Appropriateness Criteria for Active Surveillance of Prostate Cancer

Upgrading on Per Protocol versus For Cause surveillance prostate biopsies: An opportunity to decreasing the burden of active surveillance

BACKGROUND

Most prostate cancer (PC) active surveillance (AS) protocols recommend "Per Protocol" surveillance biopsy (PPSBx) every 1-3 years, even if clinical and imaging parameters remained stable. Herein, we compared the incidence of upgrading on biopsies that met criteria for "For Cause" surveillance biopsy (FCSBx) versus PPSBx.

METHODS

We retrospectively reviewed men with GG1 PC on AS in the Michigan Urological Surgery Improvement Collaborative (MUSIC) registry. Surveillance prostate biopsies obtained 1 year after diagnosis were classified as either PPSBx or FCSBx. Biopsies were retrospectively deemed FCSBx if any of these criteria were met: PSA velocity > 0.75 ng/mL/year; rise in PSA > 3 ng from baseline; surveillance magnetic resonance imaging (MRI) (sMRI) with a PIRADS ≥ 4; change in DRE. Biopsies were classified PPSBx if none of these criteria were met. The primary outcome was upgrading to ≥GG2 or ≥GG3 on surveillance biopsy. The secondary objective was to assess for the association of reassuring (PIRADS ≤ 3) confirmatory or surveillance MRI findings and upgrading for patients undergoing PPSBx. Proportions were compared with the chi-squared test.

RESULTS

We identified 1773 men with GG1 PC in MUSIC who underwent a surveillance biopsy. Men meeting criteria for FCSBx had more upgrading to ≥GG2 (45%) and ≥GG3 (12%) compared with those meeting criteria for PPSBx (26% and 4.9%, respectively, p < 0.001 and p < 0.001). Men with a reassuring confirmatory or surveillance MRI undergoing PPSBx had less upgrading to ≥GG2 (17% and 17%, respectively) and ≥GG3 (2.9% and 1.8%, respectively) disease compared with men without an MRI (31% and 7.4%, respectively).

CONCLUSIONS

Patients undergoing PPSBx had significantly less upgrading compared with men undergoing FCSBx. Confirmatory and surveillance MRI seem to be valuable tools to stratify the intensity of surveillance biopsies for men on AS. These data may help inform the development of a risk-stratified, data driven AS protocol.

Prostate Cancer Tumor Volume and Genomic Risk

Background

Despite the historic association of higher prostate cancer volume with worse oncologic outcomes, little is known about the impact of tumor volume on cancer biology.

Objective

To characterize the relationship between tumor volume (measured by percent positive cores [PPC]) and cancer biology (measured by Decipher genomic risk classifier [GC]) in men who underwent prostate biopsy.

Design setting and participants

Prostate biopsies from 52 272 men profiled with Decipher captured in a population-based prospective tumor registry were collected from 2016 to 2021.

Outcome measurements and statistical analysis

The degree of distribution and correlation of PPC with a GC score across grade group (GG) strata were examined using the Mann-Whitney U test, Pearson correlation coefficient, and multivariable linear regression controlled for clinicopathologic characteristics.

Results and limitations

A total of 38 921 (74%) biopsies passed quality control (14 331 GG1, 16 159 GG2, 5661 GG3, 1775 GG4, and 995 GG5). Median PPC and GC increased with sequentially higher GG. There was an increasingly positive correlation (r) between PPC and GC in GG2-5 prostate cancer (r [95% confidence interval {CI}]: 0.07 [0.5, 0.8] in GG2, 0.15 [0.12, 0.17] in GG3, 0.20 [0.15, 0.24] in GG4, and 0.25 [0.19, 0.31] in GG5), with no correlation in GG1 disease (r = 0.01, 95% CI [-0.001, 0.03]). In multivariable linear regression, GC was significantly associated with higher PPC for GG2-5 (all p < 0.05) but was not significantly associated with PPC for GG1. Limitations include retrospective design and a lack of final pathology from radical prostatectomy specimens.

Conclusions

Higher tumor volume was associated with worse GC for GG2-5 prostate cancer, whereas tumor volume was not associated with worse GC for GG1 disease. The finding that tumor volume is not associated with worse cancer biology in GG1 disease encourages active surveillance for most patients irrespective of tumor volume.

Patient summary

We studied the relationship between prostate cancer tumor volume and cancer biology, as measured by the Decipher genomic risk score, in men who underwent prostate biopsy. We found that tumor volume was not associated with worse cancer biology for low-grade prostate cancer. Our findings reassuringly support recent guidelines to recommend active surveillance for grade group 1 prostate cancer in most patients, irrespective of tumor volume.

Five-year follow-up study of a population-based prospective cohort of men with low-risk prostate cancer: the treatment options in prostate cancer study (TOPCS): study protocol

INTRODUCTION

Active surveillance (AS) is recommended for men with low-risk prostate cancer (LRPC) to reduce overtreatment and to maintain patients' quality of life (QOL). However, whether African American (AA) men can safely undergo AS is controversial due to concerns of more aggressive disease and lack of empirical data on the safety and effectiveness of AS in this population. Withholding of AS may lead to a lost opportunity for improving survivorship in AA men. In this study, peer-reviewed and funded by the US Department of Defense, we will assess whether AS is an equally effective and safe management option for AA as it is for White men with LRPC.

