Increasing Utilization of Multiparametric Magnetic Resonance Imaging in Prostate Cancer Active Surveillance

Active Surveillance for Prostate Cancer: Expanding the Role of MR Imaging and the Use of PRECISE Criteria

Multiparametric magnetic resonance (MR) imaging has had an expanding role in active surveillance (AS) for prostate cancer. It can improve the accuracy of prostate biopsies, assist in patient selection, and help monitor cancer progression. The PRECISE recommendations standardize reporting of serial MR imaging scans during AS. We summarize the evidence on MR imaging-led AS and provide a clinical primer to help report using the PRECISE criteria. Some limitations to both serial imaging and the PRECISE recommendations must be considered as we move toward a more individualized risk-stratified approach to AS.

Recent Developments in Speeding up Prostate MRI

The increasing incidence of prostate cancer cases worldwide has led to a tremendous demand for multiparametric MRI (mpMRI). In order to relieve the pressure on healthcare, reducing mpMRI scan time is necessary. This review focuses on recent techniques proposed for faster mpMRI acquisition, specifically shortening T2W and DWI sequences while adhering to the PI-RADS (Prostate Imaging Reporting and Data System) guidelines. Speeding up techniques in the reviewed studies rely on more efficient sampling of data, ranging from the acquisition of fewer averages or b-values to adjustment of the pulse sequence. Novel acquisition methods based on undersampling techniques are often followed by suitable reconstruction methods typically incorporating synthetic priori information. These reconstruction methods often use artificial intelligence for various tasks such as denoising, artifact correction, improvement of image quality, and in the case of DWI, for the generation of synthetic high b-value images or apparent diffusion coefficient maps. Reduction of mpMRI scan time is possible, but it is crucial to maintain diagnostic quality, confirmed through radiological evaluation, to integrate the proposed methods into the standard mpMRI protocol. Additionally, before clinical integration, prospective studies are recommended to validate undersampling techniques to avoid potentially inaccurate results demonstrated by retrospective analysis. This review provides an overview of recently proposed techniques, discussing their implementation, advantages, disadvantages, and diagnostic performance according to PI-RADS guidelines compared to conventional methods. LEVEL OF EVIDENCE: 3 TECHNICAL EFFICACY: Stage 3.

Imaging Utilization Patterns in the Follow-Up of Extremity Soft Tissue Sarcomas in the United States

This study aimed to describe patterns of imaging utilization after resection of extremity soft tissue sarcoma in the United States, assess for potential disparities, and evaluate temporal trends. A retrospective cohort study using a national database of private payer claims data was performed to determine the utilization rate of extremity and chest imaging in a 5-year postoperative follow-up period for patients with extremity soft tissue sarcoma treated between 2007 and 2019. Imaging utilization was assessed according to patient demographics (age, sex, race and ethnicity, and region of residency), calendar year of surgery, and postoperative year. Associations of demographic variables with imaging use were assessed using chi-square tests, trends in imaging use were analyzed using the Cochran-Armitage trend test or linear regression, and associations of postoperative year with imaging use were evaluated with the Pearson Correlation coefficient. A total of 3707 patients were included. Most patients received at least 1 chest (74%) and extremity (53%) imaging examination during their follow-up period. The presence of surveillance imaging was significantly associated with age (P < 0.0001) and region (P = 0.0029). Over the study period, there was an increase in use of extremity MRI (P < 0.05) and ultrasound (P < 0.01) and chest CT (P < 0.0001) and a decrease in use of chest radiographs (P < 0.0001). Imaging use declined over postoperative years (decrease by 85%-92% from year 1-5). In conclusion, the use of surveillance imaging varied according to patient demographics and has increased for extremity MRI and ultrasound and chest CT over the study period.

Beyond diagnosis: is there a role for radiomics in prostate cancer management?

The role of imaging in pretreatment staging and management of prostate cancer (PCa) is constantly evolving. In the last decade, there has been an ever-growing interest in radiomics as an image analysis approach able to extract objective quantitative features that are missed by human eye. However, most of PCa radiomics studies have been focused on cancer detection and characterisation. With this narrative review we aimed to provide a synopsis of the recently proposed potential applications of radiomics for PCa with a management-based approach, focusing on primary treatments with curative intent and active surveillance as well as highlighting on recurrent disease after primary treatment. Current evidence is encouraging, with radiomics and artificial intelligence appearing as feasible tools to aid physicians in planning PCa management. However, the lack of external independent datasets for validation and prospectively designed studies casts a shadow on the reliability and generalisability of radiomics models, delaying their translation into clinical practice.Key points• Artificial intelligence solutions have been proposed to streamline prostate cancer radiotherapy planning.• Radiomics models could improve risk assessment for radical prostatectomy patient selection.• Delta-radiomics appears promising for the management of patients under active surveillance.• Radiomics might outperform current nomograms for prostate cancer recurrence risk assessment.• Reproducibility of results, methodological and ethical issues must still be faced before clinical implementation.

