Background: Prostate cancer is the most common male malignancy. In 2021, the United States will see an estimated 248,530 new cases, 34,130 deaths, and more than 3 million survivors.1 Survival rates for local, regional, and distant prostate cancer combined is 98% at 10 years and 91% at 15 years. This creates an ever-increasing volume of survivors requiring surveillance for recurrence and treatment toxicities after initial and salvage curative therapy.
Objectives: To decrease in-clinic follow-ups and increase physician consult availability. Our aim was to create a digital health platform (DHP), driven by evidence-based algorithms, to serve as infrastructure of a virtual prostate cancer clinic (VPCC) led by advanced practice providers. The DHP would automate clinical decision-making by creating an acuity-based triage to prioritize men with cancer recurrence or with significant symptoms. The VPCC’s integration into the workflow would allow management of a larger patient volume by using remote follow-up visits.
Methods: In 2015, we developed an algorithm-based, nurse-practitioner–led VPCC with a DHP infrastructure in place of in-person follow-ups for men who had completed treatment. Virtual monitoring consisted of PSA at an affiliated lab reporting directly into our electronic health record (EHR) or a local lab, and electronic patient-submitted American Urology Association and EPIC-CP questionnaires. The DHP analyzed PSA levels to indicate relapse or no relapse and provided symptom scores based on questionnaire responses. Interaction was either by telephone, secure e-mail, SMS, or EHR portal messaging. Posttreatment symptoms were managed virtually, and patients with evidence of PSA recurrence were restaged appropriately per guidelines and discussed with the referring physician. We analyzed clinical volume, financial data, and surveyed patients on their satisfaction.
Results: From March 15, 2016, to July 31, 2020, 1397 patients enrolled; 94.3% were comfortable with this form of monitoring, with 3.4% neutral, and 2.3% uncomfortable. Per visit, 92.4% saved time, and 3.2% saved >3 hours. There were 702 in-person prostate cancer follow-up visits in fiscal year 2015 (FY15), but after the VPCC, this number was lower in each subsequent year by 13.5% (607) in FY16, 17.5% (579) in FY17, 21.0% (554) in FY18, and 24.0% (533) in FY19. There was no reimbursement for VPCC visits, but it increased physician availability for new patients and was associated with genitourinary radiation oncology revenue growth of 26.6%, 43.3%, 40.3%, and 74.4% for FY16, FY17, FY18, and FY19, respectively, compared with pre-VPCC FY15. Prior to COVID-19 (October 2019-February 2020), the FY20 monthly average was 26.4 referrals and 91.2 visits. During COVID-19 (March 2020-July 2020) dramatic increases in monthly referrals (59, +123%) and virtual visits (127, +39.3%) were observed.
Conclusion: The VPCC is a novel method of delivering follow-up care virtually with a DHP infrastructure that led to high patient satisfaction, significant patient time-savings, significant revenue growth from provider availability for new patients, and we found that during the COVID-19 era, this model allowed for very rapid switching of patients from in-person follow-ups to virtual monitoring.
- Siegel RL, Miller KD, Jemal A. Cancer statistics, 2020. CA Cancer J Clin. 2020;70:7-30.