Four‐year outcomes from a multiparametric magnetic resonance imaging (MRI)‐based active surveillance programme: PSA dynamics and serial MRI scans allow omission of protocol biopsies

Christopher, Edward; Cameron, A. F.; Little, Scott; Innes, Alasdair; Davis, Gill; Keanie, Julian; Bollina, Prasad; McNeill, Alan

doi:10.1111/bju.14513

Cited by 40 publications

(40 citation statements)

References 25 publications

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“…Some authors report treatment rates as low as 11.7%, with the majority of men treated at a yearly rate of <4% after the first 2 yr (with a median follow-up of 39 mo) [18] . We showed that Gleason grade and MRI visibility at baseline are associated with EFS and treatment-free survival, a finding previously confirmed by others [17] . We also believe that WW after AS should not necessarily be viewed as a “failure”, but often as a “graduation” event.…”

Section: Discussionsupporting

confidence: 88%

“…In other AS studies, 5-yr conversion rates are even higher [15] . By comparison, small imaging-based studies have reported active treatment rates of 27.5% (with median time to treatment 4.2 yr) and 30% (with median time to treatment 1.55 yr) [16] , [17] . Some authors report treatment rates as low as 11.7%, with the majority of men treated at a yearly rate of <4% after the first 2 yr (with a median follow-up of 39 mo) [18] .…”

Section: Discussionmentioning

confidence: 96%

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Five-year Outcomes of Magnetic Resonance Imaging–based Active Surveillance for Prostate Cancer: A Large Cohort Study

et al. 2020

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Background Although the use of multiparametric magnetic resonance imaging (mpMRI) in active surveillance (AS) for prostate cancer is of increasing interest, existing data are derived from small cohorts. Objective We describe clinical, histological, and radiological outcomes from an established AS programme, where protocol-based biopsies were omitted in favour of MRI-led monitoring. Design, setting, and participants Data on 672 men enrolled in AS between August 2004 and November 2017 (inclusion criteria: Gleason 3 + 3 or 3 + 4 localised prostate cancer, presenting prostate-specific antigen <20 ng/ml, and baseline mpMRI) were collected from the University College London Hospital (UCLH) database. Outcome measurements and statistical analysis Primary outcomes were event-free survival (EFS; event defined as prostate cancer treatment, transition to watchful waiting, or death) and treatment-free survival (TFS). Secondary outcomes included rates of all-cause or prostate cancer–related mortality, metastasis, and upgrading to Gleason ≥4 + 3. Data on radiological and histological progression were also collected. Results and limitations More than 3800 person-years (py) of follow-up were accrued (median: 58 mo; interquartile range 37–82 mo). Approximately 84.7% (95% confidence interval [CI]: 82.0–87.6) and 71.8% (95% CI: 68.2–75.6) of patients remained on AS at 3 and 5 yr, respectively. EFS and TFS were lower in those with MRI-visible (Likert 4–5) disease or secondary Gleason pattern 4 at baseline (log-rank test; p < 0.001). In total, 216 men were treated. There were 24 deaths, none of which was prostate cancer related (6.3/1000 py; 95% CI: 4.1–9.5). Metastases developed in eight men (2.1 events/1000 py; 95% CI: 1.0–4.3), whereas 27 men upgraded to Gleason ≥4 + 3 on follow-up biopsy (7.7 events/1000 py; 95% CI: 5.2–11.3). Conclusions The rates of discontinuation, mortality, and metastasis in MRI-led surveillance are comparable with those of standard AS. MRI-visible disease and/or secondary Gleason grade 4 at baseline are associated with a greater likelihood of moving to active treatment at 5 yr. Further research will concentrate on optimising imaging intervals according to baseline risk. Patient summary In this report, we looked at the outcomes of magnetic resonance imaging (MRI)-based surveillance for prostate cancer in a UK cohort. We found that this strategy could allow routine biopsies to be avoided. Secondary Gleason pattern 4 and MRI visibility are associated with increased rates of treatment. We conclude that MRI-based surveillance should be considered for the monitoring of small prostate tumours.