Prostate cancer mortality rates in low- and favorable intermediate-risk active surveillance patients: a population-based competing risks analysis

PURPOSE

To determine prostate cancer (PCa) and other-cause mortality rates in low- and favorable intermediate-risk (FIR) active surveillance (AS) patients.

METHODS

The SEER Prostate with Watchful Waiting database was used to identify men diagnosed with NCCN low or FIR PCa, between 2010 and 2015, managed with AS. FIR patients were subdivided into three subgroups, based on their intermediate risk factor: grade group two (GG2), PSA 10-20 ng/ml or cT2b-c disease. Cumulative incidence function curves with other-cause mortality as the competing risk were utilized. Predictors of PCa mortality were assessed using multivariable regression analysis with semi-parametric proportional hazards modeling.

RESULTS

Among 70,871 patients, 48,127 (67.9%) had low and 22,744 (32.1%) had FIR disease. Median patient age was 64.0 years, and median PSA was 5.70 ng/ml. Median follow-up was 49.0 months. There were 166 (0.2%) PCa and 3,176 (4.48%) other-cause mortalities. The 5-year mortality rates in the low and FIR cohorts overall were 0.29% and 0.28%, respectively (p = 0.64). Within the FIR cohort, the corresponding rates were highest in the PSA 10-20 ng/ml subgroup at 0.73%, followed by 0.32% for GG2 FIR and 0.052% for cT2b-c FIR disease (p < 0.001). Older age at diagnosis (sHR 2.38, p = 0.006), Medicaid insurance (sHR: 2.58, p < 0.001), low socioeconomic (sHR 1.39, p = 0.032), and non-married statuses (sHR: 2.58, p < 0.001) were associated with increased PCa mortality.

CONCLUSION

Intermediate-term PCa mortality rates in FIR PCa patients are non-significantly different to those with low-risk PCa. However, there is significant within-group heterogeneity, with PCa mortality rates significantly higher in the PSA 10-20 subgroup.

Impact of Prostate Health Index Results for Prediction of Biopsy Grade Reclassification During Active Surveillance

PURPOSE

We assessed whether Prostate Health Index results improve prediction of grade reclassification for men on active surveillance.

METHODS AND MATERIALS

We identified men in Canary Prostate Active Surveillance Study with Grade Group 1 cancer. Outcome was grade reclassification to Grade Group 2+ cancer. We considered decision rules to maximize specificity with sensitivity set at 95%. We derived rules based on clinical data (R1) vs clinical data+Prostate Health Index (R3). We considered an "or"-logic rule combining clinical score and Prostate Health Index (R4), and a "2-step" rule using clinical data followed by risk stratification based on Prostate Health Index (R2). Rules were applied to a validation set, where values of R2-R4 vs R1 for specificity and sensitivity were evaluated.

RESULTS

We included 1,532 biopsies (n = 610 discovery; n = 922 validation) among 1,142 men. Grade reclassification was seen in 27% of biopsies (23% discovery, 29% validation). Among the discovery set, at 95% sensitivity, R2 yielded highest specificity at 27% vs 17% for R1. In the validation set, R3 had best performance vs R1 with Δsensitivity = -4% and Δspecificity = +6%. There was slight improvement for R3 vs R1 for confirmatory biopsy (AUC 0.745 vs R1 0.724, ΔAUC 0.021, 95% CI 0.002-0.041) but not for subsequent biopsies (ΔAUC -0.012, 95% CI -0.031-0.006). R3 did not have better discrimination vs R1 among the biopsy cohort overall (ΔAUC 0.007, 95% CI -0.007-0.020).

CONCLUSIONS

Among active surveillance patients, using Prostate Health Index with clinical data modestly improved prediction of grade reclassification on confirmatory biopsy and did not improve prediction on subsequent biopsies.

Variation and Disparity in the Use of Prostate Cancer Risk Stratification Tools in the United States

In this review we summarize evidence from US studies examining variation in the use of prostate magnetic resonance imaging (MRI) and tissue-based gene expression tests (genomic tests), focusing on sources of regional and racial variation. Large observational studies indicate that prostate MRI and genomic testing vary significantly at the regional level as measured across multiple geographic boundaries. Similarly, there is lower use of prostate MRI among Black versus White-identified patients Black in comparison to those who are White, as well as evidence of less use among Hispanic and Asian versus White patients. These findings indicate opportunities to address modifiable sources of practice variation in localized prostate cancer. PATIENT SUMMARY: In this review, we found that use of prostate magnetic resonance imaging (MRI) scans and genetic testing differed by region, and race, with less prostate MRI use among Black versus White patients. These findings can help raise awareness about gaps in access to new prostate cancer tools.