METHODS AND ANALYSIS

The project extends follow-up of a large contemporary population-based cohort of LRPC patients (n=1688) with a high proportion of AA men (~20%) and well-characterised baseline and 2-year follow-up data. The objectives are to (1) determine any racial differences in AS adherence, switch rate from AS to curative treatment and time to treatment over 5 years after diagnosis, (2) compare QOL among AS group and curative treatment group over time, overall and by race and (3) evaluate whether reasons for switching from AS to curative treatment differ by race. Validation of survey responses related to AS follow-up procedures is being conducted through medical record review. We expect to obtain 5-year survey from ~900 (~20% AA) men by the end of this study to have sufficient power. Descriptive and inferential statistical techniques will be used to examine racial differences in AS adherence, effectiveness and QOL.

ETHICS AND DISSEMINATION

The parent and current studies were approved by the Institutional Review Boards at Wayne State University and Emory University. Since it is an observational study, ethical or safety risks are low. We will disseminate our findings to relevant conferences and peer-reviewed journals.

Comparison of the treatment of men with prostate cancer between the US and England: an international population-based study

INTRODUCTION

The treatment of prostate cancer varies between the United States (US) and England, however this has not been well characterised using recent data. We therefore investigated the extent of the differences between US and English patients with respect to initial treatment.

METHODS

We used the Surveillance, Epidemiology, and End Results (SEER) database to identify men diagnosed with prostate cancer in the US and the treatments they received. We also used the National Prostate Cancer Audit (NPCA) database for the same purposes among men diagnosed with prostate cancer in England. Next, we used multivariable regression to estimate the adjusted risk ratio (aRR) of receiving radical local treatment for men with non-metastatic prostate cancer according to the country of diagnosis (US vs. England). The five-tiered Cambridge Prognostic Group (CPG) classification was included as an interaction term.

RESULTS

We identified 109,697 patients from the SEER database, and 74,393 patients from the NPCA database, who were newly diagnosed with non-metastatic prostate cancer between April 1st 2014 and December 31st 2016 with sufficient information for risk stratification according to the CPG classification. Men in the US were more likely to receive radical local treatment across all prognostic groups compared to men in England (% radical treatment US vs. England, CPG1: 38.1% vs. 14.3% - aRR 2.57, 95% CI 2.47-2.68; CPG2: 68.6% vs. 52.6% - aRR 1.27, 95% CI 1.25-1.29; CPG3: 76.7% vs. 67.1% - aRR 1.12, 95% CI 1.10-1.13; CPG4: 82.6% vs. 72.4% - aRR 1.09, 95% CI 1.08-1.10; CPG5: 78.2% vs. 71.7% - aRR 1.06, 95% CI 1.04-1.07) CONCLUSIONS: Treatment rates were higher in the US compared to England raising potential over-treatment concerns for low-risk disease (CPG1) in the US and under-treatment of clinically significant disease (CPG3-5) in England.

Implications of a Novel Biopsy Downloading System on Prostate Cancer Detection Rate, Surveillance and Focal Therapy - A Prospective Study

OBJECTIVE

To examine the SmartBx, a novel biopsy downloading system, allowing downloading of biopsy cores with maximal core preservation as prostate biopsy sampling lacks preservation of core configuration & orientation.

METHODS

We prospectively collected cores from TRUS biopsy patients. Half were collected using the SmartBx & half using standard downloading. We measured length of the first ∼3200 cores through various pathology steps and within core cancer length in 160 SmartBx cores. We compared core length, yield (% of core available for final analysis/ original core on needle) and cancer detection rate between SmartBx and standard cores. T-test or chi-square were used for analysis.

RESULTS

6014 cores were collected from 429 patients. Core length (12.3mm vs. 10mm; P<.01) and core yield (77.5% vs. 62.2%; P<.01) were significantly higher using the SmartBx compared to standard method, respectively. Cancer detection rate was significantly higher using the SmartBx for patients with PSA<10 (10.1% vs. 7.96%; n=2080 & n=2073, respectively; P<.016). Other subgroups showed non-significant higher detection rate for SmartBx cores. We noticed higher detection rate of clinically significant prostate cancer. Within core cancer length in 160 SmartBx cores was significantly lower compared to standard positive whole cores (4.45mm vs. 10.9mm; P<.001). Assuming cancer site a perfect sphere, disease volume was 11-fold lower for within core compared to entire core (46.1mm vs. 679.9mm; P<.0001).

CONCLUSIONS

SmartBx results in significant higher core length, yield and cancer detection rate. Precise localization of within core tumor foci allows significant reduction in tumor volume.

