Video: PROs in Prostate Brachytherapy

Using Patient-Reported Outcomes to Assess and Improve Prostate Cancer Brachytherapy

James A. Talcott 1, 2, 10, 11, Judith Manola 3, Ronald C. Chen 4, Jack A. Clark 5, 6, Irving Kaplan 7, 8, Anthony V. D’Amico 8, 11 and Anthony L. Zietman 9, 11

1 Massachusetts General Hospital Cancer Center, Boston, MA, 2 Continuum Cancer Centers of New York, New York, NY, 3 Dana-Farber Cancer Institute, Boston, MA, 4 Department of Radiation Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, 5 Center for Health Quality, Outcomes, and Economic Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, 6 Boston University School of Public Health, 7 Beth Israel-Deaconess Medical Center, 8 Brigham and Women’s Hospital, 9 Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, 10 Albert Einstein School of Medicine, New York, NY, and 11 Harvard Medical School, Boston, MA, USA

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OBJECTIVE

To describe a successful quality improvement process that arose from unexpected differences in control groups’ short-term patient-reported outcomes (PROs) within a comparative effectiveness study of a prostate brachytherapy technique intended to reduce urinary morbidity.

PATIENTS AND METHODS

Patients planning prostate brachytherapy at one of three institutions were enrolled in a prospective cohort study.
Patients were surveyed using a validated instrument to assess treatment-related toxicity before treatment and at pre-specified intervals.
Unexpectedly, urinary PROs were worse in one of two standard brachytherapy technique control populations (US-BT₁ and US-BT₂). Therefore, we collaboratively reviewed treatment procedures, identified a discrepancy in technique, made a corrective modification, and evaluated the change.

RESULTS

The patient groups were demographically and clinically similar.
In the first preliminary analysis, US-BT₂ patients reported significantly more short-term post-treatment urinary symptoms than US-BT₁patients.
The studies treating physicians reviewed the US-BT₁ and US-BT₂ treatment protocols and found that they differed in whether they used an indwelling urinary catheter.
After adopting the US-BT₁ approach, short-term urinary morbidity in US-BT₂ patients decreased significantly. Brachytherapy procedures were otherwise unchanged.

CONCLUSION

Many procedures in cancer treatments are not evaluated, resulting in practice variation and suboptimal outcomes. Patients, the primary medical consumers, provide little direct input in evaluations of their care.
We used PROs, a sensitive and valid measure of treatment-related toxicity, for quality assessment and quality improvement (QA/QI) of prostate brachytherapy. This serendipitous patient-centred QA/QI process may be a useful model for empirically evaluating complex cancer treatment procedures and for screening for substandard care.