A narrative review of biparametric MRI (bpMRI) implementation on screening, detection, and the overall accuracy for prostate cancer

Prostate cancer is the most common malignancy in American men following skin cancer, with approximately one in eight men being diagnosed during their lifetime. Over the past several decades, the treatment of prostate cancer has evolved rapidly, so too has screening. Since the mid-2010s, magnetic resonance imaging (MRI)–guided biopsies or ‘targeted biopsies’ has been a rapidly growing topic of clinical research within the field of urologic oncology. The aim of this publication is to provide a review of biparametric MRI (bpMRI) utilization for the diagnosis of prostate cancer and a comparison to multiparametric MRI (mpMRI). Through single-centered studies and meta-analysis across all identified pertinent published literature, bpMRI is an effective tool for the screening and diagnosis of prostate cancer. When compared with the diagnostic accuracy of mpMRI, bpMRI identifies prostate cancer at comparable rates. In addition, when omitting dynamic contrast-enhanced (DCE) protocol to the MRI, patients incur reduced costs and shorter imaging time while providers can offer more tests to their patient population.

Metastasis and Mortality in Men With Low- and Intermediate-Risk Prostate Cancer on Active Surveillance

BACKGROUND

Active surveillance (AS) is a safe treatment option for men with low-risk, localized prostate cancer. However, the safety of AS for patients with intermediate-risk prostate cancer remains unclear.

PATIENTS AND METHODS

We identified men with NCCN-classified low-risk and favorable and unfavorable intermediate-risk prostate cancer diagnosed between 2001 and 2015 and initially managed with AS in the Veterans Health Administration. We analyzed progression to definitive treatment, metastasis, prostate cancer-specific mortality (PCSM), and all-cause mortality using cumulative incidences and multivariable competing-risks regression.

RESULTS

The cohort included 9,733 men, of whom 1,007 (10.3%) had intermediate-risk disease (773 [76.8%] favorable, 234 [23.2%] unfavorable), followed for a median of 7.6 years. The 10-year cumulative incidence of metastasis was significantly higher for patients with favorable (9.6%; 95% CI, 7.1%-12.5%; P<.001) and unfavorable intermediate-risk disease (19.2%; 95% CI, 13.4%-25.9%; P<.001) than for those with low-risk disease (1.5%; 95% CI, 1.2%-1.9%). The 10-year cumulative incidence of PCSM was also significantly higher for patients with favorable (3.7%; 95% CI, 2.3%-5.7%; P<.001) and unfavorable intermediate-risk disease (11.8%; 95% CI, 6.8%-18.4%; P<.001) than for those with low-risk disease (1.1%; 95% CI, 0.8%-1.4%). In multivariable competing-risks regression, favorable and unfavorable intermediate-risk patients had significantly increased risks of metastasis and PCSM compared with low-risk patients (all P<.001).

CONCLUSIONS

Compared with low-risk patients, those with favorable and unfavorable intermediate-risk prostate cancer managed with AS are at increased risk of metastasis and PCSM. AS may be an appropriate option for carefully selected patients with favorable intermediate-risk prostate cancer, though identification of appropriate candidates and AS protocols should be tested in future prospective studies.

Influence of Enema and Dietary Restrictions on Prostate MR Image Quality: A Multireader Study

PURPOSE

To evaluate the effect of enema and dietary restrictions on prostate MR image quality metrics and to assess inter-reader agreement for these metrics.

METHODS

This retrospective study included 195 men divided into groups based on their compliance with preparation instructions before prostate MRI (Enema + Diet, n = 98; Enema, n = 42; Diet, n = 35; Control [no compliance], n = 20). Four readers independently assessed six image quality metrics on a 5-point scale. Between-group comparisons were made using Wilcoxon rank sum test. Inter-reader agreement was calculated using Fleiss' kappa.

RESULTS

Compared with the Control group, image quality with respect to rectal stool/gas, distortion of diffusion-weighted images, overall image quality, and confidence in assessment was higher in the Enema + Diet, Enema, and Diet groups (p  < 0.05 for all comparisons). The Enema + Diet and Enema groups had significantly higher scores than the Diet group for rectal stool/gas (p < 0.001 and 0.005, respectively). The Enema + Diet and Diet groups had higher scores than the Control group for rectal peristalsis (p = 0.027 and 0.009, respectively), but there were no significant differences in motion artifacts on T2-weighted images. Agreement among readers was fair, with kappa values ranging from 0.25 to 0.37.

CONCLUSION

Enema and dietary restriction can improve the quality of prostate MRI by decreasing rectal distension and distortion of diffusion-weighted images and by increasing reader confidence in image assessment. Inter-reader agreement using subjective criteria for analysis of MRI quality is fair.

Disparities in magnetic resonance imaging of the prostate for traditionally underserved patients with prostate cancer

BACKGROUND

Prebiopsy magnetic resonance imaging (MRI) of the prostate improves detection of significant tumors, while decreasing detection of less-aggressive tumors. Therefore, its use has been increasing over time. In this study, the use of prebiopsy MRI among Medicare beneficiaries with prostate cancer was examined. It was hypothesized that patients of color and those in isolated areas would be less likely to undergo this approach for cancer detection.