A new three-step method for using inverse propensity weighting with latent class analysis

Bias-adjusted three-step latent class analysis (LCA) is widely popular to relate covariates to class membership. However, if the causal effect of a treatment on class membership is of interest and only observational data is available, causal inference techniques such as inverse propensity weighting (IPW) need to be used. In this article, we extend the bias-adjusted three-step LCA to incorporate IPW. This approach separates the estimation of the measurement model from the estimation of the treatment effect using IPW only for the later step. Compared to previous methods, this solves several conceptual issues and more easily facilitates model selection and the use of multiple imputation. This new approach, implemented in the software Latent GOLD, is evaluated in a simulation study and its use is illustrated using data of prostate cancer patients.

The Comparison of Imaging and Clinical Methods to Estimate Prostate Volume: A Single-Centre Retrospective Study

BACKGROUND

Prostate volume (PV) is a useful tool in risk stratification, diagnosis, and follow-up of numerous prostatic diseases including prostate cancer and benign prostatic hypertrophy. There is currently no accepted ideal PV measurement method.

OBJECTIVE

This study compares multiple means of PV estimation, including digital rectal examination (DRE), transrectal ultrasound (TRUS), and magnetic resonance imaging (MRI), and radical prostatectomy specimens to determine the best volume measurement style.

METHODS

A retrospective, observational, single-site study with patients identified using an institutional database was performed. A total of 197 patients who underwent robot-assisted radical prostatectomy were considered. Data collected included age, serum PSA at the time of the prostate biopsy, clinical T stage, Gleason score, and PVs for each of the following methods: DRE, TRUS, MRI, and surgical specimen weight (SPW) and volume.

RESULTS

A paired t test was performed, which reported a statistically significant difference between PV measures (DRE, TRUS, MRI ellipsoid, MRI bullet, SP ellipsoid, and SP bullet) and the actual prostate weight. Lowest differences were reported for SP ellipsoid volume (M = -2.37; standard deviation [SD] = 10.227; t[167] = -3.011; and p = 0.003), MRI ellipsoid volume (M = -4.318; SD = 9.53; t[167] = -5.87; and p = 0.000), and MRI bullet volume (M = 5.31; SD = 10.77; t[167] = 6.387; and p = 0.000).

CONCLUSION

The PV obtained by MRI has proven to correlate with the PV obtained via auto-segmentation software as well as actual SPW, while also being more cost-effective and time-efficient. Therefore, demonstrating that MRI estimated the PV is an adequate method for use in clinical practice for therapeutic planning and patient follow-up.

Outcomes of Active Surveillance for Men With Intermediate Risk Prostate Cancer: A Population-Based Analysis

OBJECTIVE

To assesses if active surveillance (AS) is an appropriate treatment modality for patients with intermediate risk (IR) prostate cancer (PCa) utilizing population-level data to compare the survival outcomes of men with low risk (LR) and IR PCa initially treated with AS, watchful waiting (WW) or active treatment (AT).

METHODS

In total, 166,244 patients were initially identified in the surveillance, epidemiology, and end results database using biopsy Gleason grade group (GG) alone-GG1 and GG2. In total, 94,891 patients with GG1 and GG2 disease were further stratified by National Comprehensive Cancer Network risk categories-LR, favorable IR (fIR), and unfavorable IR (uIR). Predictors of cancer-specific (CSS) and overall survival (OS) were analyzed, stratified by risk classification and initial treatment-AT (first-line curative surgery or radiotherapy), AS or WW, utilizing the new "Watchful waiting recode (2010+)" variable.

RESULTS

We found GG2 patients on AS had worse CSS and OS than GG2 patients who received AT and GG1 patients treated with AS or AT; these trends persist within the National Comprehensive Cancer Network fIR and uIR cohorts. WW patients (GG1, GG2, LR, fIR, and uIR) had the worst survival outcomes of any cohort (log-rank tests P < .05).

CONCLUSIONS

We demonstrate a significantly worse 5-year CSS and OS for men with GG2, fIR, and uIR PCa treated with AS compared to AT. Our analysis suggests that AS should not be the preferred treatment modality for IR PCa.

Immunohistochemistry for Prostate Biopsy-Impact on Histological Prostate Cancer Diagnoses and Clinical Decision Making

BACKGROUND

To test the value of immunohistochemistry (IHC) staining in prostate biopsies for changes in biopsy results and its impact on treatment decision-making.

METHODS

Between January 2017-June 2020, all patients undergoing prostate biopsies were identified and evaluated regarding additional IHC staining for diagnostic purpose. Final pathologic results after radical prostatectomy (RP) were analyzed regarding the effect of IHC at biopsy.

RESULTS

Of 606 biopsies, 350 (58.7%) received additional IHC staining. Of those, prostate cancer (PCa) was found in 208 patients (59.4%); while in 142 patients (40.6%), PCa could be ruled out through IHC. IHC patients harbored significantly more often Gleason 6 in biopsy (p < 0.01) and less suspicious baseline characteristics than patients without IHC. Of 185 patients with positive IHC and PCa detection, IHC led to a change in biopsy results in 81 (43.8%) patients. Of these patients with changes in biopsy results due to IHC, 42 (51.9%) underwent RP with 59.5% harboring ≥pT3 and/or Gleason 7-10.

