Integration of Primary Care Into the Follow-Up Protocol for Prostate Cancer Patients in Aragon, Spain. It Is Time to Follow Other Successful Models in the Region.

Abstract

Background and objective: Over the past decade, prostate cancer (PCa) survival rates have increased, largely due to advancements in modern healthcare. As a result, the majority of PCa patients worldwide are now survivors, placing a considerable burden on healthcare systems. Specialists at Miguel Servet Hospital in Zaragoza, Spain, follow the European Association of Urology (EAU) guidelines in managing PCa patients; however, these recommendations do not specifically address the follow-up of patients by nonspecialist medical staff. This study evaluates the safety of a follow-up protocol that refers PCa survivors to primary care after undergoing radical prostatectomy (RP) as a curative treatment, with a particular focus on those diagnosed with pathologic high-grade localized and locally advanced PCa.

Methods: The study includes data from 579 patients diagnosed with high-risk PCa-both localized and locally advanced-according to EAU criteria. These patients underwent RP between 1992 and 2018 at the Aragón Health Service (SALUD), Sector Zaragoza II-Hospital Universitario Miguel Servet. The follow-up protocol involves initial monitoring by the urology department. Patients who remain free of biochemical recurrence (BCR) are subsequently followed up by primary care (PC) medical staff. To evaluate the short- and long-term effectiveness of this protocol, we analyzed biochemical recurrence-free survival, stratified by risk groups.

Results: The BCR rate after referral to PC is under 20.5% in the overall high-risk group. A more detailed analysis shows that the localized subgroup has a 14.5% BCR probability, while the locally advanced subgroup experiences a fourfold increase, reaching 41.98%. The risk of BCR is 2-5 times higher in the locally advanced group compared to the localized group. BCR patterns indicate that nearly half of all cases occur within 4 years post-RP, though trends vary by risk group. In high-risk localized PCa, almost half of BCRs occur between four and ten years post-RP, whereas in locally advanced PCa, over 65% occur within the first 4 years, indicating earlier recurrence in this group. Kaplan-Meier survival curves confirm a significant difference (p < 0.001): locally advanced PCa shows a threefold higher cumulative BCR risk at 10 years (2.78) and a fourfold higher risk at 5 years (4.41). Although the overall BCR rate after referral to PC is below 20.5% in the high-risk group, recurrence risk varies significantly-14.5% in the localized subgroup versus 41.98% in the locally advanced subgroup. These findings underscore the earlier and more frequent recurrence in locally advanced PCa compared to high-risk localized PCa.

Conclusions: Referring PCa survivors for follow-up in primary care has proven to be an effective and safe approach. The success of this protocol can be attributed to clear communication with the primary care team regarding the parameters for referring patients back to specialized care for recurrence assessment. As expected, the high-risk localized group showed a lower incidence of BCR than the locally advanced group, consistent with known recurrence patterns. It is imperative that the Spanish healthcare system implement a public primary care program dedicated to cancer survivors, with the aim of reducing the substantial burden on specialized services.