Purpose: To evaluate how well the Providence VA Medical Center (PVAMC) follows established National Comprehensive Cancer Network (NCCN) guidelines regarding imaging criteria for the staging of newly diagnosed patients with limited stage prostate cancer.
Background: Prostate cancer is the second most common cancer in men worldwide with > 1 million cases diagnosed in 2012 alone. There are > 200,000 new cases diagnosed in the U.S. each year. Although there have been recent changes in prostate cancer screening recommendations, many patients are still diagnosed with low-grade, limited stage disease. With respect to rising health care costs, we explored PVAMC’s use of established NCCN guidelines for the use of imaging studies (CT and bone scans) in limited stage prostate cancer.
Methods: Tumor Registry records of patients with a new diagnosis of limited stage prostate cancers from 2011-2013 were reviewed. Information regarding staging, prostate-specific antigen (PSA), and Gleason score was collected and subsequently used to assess the likelihood of disease confined to the prostate by using an established nomogram (James Buchanan Brady Urological Institute Partin Tables). It was then determined whether or not the patient had imaging performed according to NCCN guidelines, using the staging and nomogram parameters.
Results: 195 patient charts were included in this review. Of these, the majority (86.7%) underwent appropriate imaging for prostate cancer staging. Twenty-six patients (13.3%) had inappropriate ordering of staging studies based on NCCN guidelines. Of these cases, nearly all patients (25 of the 26) had overutilization of imaging (ie, tests were ordered that were not indicated). In these cases, 17/26 (65.3%) of the overutilized tests were ordered by the Urology Department, 8/26 (30.7%) by the Oncology Department, and 1/26 (3.8%) by the Primary Care Department. In none of the cases where imaging above recommended guidelines was performed did metastatic disease or increased burden of disease become apparent.
Discussion: Utilization of health care resources is increasingly relevant to health care economics and responsible patient care. This review indicated that at PVAMC more than 1 in 10 patients are over-tested (13.3%), without clear benefit and with excess cost. We recommend improved collaboration in multidisciplinary care and continued education regarding established guidelines to maximize care and utilization of resources.