Prostate Follow Up

[RadOncBeamer]

How do you follow your prostate patients after radiation? Our clinic used to have an NP who would see these follow ups, although this NP has retired (with no plans for replacement) and now I see them all. My prostate follow ups have slowly begun to build up and are starting to take up a lot of clinic time. My schedule has been PSA q6mo x5 years, then discharge to PCP. What's your strategy for handling these? One option is to switch these to phone calls and crank them out back to back on a given day. There isn't much I do for them in person that I can't do for them via phone although there is a social aspect to these visits and in-person follow ups can be billed. I have thought about switching to yearly PSAs although that makes me nervous, though I know some docs do this. Would love to hear your thoughts, thanks!

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[medgator]

How do you follow your prostate patients after radiation? Our clinic used to have an NP who would see these follow ups, although this NP has retired (with no plans for replacement) and now I see them all. My prostate follow ups have slowly begun to build up and are starting to take up a lot of clinic time. My schedule has been PSA q6mo x5 years, then discharge to PCP. What's your strategy for handling these? One option is to switch these to phone calls and crank them out back to back on a given day. There isn't much I do for them in person that I can't do for them via phone although there is a social aspect to these visits and in-person follow ups can be billed. I have thought about switching to yearly PSAs although that makes me nervous, though I know some docs do this. Would love to hear your thoughts, thanks!

Does urology not follow them? One option i do is to tag team with them so we each end up staggering the annual visits q6 months

I'll sometimes hand them back to their pcp after 2-3 years who can order PSA surveillance and cc me as well

 

[RadOncBeamer]

Some of them come referred from a urologist whom they are already following for chronic benign conditions (BPH, etc).

Others come to me after elevated PSA from PCP -> urologist does biopsy and patient doesn't want surgery -> refer to me. Those do not follow with urology.

I can get better about staggering with those who do follow with urology.

 

[Palex80]

I often stop after a few years, if no issues exist. Why should a totally asymptomatic patient with an optimal PSA be followed up by a specialist?
A well educated patient who will call you once issues arise (bowel / bladder / erection issues) and will visit his PCP and have the PSA sent to you, does not really need to see a specialist in my opinion.
I've also done telephone follow-ups for some.
Probably in 5-10 years these patients many of these patients be followed up by an App. Some places do that already.

 

[TheWallnerus]

Telephone “followup” (in other words phoning patient to give a test result) for PSA discussion is very smart. No rad onc is having to cut back on caviar and bonbons because he’s not billing level 3 followups for the prostates anymore. On the front end, just figure out a way to add 3 or 5 extra IMRTs; that’ll easily cover the lost revenue from no longer forcing men to drive miles to your office every so often to tell them their PSA looks good. (Now, if you wanna do DREs in followup…) When the PSA starts to “act up” that’s the time to meet face to face to discuss next steps. I have done it this way for years and the men are happy and I have improved my patients’ and my own QOL.

 

[Palex80]

(Now, if you wanna do DREs in followup…)

Where is that wonderful cartoon with the finger jiggle?

 

[TheWallnerus]

Where is that wonderful cartoon with the finger jiggle?

I think it’s been banned. The doctor doing the DRE resembled Sam Brinton in an uncomfortable, uncanny way.

 

[elementaryschooleconomics]

Now, if you wanna do DREs in followup…)

 

[BobbyHeenan]

Does urology not follow them? One option i do is to tag team with them so we each end up staggering the annual visits q6 months

I'll sometimes hand them back to their pcp after 2-3 years who can order PSA surveillance and cc me as well

That's how I've done it. I have a good group of urologists I work with.

I see at 12 weeks post treatment, then after that I see once per year (urology sees once per year as well but at staggering intervals, so patients see each of us once every 6 months).

Following your prostates long term has some benefit - it lets you see the cystitis and proctitis and keeps you humble. I don't see a ton of that, but it happens and you're kidding yourself if you think it doesn't.

In COVID I started doing more telephone follow ups too and have integrated that. Especially for the out of town patients. @scarbrtj is right IMO that can be a really good strategy.

 

[medgator]

That's how I've done it. I have a good group of urologists I work with.

I see at 12 weeks post treatment, then after that I see once per year (urology sees once per year as well but at staggering intervals, so patients see each of us once every 6 months).

Following your prostates long term has some benefit - it lets you see the cystitis and proctitis and keeps you humble. I don't see a ton of that, but it happens and you're kidding yourself if you think it doesn't.

💯

 

[HolySmokes]

Is anyone else reticent to send to PCP for follow up after RT? I've just seen a handful of cases where they'll let it get to >4 because (presumably) they're just looking at the normal range and only referring back after it's above that.