METHODS

Using cancer registry data from the Surveillance, Epidemiology, and End Results (SEER) program linked to billing claims for fee-for-service Medicare beneficiaries, men with nonmetastatic prostate cancer were identified from 2010 through 2015 with prostate-specific antigen (PSA) <30 ng/mL. Outcome was prebiopsy MRI of the prostate performed within 6 months before diagnosis (ie, Current Procedural Terminology 72197). Exposures were patient race/ethnicity and rural/urban status. Multivariable regression estimated the odds of prebiopsy prostate MRI. Post hoc analyses examined associations with the registry-level proportion of non-Hispanic Black patients and MRI use, as well as disparities in MRI use in registries with data on more frequent use of prostate MRI.

RESULTS

There were 50,719 men identified with prostate cancer (mean age, 72.1 years). Overall, 964 men (1.9% of cohort) had a prebiopsy MRI. Eighty percent of patients with prebiopsy MRI lived in California, New Jersey, or Connecticut. Non-Hispanic Black men (0.6% vs 2.1% non-Hispanic White; odds ratio [OR], 0.28; 95% CI, 0.19-0.40) and men in less urban areas (1.1% vs 2.2% large metro; OR, 0.65; 95% CI, 0.44-0.97) were less likely to have prebiopsy MRI of the prostate.

CONCLUSIONS

Non-Hispanic Black patients with prostate cancer and those in less urban areas were less likely to have prebiopsy MRI of the prostate during its initial adoption as a tool for improving prostate cancer detection.

A Systematic Review for Health Disparities and Inequities in Multiparametric Magnetic Resonance Imaging for Prostate Cancer Diagnosis

RATIONALE AND OBJECTIVES

Multi-parametric Magnetic Resonance Imaging (mpMRI) is a novel procedure recommended by the American Urological Association for Prostate Cancer (PCa) diagnosis. In radiology, differences in utilization of expensive screening techniques are described but never reviewed for mpMRI. Thus, our article aims at summarizing disparities relating to the expensive yet revolutionary mpMRI in United States men with PCa while highlighting needed research areas.

MATERIAL AND METHODS

Eligible articles were gathered via PubMed query, referred publications known to the authors or from the reference lists of the identified publications. We excluded studies that didn't specifically evaluate mpMRI technique, weren't conducted in the United States, or didn't directly assess the relationship between disparities and mpMRI. No date restrictions were applied, resulting articles were published through 2020.

RESULTS

Out of 80 publications, 17 were selected. Two unique themes were identified: 1) disparities in mpMRI utilization, and 2) performance. While demographic factors such as race, age and socioeconomic status played a significant role in utilization, mpMRI demonstrated equal and sometimes superior performance in AAs.

CONCLUSION

Our findings illustrate the importance of disparity awareness in PCa mpMRI and highlight the need to examine additional mpMRI disparities across other races and social determinants. A new area of inequity in PCa was theoretically illustrated, as lower utilization of mpMRI was detected in a group that could potentially benefit from it the most. Major limitation was the selected search terms. Our review is unique as disparities related to mpMRI were found to be multilayered, affecting utilization and performance. Continued research is needed to discover additional areas in efforts to reduce disparity gaps related to mpMRI and PCa.

Increasing Utilization of MRI Before Prostate Biopsy in Black and Non-Black Men: An Analysis of the SEER-Medicare Cohort

OBJECTIVE. The potential for significant disparities exists in the setting of increased adoption of prostate MRI. We sought to assess temporal trends in the utilization of MRI before prostate biopsy in a nationally representative sample. MATERIALS AND METHODS. Using the SEER-Medicare linked database, we identified men undergoing prostate biopsy who had an MRI within 6 months of diagnosis of prostate cancer. Men were stratified according to whether they were biopsy naive or had undergone a prior negative prostate biopsy. RESULTS. We identified 82,483 men undergoing prostate biopsy in SEER-Medicare from 2008 to 2015 of whom 78,253 were biopsy naive and 4230 had a known prior negative biopsy. We found that the percentage of patients who received an MRI before biopsy has increased from 2008 to 2015 in biopsy-naive men (0.5-8.2%; p < .001), men with a prior negative biopsy (1.4-25.5%; p < .001), and overall (0.5-9.2%; p < .001). On multivariable modeling, the odds ratio (OR) of a patient undergoing an MRI before biopsy for Black men (OR, 0.4; 95% CI, 0.3-0.5; p < .001) was half that of White men, and the OR of MRI before biopsy in men from the Northeast (OR, 3.4; 95% CI, 2.8-4.3; p < .001) was more than three times that of men from the West. CONCLUSION. The steady overall increase in the utilization of MRI before prostate biopsy since 2008 has been associated with significant racial and regional disparities in utilization.

Cost-Effectiveness Analysis of Prostate Cancer Screening in Brazil

INTRODUCTION

Prostate cancer is one of the most common malignancies among men worldwide. Prostate-specific antigen (PSA) screening shows uncertain benefits and harms from clinical and economic perspectives, resulting in an important impact on healthcare systems. Because of nonstandardized studies and substantial differences among populations, data are still inconclusive.

OBJECTIVE

The objective of this study was to carry out long-term cost-effectiveness and cost-utility analysis on the PSA-screened population from the service provider's perspective in the Brazilian population.