CONCLUSIONS

Patients with IHC stains had less suspicious characteristics than patients without IHC. Moreover, in patients with positive IHC and PCa detection, a change in biopsy results was observed in >40%. Patients with changes in biopsy results partly underwent RP, in which 60% harbored significant PCa.

Active surveillance for prostate cancer: selection criteria, guidelines, and outcomes

INTRODUCTION

Active surveillance (AS) has been widely adopted for the management of men with low-risk prostate cancer. However, there is still a lack of consensus surrounding the optimal approach for monitoring men in AS protocols. While conservative management aims to reduce the burden of invasive testing without compromising oncological safety, inadequate assessment can result in misclassification and unintended over- or undertreatment, leading to increased patient morbidity, cost, and undue risk. No universally accepted AS protocol exists, although numerous strategies have been developed in an attempt to optimize the management of clinically localized disease. Variability in selection criteria, reclassification, triggers for definitive treatment, and follow-up exists between guidelines and institutions for AS. In this review, we summarize the landscape of AS by providing an overview of the existing AS protocols, guidelines, and their published outcomes.

METHODS

A comprehensive electronic search was performed to identify representative studies and guidelines pertaining to AS selection criteria and outcomes.

CONCLUSION

While AS is a safe and increasingly utilized treatment modality for lower-risk forms of PCa, ongoing research is needed to optimize patient selection as well as surveillance protocols along with improved implementation across practices. Further, assessment of companion risk assessment tools, such as mpMRI and tissue-based biomarkers, is also needed and will require rigorous prospective study.

Urologists' Perceptions of Active Surveillance and Their Recommendations for Low-risk Prostate Cancer Patients

OBJECTIVE

To assess practicing urologists' attitudes and perceptions of active surveillance (AS) and other treatment options for low-risk prostate cancer.

METHODS

This was a cross-sectional survey of urologists practicing in Michigan and Georgia. Urologists were asked about perceptions and practices pertaining to AS.

RESULTS

Overall, 225 urologists completed the survey; 147 (65%) were from Michigan and 78 (35%) were from Georgia. Most urologists reported they provided (99%), discussed (97%), and offered (61%) AS to all of their low-risk patients. Most believed AS is effective (97%) and underused (90%), while 80% agreed that curative therapy (surgery, radiation) is overused in the United States. Although most (79%) endorse that Black men are more likely to have aggressive low-risk disease, 89% reported feeling comfortable recommending AS to Black men. In multivariable analysis, significant provider-related predictors of AS recommendation were practice location, number of years in practice, beliefs pertaining to survival benefit of prostatectomy and effectiveness of AS, and expectation that patients are not interested in AS. The patient characteristics of race, age, life expectancy, fear of cancer progression, and fear of treatment side effects were also significant predictors of AS recommendations.

CONCLUSION

Most urologists surveyed stated that AS is effective and underused for low-risk prostate cancer . Overall, urologists are much less likely to recommend AS to younger men and slightly less to Black men. AS recommendations varied by practice location and by years in practice. These findings indicate targeted educational efforts in the US are needed to influence urologists toward greater acceptance of AS.

Initial Observation of a Large Proportion of Patients Presenting with Clinical Stage T1 Renal Masses: Results from the MUSIC-KIDNEY Statewide Collaborative

BACKGROUND

While surgical excision remains the principal management strategy for clinical T1 renal masses (cT1RMs), the rates of noninterventional approaches are not well known. Most single-institution and population-based series suggest rates below 10%.

OBJECTIVE

To evaluate the use of observation for newly diagnosed cT1RM patients in academic and community-based practices across a statewide collaborative.

DESIGN SETTING AND PARTICIPANTS

The Michigan Urological Surgery Improvement Collaborative-Kidney mass: Identifying and Defining Necessary Evaluation and therapY (MUSIC-KIDNEY) commenced data collection in September 2017 by recording clinical, radiographic, pathologic, and short-term follow-up data for cT1RM patients at 13 diverse practices. Patients with complete data were assessed at >90 d after initial evaluation as to whether observation or treatment was performed.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Relationships with outcomes were analyzed using multivariable logistic regression, chi-square test, and Wilcoxon rank-sum test.

RESULTS AND LIMITATIONS

Out of 965 patients, observation was employed in 48% (n = 459), with practice-level rates ranging from 0% to 68%. Patients managed with observation (vs treatment) were significantly older (71.2 vs 62.8 yr, p <  0.0001) and had smaller tumors (2.3 vs 3.4 cm, p <  0.0001). Observation was used for 53.5% of cT1a renal masses, for 29.9% of cT1b renal masses, and for 42.5%, 53.7%, and 63.9% of radiographically solid, Bosniak III-IV cystic, and indeterminate cT1RMs, respectively. Factors significantly associated with observation in multivariable analysis included lesion type (Bosniak III-IV vs solid, p =  0.017), tumor stage (cT1a vs cT1b, p <  0.001), and higher age (p <  0.001). A short duration of follow-up limits the assessment of longer-term patient management.

CONCLUSIONS

Noninterventional management of cT1RMs is common across the MUSIC-KIDNEY collaborative, with wide variability across practices. Factors associated with observation were advanced age, smaller tumor size, and cystic tumor type. Durability of the initial decision for observation (delayed intervention vs active surveillance vs less active surveillance) will be a focus of subsequent study.