 

[TheWallnerus]

I see at 12 weeks post treatment, then after that I see once per year (urology sees once per year as well but at staggering intervals, so patients see each of us once every 6 months).

After we get prostate cancer when we are old men, you'll be making a doctor's office visit twice a year for twice a year PSA results and once a year DRE by the urologist? Getting a DRE at the urologist office is mandatory right? Not getting a DRE from the urologist if you've had prostate cancer... It's like trying to leave grandma's house without her giving you food. Ain't gonna happen. I'm just going to make a once a year visit to LabCorp.

 

[TheWallnerus]

Is anyone else reticent to send to PCP for follow up after RT? I've just seen a handful of cases where they'll let it get to >4 because (presumably) they're just looking at the normal range and only referring back after it's above that.

Randomized trial of long-term follow-up for early-stage breast cancer: a comparison of family physician versus specialist care - PubMed

Breast cancer patients can be offered follow-up by their family physician without concern that important recurrence-related SCEs will occur more frequently or that HRQL will be negatively affected.

pubmed.ncbi.nlm.nih.gov

Specialist versus Primary Care Prostate Cancer Follow-Up: A Process Evaluation of a Randomized Controlled Trial

Worldwide, there is an increased focus on reorganizing prostate cancer survivorship care. In this study, we describe for the first time a process evaluation as part of a randomized controlled trial that is currently comparing the effectiveness of specialist- ...

www.ncbi.nlm.nih.gov

 

[BobbyHeenan]

After we get prostate cancer when we are old men, you'll be making a doctor's office visit twice a year for twice a year PSA results and once a year DRE by the urologist? Getting a DRE at the urologist office is mandatory right? Not getting a DRE from the urologist if you've had prostate cancer... It's like trying to leave grandma's house without her giving you food. Ain't gonna happen. I'm just going to make a once a year visit to LabCorp.

Our urologists don't do DRE's post treatment. Neither do I.

We do adjust flomax and other meds though based on symptoms - though like you mentioned can be done over phone.

Side note - I treated a retired cardiologist recently. He said one of his most frequent outpatient consults was old men passing out getting up to pee...often on flomax....he's on flomax and likes it. He's just cognoscente enough to get up slowly.

 

[BobbyHeenan]

Randomized trial of long-term follow-up for early-stage breast cancer: a comparison of family physician versus specialist care - PubMed

Breast cancer patients can be offered follow-up by their family physician without concern that important recurrence-related SCEs will occur more frequently or that HRQL will be negatively affected.

pubmed.ncbi.nlm.nih.gov

Specialist versus Primary Care Prostate Cancer Follow-Up: A Process Evaluation of a Randomized Controlled Trial

Worldwide, there is an increased focus on reorganizing prostate cancer survivorship care. In this study, we describe for the first time a process evaluation as part of a randomized controlled trial that is currently comparing the effectiveness of specialist- ...

www.ncbi.nlm.nih.gov

This is a problem. Some of the better PCP's are aware....but there are pitfalls.

True story - I had a consult/business meeting with a medical director for an HMO. Retired from clinical practice but was a family doc back when practicing. Now an admin. He asked this exact question - why can't the breast and prostates just see their family docs?

I asked him. "OK, what should a post prostectomy psa be?" He said "very low, like less than 1."

Well there you go.

 

[fiji128]

I see a decent amount of prostate. Typically will see the patients at 1 month, 7 months and then yearly post RT (usually urology seeing them at same time so patient is being seen about every 6 months for the first several years). After 5 years, if the patient is still showing to these follow ups, I I will see them yearly if the patient's wants. Issue is not every pcp is completely up on how to follow these PSA's and there are plenty of salvage and high risk patients that need appropriate follow up. Overall these appointments tend to be very quick and easy so not a huge time sink for me and they can always be done over the telephone now.

 

[medgator]

Is anyone else reticent to send to PCP for follow up after RT? I've just seen a handful of cases where they'll let it get to >4 because (presumably) they're just looking at the normal range and only referring back after it's above that.

Pt education key here before you let them go. I try to follow them for at least 2-3 years before that happens

 

[TheWallnerus]

I asked him. "OK, what should a post prostectomy psa be?" He said "very low, like less than 1."

 

[Ray D. Ayshun]

This is a problem. Some of the better PCP's are aware....but there are pitfalls.

True story - I had a consult/business meeting with a medical director for an HMO. Retired from clinical practice but was a family doc back when practicing. Now an admin. He asked this exact question - why can't the breast and prostates just see their family docs?

I asked him. "OK, what should a post prostectomy psa be?" He said "very low, like less than 1."

Well there you go.

You should send him a bottle of bourbon for making the psma pet approval process so easy.