METHODS

We performed a cost-effectiveness and cost-utility analysis using clinical outcomes obtained from 9692 men enrolled in the PSA screening program. Prostate cancer treatments, 5-year follow-up outcomes, and all related costs were examined. Data were compared with a nonscreened prostate cancer population to calculate incremental cost-effectiveness ratio (ICER) and incremental cost-utility ratio (ICUR). ICER and ICUR were compared with the Brazilian-established willingness-to-pay (WTP) threshold (WTP = R$ 114 026.55).

RESULTS

A total of 251 of 9692 men had a diagnosis of prostate cancer (2.6%), of which 90% had localized disease. Two hundred and five patients were treated as follows: surgery (45.37%); radiation therapy (11.22%); radiation plus androgen deprivation therapy (21.95%); active surveillance (13.17%); exclusive androgen deprivation therapy (7.32%); and watchful waiting (0.98%). Two simulated cohorts were compared based on screening and nonscreening groups. Values obtained were-ICER of R$ 44 491.39 per life saved and ICUR of R$ 10 851.56 per quality-adjusted life year (QALY) gained-below the Brazilian WTP threshold and showed cost-effectiveness and cost-utility advantages.

CONCLUSION

According to the Brazilian WTP, PSA screening is a cost-effective policy from a hospital and long-term perspective and should have more standardized studies developed in different populations and economies.

Influence of Sociodemographic Factors on Definitive Intervention Among Low-risk Active Surveillance Patients

OBJECTIVES

To investigate sociodemographic factors influencing decision of initially active surveillance (AS) prostate cancer (CaP) patients to opt for definitive therapy, and, specifically, choice of radical prostatectomy (RP) versus radiation therapy (XRT).

METHODS

The Surveillance, Epidemiology, and End Results (SEER) Prostate with Watchful Waiting database was used to identify AS patients diagnosed with NCCN low-risk CaP between 2010 and 2015. We sought to determine predictors of treatment type using multivariable logistic regression analyses.

RESULTS

Out of 32,874 men included, 21,255 (64.7%) underwent delayed treatment, with 3,751 (17.6%) and 17,463 (82.2%) opting for RP and XRT, respectively. Patients who were married (Odds Ratio [OR]: 1.18, P <.001), insured (OR 2.94, P <.001), of higher socioeconomic status (OR 1.67 for highest vs lowest, P <.01), and residing in a Southeastern or Midwestern region (ORs 1.26 and 1.22 vs Northeast, respectively, P <.01) were significantly more likely to undergo definitive intervention. A significant interaction between patient race and marital/socioeconomic statuses on the decision-making process was identified. Decision for XRT (vs RP) was more likely in older (OR 11.6 for 70-79 vs 50-59 years, P <.01), unmarried (OR 1.89, P <.01), African American (OR 1.41, P .018), and higher socioeconomic status (OR 1.54 for highest versus lowest quartile, P <.01) patients.

CONCLUSION

The majority of patients initially treated with AS underwent delayed treatment. After accounting for pathologic characteristics, the interaction of sociodemographic factors including race, socioeconomic status, marital status, insurance status, and region of residence are significantly associated with the likelihood of undergoing definitive therapy.

Management of prostate cancer radiotherapy during the COVID-19 pandemic: A necessary paradigm change

PURPOSE

To adapt the management of prostate malignancy in response to the COVID-19 pandemic.

METHODS

In according to the recommendations of the European Association of Urology, we have developed practical additional document on the treatment of prostate cancer.

RESULTS

Low-Risk Group Watchful Waiting should be offered to patients >75 years old, with a limited life expectancy and unfit for local treatment. In Active Surveillance (AS) patients re-biopsy, PSA evaluation and visits should be deferred for up to 6 months, preferring non-invasive multiparametric-MRI. The active treatment should be delayed for 6-12 months. Intermediate-Risk Group AS should be offered in favorable-risk patients. Short-course neoadjuvant androgen deprivation therapy (ADT) combined with ultra-hypo-fractionation radiotherapy should be used in unfavorable-risk patients. High-Risk Group Neoadjuvant ADT combined with moderate hypofractionation should be preferred. Whole-pelvis irradiation should be offered to patients with positive lymph nodes in locally advanced setting. ADT should be initiated if PSA doubling time is < 12 months in radio-recurrent patients, as well as in low priority/low volume of metastatic hormone sensitive prostate cancer. If radiotherapy cannot be delayed, hypo-fractionated regimens should be preferred. In high priority class metastatic disease, treatment with androgen receptor-targeted agents should be offered. When palliative radiotherapy for painful bone metastasis is required, single fraction of 8 Gy should be offered.

CONCLUSIONS

In Covid-19 Era, the challenge should concern a correct management of the oncologic patient, reducing the risk of spreading the virus without worsening tumor prognosis.