PATIENT SUMMARY

The Michigan Urological Surgery Improvement Collaborative: Kidney mass: Identifying and Defining Necessary Evaluation and therapY (MUSIC-KIDNEY) quality improvement collaborative assessed the current utilization of initial observation of a renal mass ≤7 cm across a diverse group of urology practices and found it to be used in 48% of patients. We found that the factors predicting observation were advanced age, smaller tumor size, and cystic tumor type.

Management of prostate cancer after holmium laser enucleation of the prostate

INTRODUCTION

Holmium laser enucleation of the prostate (HoLEP) is effective in treating lower urinary tract symptoms from prostatic disease. We investigate the role of HoLEP in the management of patients with benign prostatic hypertrophy (BPH) and prostate cancer (CaP).

METHODS

Retrospective review of data regarding all patients undergoing HoLEP at a single institution was performed. Pre- and postoperative PSA, multiparametric MRI, and pathology results were analyzed for those with CaP identified prior to or incidentally at HoLEP.

RESULTS

From February 2016 to February 2020, 201 patients underwent HoLEP. Twelve patients had CaP diagnosed before HoLEP: 6 patients with GG1 are on active surveillance (AS), 3 of 4 intermediate-risk patients are on AS and 1 received treatment for disease progression, and both high-risk CaP patients achieved symptomatic benefit from HoLEP and are receiving systemic therapy for CaP. Twenty-one patients (11.1%) with incidentally detected CaP at HoLEP remain on AS or watchful waiting based on clinical scenario.

CONCLUSION

Screening for CaP in HoLEP candidates with PSA and MRI is recommended given that >10% will have incidental CaP. After HoLEP for BPH/LUTS, patients with CaP can be surveilled with PSA and/or MRI. Further investigation is warranted to determine the durability of success of these approaches.

Impact of Early Confirmatory Tests on Upgrading and Conversion to Treatment in Prostate Cancer Patients on Active Surveillance

OBJECTIVES

To assess the impact of confirmatory tests on active surveillance (AS) biopsy disease reclassification and progression to treatment in men with favorable risk prostate cancer (FRPC).

METHODS

We searched the MUSIC registry for men with FRPC managed with AS without or with a confirmatory test. Confirmatory tests included (1) repeat prostate biopsy, (2) genomic tests, (3) prostate magnetic resonance imaging (MRI), or (4) MRI followed by a post-MRI biopsy. Confirmatory test results were deemed reassuring (RA) or nonreassuring (nonRA) according to predefined criteria. Kaplan-Meier curves and multivariable Cox regression models were used to compare surveillance biopsy disease reclassification-free survival and treatment-free survival.

RESULTS

Of the 2,514 men with FRPC who were managed on AS, 1211 (48%) men obtained a confirmatory test. We noted differences in the 12-month unadjusted surveillance biopsy disease reclassification-free probability (68%, 83%, and 90%, P < .0001) and 24-month unadjusted treatment-free probability (55%, 81%, and 79%, P < .0001), for men with nonRA confirmatory tests, no confirmatory test, and RA confirmatory tests, respectively. Excluding patients with genomic confirmatory tests, men with RA confirmatory tests were associated with a lower hazard (hazard ratio [HR] 0.57, 95% confidence interval [CI] 0.38-0.84, P = .005) and men with nonRA confirmatory tests had an increased hazard (HR 1.97, 95% CI 1.22-3.19, P = .006) of surveillance disease reclassification compared with men without confirmatory tests in the multivariable model.

CONCLUSION

These data suggest men with RA confirmatory tests have less surveillance biopsy reclassification and remain on AS longer than men with nonRA test results. Confirmatory tests may help risk stratify men considering active surveillance.

Prostate Cancer, Version 2.2019, NCCN Clinical Practice Guidelines in Oncology

The NCCN Guidelines for Prostate Cancer include recommendations regarding diagnosis, risk stratification and workup, treatment options for localized disease, and management of recurrent and advanced disease for clinicians who treat patients with prostate cancer. The portions of the guidelines included herein focus on the roles of germline and somatic genetic testing, risk stratification with nomograms and tumor multigene molecular testing, androgen deprivation therapy, secondary hormonal therapy, chemotherapy, and immunotherapy in patients with prostate cancer.

Limitations of abdominopelvic CT and multiparametric MR imaging for detection of lymph node metastases prior to radical prostatectomy

PURPOSE

To investigate the performance of pre-surgery CT and multiparametric MRI (mpMRI) to identify lymph node (LN) metastases in the Michigan Urological Surgery Improvement Collaborative (MUSIC). Abdominopelvic CT and mpMRI are commonly used for intermediate- and high-risk prostate cancer (PCa) staging.

METHODS

Retrospective analysis of the MUSIC registry identified patients undergoing robot-assisted radical prostatectomy (RP) between 3/2012 and 7/2018. Patients were classified according to pre-surgery imaging modality. Primary outcomes were operating characteristics of CT and mpMRI for detection of pathologic LN involvement (pN1).

