I spoke with Arvin George, MD, an associate professor of urology at the University of Michigan and director of the MUSIC Prostate Program. The Michigan Urological Surgery and Improvement Collaborative (MUSIC) is a novel effort to improve patients’ lives by inspiring high-quality care through data-driven best practices, education, and innovation. MUSIC’s current focus is on improving care for prostate, kidney stone surgery, and small renal mass patients.
Can you tell us about MUSIC?
Dr. George: MUSIC is a physician-led collaborative quality improvement (CQI) initiative funded by Blue Cross Blue Shield of Michigan. The organization is governed by its constituents and urology providers. There are 46 practices representing approximately 90% of the urologists within the state of Michigan. It’s a consortium of different practices, including academic practices like the University of Michigan as well as private practices, smaller single-person urology practices, academic community partnerships or hybrid programs, and large health systems. It’s representative of a cross-section of urology that translates into what we see across the rest of the country.
The goal of designing MUSIC was to evaluate and improve quality and cost-efficiency in urologic care. The focus is on identifying gaps in quality improvement to improve patient lives by inspiring high-quality care through data, different practices, education, and innovation.
How and when did MUSIC begin?
Dr. George: There are other similar collaborations in existence involving cardiothoracic surgery, radiation oncology, oncology, and so on that focus on different aspects of improving quality of care, but MUSIC started all the way back in 2011. The idea was visionary at its inception. It was started by Dr. David Miller, a urologic oncologist who is currently serving as the president of the University of Michigan Health System, and Dr. Jim Montie, a urologic oncologist and chairman emeritus of the University of Michigan.
The goal at the time was to make Michigan the number one place to be treated for prostate cancer. That goal has evolved over time, but they started by driving across Michigan and approaching individual practices to build a coalition. It was wildly successful and continues to grow in number of participating practices. MUSIC now includes other diseases outside of prostate cancer. Under the leadership of the current director, Dr. Khurshid Ghani, it has expanded to include MUSIC Kidney, which is led by Drs. Brian Lane and Craig Rogers and focuses on the management of renal masses and kidney cancer, and MUSIC Rocks, which is led by Dr. Casey Dauw and focuses on the management of kidney stones.
What has been the greatest challenge that MUSIC has had to overcome?
Dr. George: One of the greater challenges has been maintaining a collaborative effort while there is ongoing competition between practices. We have emphasized creating and maintaining a collaborative culture by keeping a set of ground rules and principles regarding transparency, specific data collection, and more. We focus on the community, and we make sure to obtain approval from a number of urologists across the state who serve on working groups or on the executive member committee before any projects are moved forward. Any progress MUSIC achieves is driven by the urologists in the state of Michigan.
Can you speak to the recent guidelines regarding active surveillance that have come from MUSIC?
Dr. George: As a field, we’ve come to the general consensus that active surveillance is the preferred treatment option for low-risk and favorable intermediate-risk prostate cancer. Within MUSIC, we developed the Active Surveillance Roadmap and Appropriateness Criteria, a collaboration that incorporated the MUSIC members’ opinions to develop state-specific guidelines as a patient and physician resource.
Some factors that were emphasized included estimated life expectancy, identifying appropriate candidates, and when and what appropriate testing should be employed. We currently advocate for confirmatory testing to better risk-stratify and provide additional supporting data to increase confidence in shared decision-making.
There are 3 confirmatory tests—repeat biopsy, prostate magnetic resonance imaging (MRI), and genomic testing—that are typically performed within 6 months of diagnosis. Of course, a prostate MRI prior to biopsy would count as a confirmatory test. We have described high- and low-intensity active surveillance protocols, which adjust the intensity of surveillance testing with MRI biopsy and prostate-specific antigen (PSA) to a patient’s individual risk. For example, a very low-risk prostate cancer patient would be better served with a low-intensity surveillance regimen, which would mean less frequent PSA testing.
Recommendations are not meant to be prescriptive. Rather, the goal is to provide clinical evidence-based guidance that can support provider discussions with patients.
What has the data from MUSIC shown for favorable intermediate-risk disease?
Dr. George: There have been a few long-term active surveillance series, including the ProtecT trial, that support the use of active surveillance. As a country, we have now achieved really high rates of active surveillance in low-risk disease—approximately 85%. We know that a number of favorable intermediate-risk patients perform very similarly to low-risk patients when appropriately selected. However, while the numbers are so high for active surveillance among low-risk patients, we still see a steep drop-off among intermediate-risk patients.