Attitudes and perceptions towards multiparametric magnetic resonance imaging of the prostate: A national survey among Italian urologists

OBJECTIVE

We aimed to assess the attitudes and perceptions towards multiparametric magnetic resonance imaging (mpMRI) of the prostate among Italian urologists.

MATERIAL AND METHODS

A national, web-based survey was performed. A questionnaire composed of 18 multiple choice questions was e-mailed to 941 currently active urologists, members of the Italian Society of Urology. Preserving anonymity, respondents' demographics were collected (e.g. geographic region, type of workplace, prostate procedures performed) as well as data concerning their attitudes and perceptions towards mpMRI (e.g. indications deemed appropriate, degree of confidence in mpMRI results). Data were expressed as raw numbers and percentages of survey answers.

RESULTS

In total, 98 responses were received (participation rate = 10.4%). Respondents mostly worked in urban areas (96%) and primarily in hospital settings (89%), while 48% of them worked in southern Italy. 97% of respondents considered mpMRI useful to detect Prostate Cancer (PCa) in patients with prior negative biopsy, 64% in biopsy-naïve patients and 60% for PCa pre-operatory staging. About half (42%) of the participants declared that mpMRI results frequently lead them to change PCa management strategy. Standardization of mpMRI acquisition and reporting was partially unsatisfactory. Reported waiting time for mpMRI scans was longer than 4 weeks for 51% of respondents. The major limitation of this survey includes the small number of participants.

CONCLUSIONS

Prostate mpMRI is used by Italian urologists mainly for detection and for pre-operative staging of PCa. Further improvements in terms of mpMRI availability and report standardization are required.

Real-world Evidence to Estimate Prostate Cancer Costs for First-line Treatment or Active Surveillance

Background

Prostate cancer is the most common cancer in men and second leading cause of cancer-related deaths. Changes in screening guidelines, adoption of active surveillance (AS), and implementation of high-cost technologies have changed treatment costs. Traditional cost-effectiveness studies rely on clinical trial protocols unlikely to capture actual practice behavior, and existing studies use data predating new technologies. Real-world evidence reflecting these changes is lacking.

Objective

To assess real-world costs of first-line prostate cancer management.

Design setting and participants

We used clinical electronic health records for 2008-2018 linked with the California Cancer Registry and the Medicare Fee Schedule to assess costs over 24 or 60 mo following diagnosis. We identified surgery or radiation treatments with structured methods, while we used both structured data and natural language processing to identify AS.

Outcome measurements and statistical analysis

Our results are risk-stratified calculated cost per day (CCPD) for first-line management, which are independent of treatment duration. We used the Kruskal-Wallis test to compare unadjusted CCPD while analysis of covariance log-linear models adjusted estimates for age and Charlson comorbidity.

Results and limitations

In 3433 patients, surgery (54.6%) was more common than radiation (22.3%) or AS (23.0%). Two years following diagnosis, AS ($2.97/d) was cheaper than surgery ($5.67/d) or radiation ($9.34/d) in favorable disease, while surgery ($7.17/d) was cheaper than radiation ($16.34/d) for unfavorable disease. At 5 yr, AS ($2.71/d) remained slightly cheaper than surgery ($2.87/d) and radiation ($4.36/d) in favorable disease, while for unfavorable disease surgery ($4.15/d) remained cheaper than radiation ($10.32/d). Study limitations include information derived from a single healthcare system and costs based on benchmark Medicare estimates rather than actual payment exchanges.

Patient summary

Active surveillance was cheaper than surgery (-47.6%) and radiation (-68.2%) at 2 yr for favorable-risk disease, which decreased by 5 yr (-5.6% and -37.8%, respectively). Surgery was less costly than radiation for unfavorable risk for both intervals (-56.1% and -59.8%, respectively).

Health disparities and inequities in the utilization of diagnostic imaging for prostate cancer

PURPOSE

To review and summarize the reported health disparities and inequities in diagnostic imaging for prostate cancer.

METHODS

We queried the PubMed search engine for original publications studying disparate utilization of diagnostic imaging for prostate cancer. Query terms were as follows: prostate AND cancer AND diagnostic AND imaging AND (magnetic resonance imaging (MRI) OR computed tomography (CT) OR bone scintigraphy OR positron emission tomography (PET)-CT)) AND (inequities OR disparities OR socioeconomic OR race). Studies were included if they involved United States patients, had diagnostic imaging as a part of their care, and addressed health inequities.

RESULTS

A total of 104 studies were captured in the initial query with 17 meeting inclusion criteria, comprising 10 population-based analyses, 5 single institutional analyses, 1 multi-institutional analysis, and 1 review. Socioeconomic status and race were frequently associated with imaging utilization and guideline-concordant care. SEER analyses revealed that African-American men had higher odds of experiencing overuse of pelvic CT/pelvic MRI and bone scans, while older men experienced underuse. Higher income and younger age were more likely to receive imaging that was adherent to NCCN guidelines. African-American and Hispanic men were less likely than white men to receive prostate multiparametric MRI.