RESULTS

A total of 10,250 patients underwent RP and 3924 patients (38.3%) underwent CT and/or mpMRI prior to surgery. Suspicion for LN involvement was identified on 2.3% CT and 1.9% mpMRI. Overall, 391 patients were pN1(3.8%), including 0.1% low-, 2.1% intermediate-, and 10.9% high-risk PCa patients. Of 235 pN1 patients that underwent CT prior, far more had negative (91.1%) than positive (8.9%) findings, yielding sensitivity: 8.9%, specificity: 98.3%, negative predictive value (NPV): 92.1%, and positive predictive value (PPV): 32.3% for CT with regard to LN metastases. Similarly, more patients with pN1 disease had negative mpMRI (81.0%) then suspicious or indeterminate MRI (19.0%), yielding sensitivity: 19.0%, specificity: 97.3%, NPV: 95.9%, and PPV: 26.7%.

CONCLUSIONS

Abdominopelvic CT and mpMRI have clear limitations in identifying LN metastases. Additional clinicopathologic features should be considered when making management decisions, as 2.1% and 10.9% with intermediate-and high-risk cancer had metastatic LNs. The majority of pN1 patients had a negative CT or a negative/indeterminate mpMRI prior to RP. Pelvic LN dissection should be performed in RP patients with intermediate- or high-risk PCa, independent of preoperative imaging results.

A systematic review of the unmet supportive care needs of men on active surveillance for prostate cancer

OBJECTIVE

Understanding the unmet supportive care needs of men on active surveillance for prostate cancer may enable researchers and health professionals to better support men and prevent discontinuation when there is no evidence of disease progression. This review aimed to identify the specific unmet supportive care needs of men on active surveillance.

METHODS

A systematic review following PRISMA guidelines was conducted. Databases (Pubmed, Embase, PsycINFO, and CINAHL) were searched to identify qualitative and/or quantitative studies that reported unmet needs specific to men on active surveillance. Quality appraisals were conducted before results were narratively synthesised.

RESULTS

Of the 3613 unique records identified, only eight articles were eligible (five qualitative and three cross-sectional studies). Unmet Informational, Emotional/Psychological, Social, and "Other" needs were identified. Only three studies had a primary aim of investigating unmet supportive care needs. Small active surveillance samples, use of nonvalidated measures, and minimal reporting of author reflexivity in qualitative studies were the main quality issues identified.

CONCLUSIONS

The unmet needs of men on active surveillance is an underresearched area. Preliminary evidence suggests the information available and provided to men during active surveillance is perceived as inadequate and inconsistent. Men may also be experiencing unmet psychological/emotional, social, and other needs; however, further representative, high-quality research is required to understand the magnitude of this issue. Reporting results specific to treatment type and utilising relevant theories/models (such as the social ecological model [SEM]) is recommended to ensure factors that may facilitate unmet needs are appropriately considered and reported.

Leveraging the clinical collaborative model to drive value improvement

PURPOSE OF REVIEW

Physician-led quality improvement collaboratives have emerged across surgical disciplines as a means to measure and subsequently improve the quality and cost of care. In this review, we will provide an overview of recent successes within quality improvement collaboratives, as well as discuss future opportunities for such initiatives.

RECENT FINDINGS

Successful quality improvement collaboratives have coupled data registries with a collegial environment to achieve data-driven improvements in care across diverse practice settings. Such efforts have a track record for accomplishing specific patient safety gains, and have more recently addressed complex care scenarios where data and consensus building have been leveraged to clarify optimal care pathways. Collaboratives are currently exploring mechanisms to meaningfully impact increasingly complex elements of care delivery, such as individual surgeon performance.

SUMMARY

Quality improvement collaboratives are in a unique position to understand patterns in care across populations, lead evidence-based assessments of variation in quality, and to attempt to intervene to improve outcomes based on the data they accumulate. As healthcare increasingly shifts to emphasize quality of care, physician-led collaboratives represent an important mechanism to drive improvement.

The use of prostate MR for targeting prostate biopsies

Management of prostate cancer relies heavily on accurate risk stratification obtained through biopsies, which are conventionally performed under transrectal ultrasound (TRUS) guidance. Yet, multiparametric MRI has grown to become an integral part of the care of males with known or suspected prostate cancer. This article will discuss in detail the different MRI-targeted biopsy techniques, their advantages and disadvantages, and the impact they have on patient management.

Determination of Prostate Volume: A Comparison of Contemporary Methods

RATIONALE AND OBJECTIVES

Prostate volume (PV) determination provides important clinical information. We compared PVs determined by digital rectal examination (DRE), transrectal ultrasound (TRUS), magnetic resonance imaging (MRI) with or without three-dimensional (3D) segmentation software, and surgical prostatectomy weight (SPW) and volume (SPV).

MATERIALS AND METHODS

This retrospective review from 2010 to 2016 included patients who underwent radical prostatectomy ≤1 year after multiparametric prostate MRI. PVs from DRE and TRUS were obtained from urology clinic notes. MRI-based PVs were calculated using bullet and ellipsoid formulas, automated 3D segmentation software (MRI-A3D), manual segmentation by a radiologist (MRI-R3D), and a third-year medical student (MRI-S3D). SPW and SPV were derived from pathology reports. Intraclass correlation coefficients compared the relative accuracy of each volume measurement.

