA value posttreatment. 2 Multiple clinical trials have used this method to determine whether or not a certain intervention is successful.

Although high rates of survival and clear biochemical indicators exist, patients diagnosed with and treated for prostate cancer are at significant risk of PSA failure. The risk can range from 5% to 70% by 10 years, depending on the the treatment modality, risk group, and series reported. 3 These patients require long-term follow-up for disease recurrence and management of adverse effects. The current guidelines recommend annual follow-up care 5 years after treatment. 4

The number of veterans requiring follow-up care for prostate cancer constitutes a disproportionately large share of visits compared with those of other cancers, such as cancers of the head and neck region, chest, or gastrointestinal system, and there are many challenges to providing quality long-term care. Veterans in rural locations face barriers to accessing follow-up care for effective management.

Missed appointments can compromise long-term care, escalating the risk of nonadherence over time. Missed appointments occur commonly and may negatively impact outcomes and can restrict care for other patients. 5 In a recently published article by Percac-Lima and colleagues, no-show rates among 5 cancer center clinics at the Massachusetts General Hospital were as high as 10%. 6

Missed appointments have also been associated with decreased quality of care and increased resource use. 7 Patients with prostate cancer who miss follow-up visits are at risk for having their cancer progress to the point it becomes symptomatic and no longer treatable with salvage therapies. These patients also risk lost efficacy of treatments that are still available.

Due to these challenges, automated PSA tracking systems can be an effective way to ensure that quality, longterm care is provided to the patient. The purpose of the PSA tracking system is to identify patients who require intervention before they present with clinical problems. A PSA tracking system helps prevent patients being inappropriately lost to follow-up or missing a needed followup PSA blood test. The tracker would serve to correctly identify, among thousands or millions of patients in the electronic medical record system (EMR), which patients were at risk of failure or active failing biochemically by triggering an alert to the cancer specialist to assess that patient’s chart and determine whether a higher level of intervention is required. It could also serve to avoid unnecessary travel or inconvenience to a patient whose prostate cancer disease status can correctly be confirmed as under control by a simple blood test and related to the patient by phone, letter, or online.


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