CONCLUSION

Race, age, and socioeconomic status play a significant role in the diagnostic management of prostate cancer. Certain demographics are more disparately affected and less likely to receive guideline-concordant care. Continued research and interventions are needed to ensure appropriate and accessible diagnostic imaging for prostate cancer and ultimately the delivery of quality and equitable care.

Predictors of ISUP score upgrade in patients with low-risk prostate cancer

INTRODUCTION

The literature contains few studies that focus on the relationship between International Society of Urological Pathology (ISUP) score upgrade and complete blood count (CBC) parameters for patients with low-risk prostate cancer and studies achieved inconclusive results.

METHODS

We retrospectively analyzed our institutional database for patients with prostate cancer who underwent radical prostatectomy (RP) between 1994 and 2017. In total, we included 633 patients with low-risk prostate cancer in the study. We investigated the effects of clinicopathologic factors on ISUP score upgrade. Moreover, we compared RP pathologic outcomes between the patients with and without ISUP score upgrade.

RESULTS

The mean age and follow-up periods were 61.09±6.61 years and 41.9±1.8 months, respectively. ISUP score upgrade was observed in 207 patients (32.7%). In multivariate analysis, high prostate-specific antigen (PSA) density and percentage of positive cores were found to be significantly associated with ISUP score upgrade (p = 0.003 and p = 0.003, respectively). The neutrophil-lymphocyte ratio, platelet-lymphocyte ratio, monocyte-lymphocyte ratio, and eosinophil-lymphocyte ratio were found to have no effect on ISUP score upgrade (p = 0.856, p = 0.353, p = 0.128, and p = 0.074, respectively). The percentage of tumors, surgical margin positivity, seminal vesicle invasion rate, and extraprostatic extension rate in RP pathology were higher in patients with ISUP score upgrade (p < 0.001, p < 0.001, p < 0.001, and p < 0.001, respectively).

CONCLUSIONS

Approximately one-third of the patients in our series had ISUP score upgrade in RP pathology. PSA density and the percentage of positive cores were found to be the factors significantly associated with ISUP score upgrade. CBC-related factors had no effect on ISUP score upgrade.

Multiparametric magnetic resonance imaging can exclude prostate cancer progression in patients on active surveillance: a retrospective cohort study

Objectives

To assess the ability of multiparametric MRI (mp-MRI) of the prostate to exclude prostate cancer (PCa) progression during monitoring patients on active surveillance (AS).

Methods

One hundred forty-seven consecutive patients on AS with mp-MRI (T2WI, DWI, DCE-MRI) at 3T were initially enrolled. Fifty-five received follow-up mp-MRI after a minimum interval of 12 months and subsequent targeted MR/US fusion-guided biopsy (FUS-GB) plus concurrent systematic transrectal ultrasound-guided (TRUS-GB) biopsy as reference standard. Primary endpoint was the negative predictive value (NPV) of the follow-up mp-MRI to exclude histopathologic tumor progression using PRECISE recommendations. Secondary endpoints were the positive predictive value (PPV), sensitivity, specificity, Gleason score (GS) upgrades, and comparison of biopsy method.

Results

Of 55 patients, 29 (53%) had a GS upgrade on re-biopsy. All 29 patients showed a tumor progression on follow-up mp-MRI. Fifteen of 55 patients (27%) displayed signs of tumor progression, but had stable GS on re-biopsy. None of the 11 patients (20%) without signs of progression on follow-up mp-MRI had a GS upgrade on re-biopsy. The NPV was 100%, PPV was 66%, sensitivity was 100%, and specificity 42%. FUS-GB resulted in GS upgrade significantly more often (n = 28; 51%) compared with TRUS-GB (n = 12; 22%; p < 0.001).

Conclusions

(Follow-up) Mp-MRI can reliably exclude PCa progression in patients on AS. Standard serial re-biopsies might be waived if follow-up mp-MRIs are stable. Over 60% of patients with signs of tumor progression on mp-MRI during AS had a GS upgrade on re-biopsy. Targeted re-biopsies should be performed if cancer progression or higher-grade PCa is suspected on mp-MRI.

Key Points

• None of the patients with unsuspicious mp-MRI had a GS upgrade in re-biopsy and mp-MRI might replace serial biopsies in these cases

• More than 60% of patients with mp-MRI signs of tumor progression had subsequent Gleason score (GS) upgrades

• Targeted re-biopsies should be performed in case of higher GS cancer suspicion on mp-MRI

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

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.

Termination rates and histological reclassification of active surveillance patients with low- and early intermediate-risk prostate cancer: results of the PREFERE trial

Purpose

Active surveillance (AS) strategies for patients with low- and early intermediate-risk prostate cancer are still not consistently defined. Within a controlled randomized trial, active surveillance was compared to other treatment options for patients with prostate cancer. Aim of this analysis was to report on termination rates of patients treated with AS including different grade groups.

Methods

A randomized trial comparing radical prostatectomy, active surveillance, external beam radiotherapy and brachytherapy was performed from 2013 to 2016 and included 345 patients with low- and early intermediate-risk prostate cancer (ISUP grade groups 1 and 2). The trial was prematurely stopped due to slow accrual. A total of 130 patients were treated with active surveillance. Among them, 42 patients were diagnosed with intermediate-risk PCA. Reference pathology and AS quality control were performed throughout.