To a certain degree, MUSIC reflects what is happening in the rest of the country, but as a result of the CQI initiatives underway, our data may separate from national data. Of the patients in Michigan with favorable intermediate-risk prostate cancer, approximately 31% are currently managed with active surveillance, which is significantly high. In 2012, this approach was only done in 13% of patients. Over time, it has been increasingly possible to raise the percentage because confirmatory tests assist in improving the confidence of risk stratification.
The data have been reassuring. The 5-year treatment-free probability for men is 73% for Gleason grade group (GG) 1 disease and 57% for GG2 favorable intermediate-risk disease.
How does confirmatory testing impact whether patients pursue active surveillance?
Dr. George: Confirmatory tests typically provide a greater degree of confidence. For example, for a patient with low-volume, Gleason 3+4 disease, genomic testing may be incorporated. If a low genomic score is found, both the physician and the patient will be much more confident that their long-term outcome is not going to be compromised by pursuing active surveillance.
On the flip side, a patient initially diagnosed with Gleason 3+3 disease, who then has a multiparametric MRI that shows a PI-RADS 5 lesion that targeted biopsy confirms to be Gleason 4+3 disease, that patient may not be a good candidate for active surveillance and may choose to pursue immediate treatment. There is not much belief or confidence that candidates with this diagnosis will benefit from active surveillance.
What has the data from MUSIC shown regarding the use of transperineal biopsy?
Dr. George: We were able to answer a number of questions pertaining to quality improvement gaps or questions on transperineal biopsy, including the cancer detection rate equivalency with the standard transrectal biopsy. Through MUSIC, we were able to optimize the transperineal biopsy template. Furthermore, we were able to evaluate the patient discomfort that initially was a concern for transperineal biopsy. We have more than 1000 patients who have undergone transperineal biopsy and taken a survey immediately after. Responses pertaining to pain scores on a visual analog pain scale indicate no significant differences compared with transrectal biopsy once local anesthetic block has been delivered.
What are some of the future directions and goals of MUSIC?
Dr. George: Ultimately, our goal is to identify and tackle the most complex and challenging problems in urology. MUSIC offers the advantage of being able to study rare events quickly by collecting data on an entire state within a very short period of time. This allows us to identify trends, understand variation, and implement concepts successfully and efficiently on a local level. However, one concern has been the feasibility of reproducing such concepts outside of Michigan.
To address this, we have started a program called Outdoor MUSIC, which has allowed programs outside of Michigan to participate in a number of MUSIC projects. Among the programs that have joined are the University of North Carolina and Montefiore in New York. While they don’t receive the financial support from Blue Cross Blue Shield, they receive the suite of resources provided by MUSIC. Practices contribute their data, and MUSIC helps analyze and provide feedback so they can realize and apply their own outcomes.
The next initiative to come is the prostate-specific membrane antigen positron emission tomography (PSMA PET) project. With the approval of commercially available PSMA PET imaging, utilization has become standard-of-care in treatment guidelines. According to the National Comprehensive Cancer Network Guidelines, you do not need to have additional soft tissue imaging (eg, computed tomography [CT] scans) to employ PSMA PET imaging.
Urologists are using PSMA PET imaging routinely at very low PSAs because of its sensitivity. We do not know whether this use is appropriate. Historically, decisions were made based on CT and bone scan, which identify macroscopic disease. PSMA PET imaging has the ability to identify microscopic disease. We do not know for certain whether it is appropriate to treat in the same way, and so MUSIC is addressing this question with our latest initiative.
What are the ongoing clinical trials happening within MUSIC?
Dr. George: There are 2 ongoing clinical trials within the MUSIC Rocks program. The first is investigating a specific stent, and the second is investigating a stent omission protocol. There are also genomic marker studies, led by Drs. Todd Morgan and Dan Spratt, that are investigating the clinical utility of genomic markers in decision-making for patients who are candidates for active surveillance.
David Ambinder, MD is a urology resident at New York Medical College / Westchester Medical Center. His interests include surgical education, GU oncology and advancements in technology in urology. A significant portion of his research has been focused on litigation in urology.