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Section: Discussionsupporting

confidence: 88%

Section: Discussionmentioning

confidence: 96%

Five-year Outcomes of Magnetic Resonance Imaging–based Active Surveillance for Prostate Cancer: A Large Cohort Study

et al. 2020

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“…This study supports a growing body of evidence that mpMRI may be adopted as the primary surveillance tool for men on AS. The finding regarding PSA velocity should be interpreted carefully as it contrasts with previous studies, which found that PSA dynamics have a limited role as independent predictors of disease progressions in AS .…”

supporting

confidence: 85%

“…In this issue of the BJUI , Gallagher et al. report the outcomes of an AS programme using selective repeat biopsy based on multiparametric MRI (mpMRI) and PSA dynamics. The authors address the important issue of whether mpMRI can be used to safely avoid repeat biopsies in AS protocols.…”

mentioning

confidence: 99%

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Re‐thinking active surveillance for the multiparametric magnetic resonance imaging era

Eldred‐Evans

Ahmed

2019

BJU International

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Unified model involving genomics, magnetic resonance imaging and prostate‐specific antigen density outperforms individual co‐variables at predicting biopsy upgrading in patients on active surveillance for low risk prostate cancer

et al. 2021

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Background Active surveillance (AS) is the reference standard treatment for the management of low risk prostate cancer (PCa). Accurate assessment of tumor aggressiveness guides recruitment to AS programs to avoid conservative treatment of intermediate and higher risk patients. Nevertheless, underestimating the disease risk may occur in some patients recruited, with biopsy upgrading and the concomitant potential for delayed treatment. Aim To evaluate the accuracy of mpMRI and GPS for the prediction of biopsy upgrading during active surveillance (AS) management of prostate cancer (PCa). Method A retrospective analysis was performed on 144 patients recruited to AS from October 2013 to December 2020. Median follow was 4.8 (IQR 3.6, 6.3) years. Upgrading was defined as upgrading to biopsy grade group ≥2 on follow up biopsies. Cox proportional hazard regression was used to investigate the effect of PSA density (PSAD), baseline Prostate Imaging‐Reporting and Data System (PI‐RADS) v2.1 score and GPS on upgrading. Time‐to‐event outcome, defined as upgrading, was estimated using the Kaplan–Meier method with log‐rank test. Results Overall rate of upgrading was 31.9% (n = 46). PSAD was higher in the patients who were upgraded (0.12 vs. 0.08 ng/ml 2 , p = .005), while no significant difference was present for median GPS in the overall cohort (overall median GPS 21; 22 upgrading vs. 20 no upgrading, p = .2044). On univariable cox proportional hazard regression analysis, the factors associated with increased risk of biopsy upgrading were PSA (HR = 1.30, CI 1.16–1.47, p = <.0001), PSAD (HR = 1.08, CI 1.05–1.12, p = <.0001) and higher PI‐RADS score (HR = 3.51, CI 1.56–7.91, p = .0024). On multivariable cox proportional hazard regression analysis, only PSAD (HR = 1.10, CI 1.06–1.14, p = <.001) and high PI‐RADS score (HR = 4.11, CI 1.79–9.44, p = .0009) were associated with upgrading. A cox regression model combining these three clinical features (PSAD ≥0.15 ng/ml 2 at baseline, PI‐RADS Score and GPS) yielded a concordance index of 0.71 for the prediction of upgrading. Conclusion In this study PSAD has higher accuracy over baseline PI‐RADS score and GPS score for the prediction of PCa upgrading during AS. However, combined use of PSAD, GPS and PI‐RADS Score yielded the highest predictive ability with a concordance index of 0.71.

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Four‐year outcomes from a multiparametric magnetic resonance imaging (MRI)‐based active surveillance programme: PSA dynamics and serial MRI scans allow omission of protocol biopsies

Abstract: Men with low-risk Gleason 3 + 3 prostate cancer on active surveillance can forgo protocol biopsies in favour of MRI and PSA monitoring with selective re-biopsy.

Cited by 40 publications

References 25 publications

Five-year Outcomes of Magnetic Resonance Imaging–based Active Surveillance for Prostate Cancer: A Large Cohort Study

Five-year Outcomes of Magnetic Resonance Imaging–based Active Surveillance for Prostate Cancer: A Large Cohort Study

Re‐thinking active surveillance for the multiparametric magnetic resonance imaging era

Unified model involving genomics, magnetic resonance imaging and prostate‐specific antigen density outperforms individual co‐variables at predicting biopsy upgrading in patients on active surveillance for low risk prostate cancer

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