RESULTS

Ninety-nine patients were analyzed. Median PVs were DRE 35 mL, TRUS 35 mL, MRI-bullet 49 mL, MRI-ellipsoid 39 mL, MRI-A3D 37 mL, MRI-R3D 36 mL, MRI-S3D 36 mL, SPW 54 mL, SPV-bullet 47 mL, and SPV-ellipsoid 37 mL. SPW and bullet formulas had consistently large PV, and formula-based PV had a wider spread than PV based on segmentation. Compared to MRI-R3D, the intraclass correlation coefficient was 0.91 for MRI-S3D, 0.90 for MRI-ellipsoid, 0.73 for SPV-ellipsoid, 0.72 for MRI-bullet, 0.71 for TRUS, 0.70 for SPW, 0.66 for SPV-bullet, 0.38 for MRI-A3D, and 0.33 for DRE.

CONCLUSIONS

With MRI-R3D measurement as the reference, the most reliable methods for PV estimation were MRI-S3D and MRI-ellipsoid formula. Automated segmentations must be individually assessed for accuracy, as they are not always truly representative of the prostate anatomy. Manual segmentation of the prostate does not require expert training.

An Integrative Approach to Prostate Cancer

OBJECTIVES

The mostly indolent natural history and long overall survival associated with a diagnosis of prostate cancer provides a unique opportunity for men to explore diet and lifestyle interventions to alter the trajectory of their disease. As many patients may be appropriate for postponing conventional therapy, the effects of various integrative interventions can be investigated. In addition, treatment of prostate cancer with surgery, radiation, or androgen deprivation therapy, all may produce physical or psychological side effects that could be amenable to complementary therapies. This article serves to review salient information in the published literature.

DESIGN

A review of published research was conducted.

RESULTS

A plant-based antioxidant-rich diet with an emphasis on cruciferous vegetables, tomatoes, soy, pomegranate, and marine omega 3 fatty acids while avoiding saturated fats, including dairy products is the best option. Supplementation with vitamin D3, omega 3, and some nutraceutical-based preparations may be advised. It is likely prudent to avoid vitamin E and selenium supplements. Physical activity has been shown to have multiple benefits in men diagnosed with all stages of prostate cancer from strengthening bones, improving body habitus, and enhancing overall wellbeing. Yoga, combining physical activity with a mind-body component, has been shown to have a salutogenic effect in both prostate cancer patients and their caregivers. Traditional Chinese Medicine may be particularly useful in managing side effects of conventional treatments, especially the hot flashes associated with androgen deprivation therapy. Although the long natural history, availability of a useful blood marker of disease progression and prolonged survival are overall positive features, they also combine to allow men to live for a long time with diagnosed cancer, fear of progression, or recurrence and fixation on changes in their prostate-specific antigen level. The resultant stress can be deleterious to general health as well as possibly the natural history of their disease. Mind-body interventions to reduce stress, including mindfulness-based stress reduction and support groups may be useful adjunctive therapies.

CONCLUSION

Men with prostate cancer may benefit from lifestyle and complementary interventions integrated with their conventional care.

askMUSIC: Leveraging a Clinical Registry to Develop a New Machine Learning Model to Inform Patients of Prostate Cancer Treatments Chosen by Similar Men

BACKGROUND

Clinical registries provide physicians with a means for making data-driven decisions but few opportunities exist for patients to interact with registry data to help make decisions.

OBJECTIVE

We sought to develop a web-based system that uses a prostate cancer (CaP) registry to provide newly diagnosed men with a platform to view predicted treatment decisions based on patients with similar characteristics.

DESIGN, SETTING, AND PARTICIPANTS

The Michigan Urological Surgery Improvement Collaborative (MUSIC) is a quality improvement consortium of urology practices that maintains a prospective registry of men with CaP. We used registry data from 45 MUSIC urology practices from 2015 to 2017 to develop and validate a random forest machine learning model. After fitting the random forest model to a derivation cohort consisting of a random two-thirds sample of patients after stratifying by practice location, we evaluated the model performance in a validation cohort consisting of the remaining one-third of patients using a multiclass area under the curve (AUC) measure and calibration plots.

RESULTS AND LIMITATIONS

We identified 7543 men diagnosed with CaP, of whom 45% underwent radical prostatectomy, 30% surveillance, 17% radiation therapy, 5.6% androgen deprivation, and 1.8% watchful waiting. The personalized prediction for patients in the validation cohort was highly accurate (AUC 0.81).

CONCLUSIONS

Using clinical registry data and machine learning methods, we created a web-based platform for patients that generates accurate predictions for most CaP treatments.

PATIENT SUMMARY

We have developed and tested a tool to help men newly diagnosed with prostate cancer to view predicted treatment decisions based on similar patients from our registry. We have made this tool available online for patients to use.