 

[evilbooyaa]

Is a f/u every 6 months that takes 15 minutes really so burdensome to one's clinic? I guess if there's really that many of them... IMO, prostate f/us are one of the best uses of a NP within the RO dept. And they're chipshots so the NP doesn't really have to be 'good' to monitor them. There may be some PCPs that are well versed on what to do with PSA f/u, but I'm sure there are many that are not.

This is relevant for both intact disease post-RT, but arguably more so for post-salvage RT in terms of lower threshold for action such as PSMA PET/CT, RT for oligomets, etc. etc.

This is a problem. Some of the better PCP's are aware....but there are pitfalls.

True story - I had a consult/business meeting with a medical director for an HMO. Retired from clinical practice but was a family doc back when practicing. Now an admin. He asked this exact question - why can't the breast and prostates just see their family docs?

I asked him. "OK, what should a post prostectomy psa be?" He said "very low, like less than 1."

Well there you go.

Lmao. Ya don't know what ya don't know. FMs have to know a lot, but the concept of 'no value' of having a urologist or Rad Onc f/u a prostate cancer patient for the first 5-10 years is... a bit silly unless you have a specific training for those.

 

[madchemist89]

If you don't have an NP, they can get burdensome when you have several a day. Not to mention all the T1 breast patients too.

 

[seper]

It depends how you are incentivized. Quick follow ups can be a reasonable source of productivity and reimbursement. Also if you have a full follow up day, it may protect you from service obligations

 

[medgator]

It depends how you are incentivized. Quick follow ups can be a reasonable source of productivity and reimbursement. Also if you have a full follow up day, it may protect you from service obligations

Conversely if you are routinely seeing double digit consults weekly with a lot of sims and complex caseload, straightforward f/u's can be a real time suck and productivity killer

 

[RadOncDoc21]

Conversely if you are routinely seeing double digit consults weekly with a lot of sims and complex caseload, straightforward f/u's can be a real time suck and productivity killer

Agree, know a few docs who stopped seeing pretty much all follow ups. I know it’s frowned upon but definitely makes their time more efficient in regards to time for consults, sims, contouring, dictations and tumor boards.

 

[sirspamalot]

Followups: when your schedule is light and you're gunning for wRVU's.

Otherwise, if ya'll on a fixed income: 90 day (120 day for lung w/Chest CT) and then return to referring physician 98% of the time. (Assumes no immediate post-treatment sequelae in which case, weekly or q2 wk as appropriate until resolved).

Next..

 

[medgator]

Followups: when your schedule is light and you're gunning for wRVU's.

Otherwise, if ya'll on a fixed income: 90 day (120 day for lung w/Chest CT) and then return to referring physician 98% of the time. (Assumes no immediate post-treatment sequelae in which case, weekly or q2 wk as appropriate until resolved).

Next..

Hate to say it but I've been diuresing f/u like crazy as consult and sim volume continue to grow. I generally will still follow though if no one else is or i don't trust the specialists following lol

 

[madchemist89]

I have pretty much everyone on 6-12 months except head and neck.

 

[elementaryschooleconomics]

I decide based on who else is following the patient. In general, I want zero follow-ups, if possible.

Prostates, after their initial (4-6 week) post-treatment appointment, it depends on if they have a Urologist they already see regularly or not. If yes, I ask if they want to see just Urology or me and Urology. If both of us, I try to space it out "leap frog" style, where it's q6 months (but each of us once a year).

Breast...if they're already seeing MedOnc and a surgeon, see you never.

Head and neck I see q3 months or leap frog with ENT. Gyn is the same, q3 months or alternating with GynOnc.

Post-treatment DREs should be a misdemeanor punishable by a $2000 fine or 90 days probation.

 

[salubalu]

Our urologists don't do DRE's post treatment. Neither do I.

We do adjust flomax and other meds though based on symptoms - though like you mentioned can be done over phone.

Side note - I treated a retired cardiologist recently. He said one of his most frequent outpatient consults was old men passing out getting up to pee...often on flomax....he's on flomax and likes it. He's just cognoscente enough to get up slowly.

Y’all don’t do dres on every otv?

 

[communitydoc13]

You can always schedule prostates annually with q6mos PSA. Offer f/u in person if symptoms to address or PSA not behaving as expected. Cuts f/u in half. No meaningful physical exam for prostate f/u.

If they want to stay with URO, I will cut loose within year if PSA behaving as expected.

Salvage is more complicated but a good URO knows what to do. Risk profile much higher, toxicity is higher and seems like more of these guys want you involved with prostate f/u.

Decision to start ADT after failed salvage one of the hardest out there IMO. Question is do you want to help direct this or do you want to leave this to someone else.

Not sure there is a right recipe to f/u schedule. It depends where you are, who is around, what the other docs want to do.