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Multilevel Predictors of Surveillance PSA Guideline Concordance After Radical Prostatectomy: A National Veterans Affairs Study

Abstract: 2018 AVAHO Meeting


Purpose/Rationale: To examine national trends and predictors of annual surveillance prostate specific antigen (PSA attainment after radical prostatectomy among veterans with prostate cancer.

Background: Guidelines recommend men treated for prostate cancer undergo PSA surveillance at least annually, as salvage treatments exist when recurrence is detected early. Predictors of adherence are poorly understood. We therefore examined national trends in PSA surveillance after prostatectomy.

Methods: We used the Veterans Affairs Central Cancer Registry to identify 9,648 patients treated with radical prostatectomy from 2005-2008 with follow up through 2012. We defined guideline-concordant PSA surveillance as receipt of at least one PSA annually. We used multivariable logistic regression to examine associations between guideline concordance and demographic and clinical factors, including PSA values in the preceding year. We assessed facility predictors and variation using multilevel regression.

Results: We found decreasing annual concordance over time ( > 90% years 1-2, 80% year 7) and 69.7% five-year concordance. On multivariable analysis, guideline concordance was lower among those who were black, non-married, non-Hispanic, had PSA at diagnosis > 10 and 20, and had negative or unknown surgical margins (P < .05). Guideline concordance significantly increased once the PSA increased beyond 4 ng/ml. Controlling for facility level variation and covariates eliminated the disparity for black men. Facility-level guideline concordance ranged from 17-100% and was inversely related to urologist workforce (aOR 0.97 [FTE/patient], P = .009).

Conclusions: The majority of patients receive guideline concordant PSA surveillance after prostate cancer surgery, but wide facility level variation exists. Concordance sharply increases when PSA values increase past 4, suggesting that a lab threshold that is not relevant in the post-prostatectomy setting is providing false reassurance to providers and possibly contributing to missed opportunities to salvage men with curable disease. Racial disparities exist, which are related to facility-level variation. Better understanding risk stratification for surveillance and the impact of broad interventions (eg, survivorship care plans, electronic reminders, provider education) on guideline concordance appears warranted.

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