Association Between Early Confirmatory Testing and the Adoption of Active Surveillance for Men With Favorable-risk Prostate Cancer

OBJECTIVE

To examine the relationship between the use and results of early confirmatory testing and persistence on active surveillance (AS).

METHODS

We identified all men in the Michigan Urological Surgery Improvement Collaborative registry diagnosed with favorable-risk prostate cancer from June 2016 to June 2017. We next examined trends in the use of early confirmatory test(s), defined as repeat biopsy, prostate magnetic resonance imaging, or molecular classifiers obtained within 6 months of the initial cancer diagnosis, in patients with favorable-risk prostate cancer. We then compared the proportion of men remaining on AS 6 months after diagnosis according to reassuring vs nonreassuring results, also stratifying by age and Gleason score.

RESULTS

Among 2529 patients, 32.7% underwent early confirmatory testing within 6 months of diagnosis. Its use increased from 25.4% in the second quarter of 2016 to 34.9% in the second quarter of 2017 (P = .025). Molecular classifiers were most frequently used (55%), followed by magnetic resonance imaging (34%) and repeat biopsy (11%). Sixty-four percent (n = 523) had a reassuring result. Rates of AS were higher for patients with early reassuring results; 82% remained on AS (n = 427) compared to 52% (n = 157) of those with nonreassuring results and 51% (n = 873) with no early confirmatory testing (P <.001).

CONCLUSION

Rates of AS are higher among men with early reassuring results, supporting the clinical utility of these tests. Nonetheless, high rates of AS among patients with nonreassuring results underscore the complexity of shared decision-making in this setting.

Collaborative quality improvement

PURPOSE OF REVIEW

Quality improvement collaboratives were developed in many medical and surgical disciplines with the goal of measuring and improving the quality of care provided to patients. The aim of this review is to provide an overview of surgical quality improvement collaboratives, and in particular those aimed at improving urological care.

RECENT FINDINGS

Quality improvement collaboratives collect high-quality data using standardized methodologies, and use the data to provide feedback to physicians and practices, and then implement processes to improve patient outcomes. The largest regional collaborative in urology is the Michigan Urological Surgery Improvement Collaborative (MUSIC). Recent efforts by this group have been focused at understanding variation in care, improving patient selection for treatment, reducing treatment morbidity and measuring and optimizing technical skill. The American Urological Association has also recently launched a national quality registry (AQUA), with an initial focus on prostate cancer care.

SUMMARY

By understanding factors that result in exemplary performance, quality improvement collaboratives are able to develop best practices around areas of care with high variation that have the potential to improve outcomes and reduce costs. These developments have been made possible by the unique model offered by the collaborative structure with the goal of improving patient care at a population level.

Targeted Prostate Biopsy in the Era of Active Surveillance

Targeted prostate biopsy using magnetic resonance imaging (MRI) guidance is improving the accuracy of prostate cancer (CaP) diagnosis. This new biopsy technology is especially important for men undergoing active surveillance, improving patient selection for enrollment and enabling precise longitudinal monitoring. Magnetic resonance imaging/ultrasound fusion biopsy allows for 3 functions not previously possible with US-guided biopsy: targeting of suspicious regions, template-mapping for systematic sampling, and tracking of cancer foci over time. This article reviews the evolving role of the new biopsy methods in active surveillance, including the UCLA Active Surveillance pathway, which has incorporated magnetic resonance imaging/ultrasound fusion biopsy from program inception as a possible model.

Active Surveillance Use Among a Low-risk Prostate Cancer Population in a Large US Payer System: 17-Gene Genomic Prostate Score Versus Other Risk Stratification Methods

Many men with low-risk prostate cancer (PCa) receive definitive treatment despite recommendations that have been informed by two large, randomized trials encouraging active surveillance (AS). We conducted a retrospective cohort study using the Optum™ Research Database (Eden Prairie, MN) of electronic health records and administrative claims data to assess AS use for patients tested with a 17-gene Genomic Prostate Score™ (GPS; Genomic Health, Redwood City, CA) assay and/or prostate magnetic resonance imaging (MRI). De-identified records were extracted on health plan members enrolled from June 2013 to June 2016 who had ≥1 record of PCa (n 5 291,876). Inclusion criteria included age ≥18 years, new diagnosis, American Urological Association low-risk PCa (stage T1-T2a, prostate-specific antigen ≤10 ng/mL, Gleason score 5 6), and clinical activity for at least 12 months before and after diagnosis. Data included baseline characteristics, use of GPS testing and/or MRI, and definitive procedures. GPS or MRI testing was performed in 17% of men (GPS, n 5 375, 4%; MRI, n 5 1174, 13%). AS use varied from a low of 43% for men who only underwent MRI to 89% for GPStested men who did not undergo MRI (P <.001). At 6-month follow-up, AS use was 31.0% higher (95% CI, 27.6%-34.5%; P <.001) for men receiving the GPS test only versus men who did not undergo GPS testing or MRI; the difference was 30.5% at 12-month follow-up. In a large US payer system, the GPS assay was associated with significantly higher AS use at 6 and 12 months compared with men who had MRI only, or no GPS or MRI testing.