Results

After a median follow-up time of 18.8 months, 73 out of the 130 patients (56%) terminated active surveillance. Of these, 56 (77%) patients were histologically reclassified at the time of rebiopsy, including 35% and 60% of the grade group 1 and 2 patients, respectively. No patients who underwent radical prostatectomy at the time of reclassification had radical prostatectomy specimens ≥ grade group 3.

Conclusion

In this prospectively analyzed subcohort of patients with AS and conventional staging within a randomized trial, the 2-year histological reclassification rates were higher than those previously reported. Active surveillance may not be based on conventional staging alone, and patients with grade group 2 cancers may be recommended for active surveillance in carefully controlled trials only.

Role of Changes in Magnetic Resonance Imaging or Clinical Stage in Evaluation of Disease Progression for Men with Prostate Cancer on Active Surveillance

BACKGROUND

Active surveillance (AS) protocols rely on rectal examination, prostate-specific antigen, imaging, and biopsy to identify disease progression.

OBJECTIVE

To evaluate whether an AS regimen based on magnetic resonance imaging (MRI) or clinical stage changes can detect reclassification to grade group (GG) ≥2 disease compared with scheduled systematic biopsies.

DESIGN, SETTING, AND PARTICIPANTS

We identified a cohort of men initiated on AS between January 2013 and April 2016 at a single tertiary-care center. Patients completed confirmatory testing and prostate MRI prior to enrollment, then underwent laboratory and physical evaluation every 6 mo, MRI every 18 mo, and biopsy every 3yr.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

MRI results were evaluated using composite Likert/Prostate Imaging Reporting and Data System v2 scoring. MRI and clinical changes were assessed for association with disease progression. Univariable and multivariable regression models were used to predict upgrading on 3-yr biopsy.

RESULTS AND LIMITATIONS

At 3yr, of 207 men, 66 (32%) had≥GG2 at biopsy: 55 (83%) with GG2, 10 (15%) with GG3, and one (1.5%) with GG4. Among patients with a 3-yr MRI score of ≥3, 41% had≥GG2 disease, compared with 15% with an MRI score of <3 (p=0.0002). The MRI score increased in 48 men (23%), decreased in 27 (13%), and was unchanged in 132 (64%) men. Increases in MRI score were not associated with reclassification after adjusting for the 3-yr MRI score (p=0.9). Biopsying only for an increased MRI score or clinical stage would avoid 681 biopsies per 1000 men, at the cost of missing ≥GG2 disease in 169 patients.

CONCLUSIONS

An AS strategy that uses MRI or clinical changes to trigger prostate biopsy avoids many biopsies but misses an unacceptable amount of clinically significant disease. Prostate biopsy for men on AS should be performed at scheduled intervals, regardless of stable imaging or examination findings.

PATIENT SUMMARY

An active surveillance strategy for biopsy based only on increases in magnetic resonance imaging score or clinical stage will avoid many biopsies; however, it will miss many patients with clinically significant prostate cancer.

Defining and Measuring Adherence in Observational Studies Assessing Outcomes of Real-world Active Surveillance for Prostate Cancer: A Systematic Review

CONTEXT

Evidence-based guidelines for active surveillance (AS), a treatment option for men with low-risk prostate cancer, recommend regular follow-up at periodic intervals to monitor disease progression. However, gaps in monitoring can lead to delayed detection of cancer progression, leading to a missed window of curability.

OBJECTIVE

We aimed to identify the extent to which real-world observational studies reported adherence to monitoring protocols among prostate cancer patients on AS. When reported, we sought to characterize definitions of adherence.

EVIDENCE ACQUISITION

We systematically reviewed observational studies assessing outcomes of prostate cancer patients on AS, published before March 22, 2019 in PubMed, Embase, and CENTRAL. Adherence definitions were considered time bound if they included prespecified time and binary if adherence was assessed but did not specify a time interval. We assessed study quality using the Strengthening the Reporting of Observational Studies in Epidemiology checklist.

EVIDENCE SYNTHESIS

Forty-five studies met our inclusion criteria. Eleven studies did not report any data on adherence to AS protocols. Twenty-five studies did not explicitly measure adherence, but provided relevant data (eg, number of patients who received a repeat biopsy). Six studies reported adherence using a time-bound definition, while three studies used a binary definition. Twenty-three studies provided information on patients lost to follow-up.

CONCLUSIONS

Most studies reporting outcomes of patients on AS did not measure or report adherence. When reported, adherence was often not time specific. As some AS patients will benefit from maintaining a window of curability, clinical practices and future studies should track and report adherence and associated factors.

PATIENT SUMMARY

We reviewed real-world observational studies examining outcomes of prostate cancer patients on active surveillance. Most studies did not clearly define or report adherence to monitoring protocols, which is important to consider for appropriate disease management.