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Faraj KS, Kaufman SR, Herrel LA, Oerline MK, Maganty A, Shahinian VB, Hollenbeck BK. Association between urology practice use of multiparametric MRI and genomic testing and treatment of men with newly diagnosed prostate cancer. Urol Oncol 2023; 41:430.e17-430.e23. [PMID: 37580226 PMCID: PMC10836888 DOI: 10.1016/j.urolonc.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 07/12/2023] [Accepted: 08/02/2023] [Indexed: 08/16/2023]
Abstract
INTRODUCTION Biomarkers for prostate cancer, such as multiparametric MRI (mpMRI) and tissue-based genomics, are increasingly used for treatment decision-making. Using biomarkers indiscriminately and thus ignoring competing risks of mortality may lead to treatment in some men who derive little clinical benefit. We assessed the relationship between urology practice use of biomarkers and subsequent treatment in men with newly diagnosed prostate cancer. METHODS We used a 20% random sample of national Medicare data to perform a retrospective cohort study of men with newly diagnosed prostate cancer diagnosed from 2015 through 2019. Urology practice-level use of biomarkers was characterized based on urology practice propensity to use either biomarker after diagnosis (never, below median, above the median). Noncancer mortality risk within 10 years of diagnosis was calculated for all men. Multilevel models were used to assess the relationship between practice-level biomarker use and treatment by noncancer mortality risk. RESULTS Between 2015 and 2019, 1,764 (65%) urology practices used mpMRI and 897 (33%) used genomic testing for prostate cancer. Compared with urology practices never using each biomarker, those using mpMRI above the median (56% vs. 47%, P = 0.003) and tissue-based genomics below the median (56% vs. 50%, P = 0.03) were more likely to treat men with >75% risk of noncancer mortality. Additionally, compared with urology practices never using either biomarker, use of mpMRI (72% vs. 69%, P = 0.07) or tissue-based genomics (71% vs. 70%, P = 0.65) did not impact treatment in the healthiest group (i.e., those with <25% risk of noncancer mortality). CONCLUSIONS Compared to practices that do not use each biomarker in men with newly diagnosed prostate cancer, urology practices using mpMRI, and tissue-based genomics to a lesser extent, are more likely to treat men at very high risk of dying from competing risks of mortality within 10 years of prostate cancer diagnosis.
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Affiliation(s)
- Kassem S Faraj
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI.
| | - Samuel R Kaufman
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - Lindsey A Herrel
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - Mary K Oerline
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - Avinash Maganty
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - Vahakn B Shahinian
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
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Gandaglia G, Leni R, Plagakis S, Stabile A, Montorsi F, Briganti A. Active surveillance should not be routinely considered in ISUP grade group 2 prostate cancer. BMC Urol 2023; 23:153. [PMID: 37777767 PMCID: PMC10542696 DOI: 10.1186/s12894-023-01315-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 09/03/2023] [Indexed: 10/02/2023] Open
Abstract
Active surveillance has been proposed as a therapeutic option in selected intermediate risk patients with biopsy grade group 2 prostate cancer. However, its oncologic safety in this setting is debated. Therefore, we conducted a non-systematic literature research of contemporary surveillance protocols including patients with grade group 2 disease to collect the most recent evidence in this setting. Although no randomized controlled trial compared curative-intent treatments, namely radical prostatectomy and radiotherapy vs. active surveillance in patients with grade group 2 disease, surgery is associated with a benefit in terms of disease control and survival when compared to expectant management in the intermediate risk setting. Patients with grade group 2 on active surveillance were at higher risk of disease progression and treatment compared to their grade group 1 counterparts. Up to 50% of those patients were eventually treated at 5 years, and the metastases-free survival rate was as low as 85% at 15-years. When considering low- and intermediate risk patients treated with radical prostatectomy, grade group 2 was one of the strongest predictors of grade upgrading and adverse features. Available data is insufficient to support the oncologic safety of active surveillance in all men with grade group 2 prostate cancer. Therefore, those patients should be counselled regarding the oncologic efficacy of upfront active treatment modalities and the lack of robust long-term data supporting the safety of active surveillance in this setting.
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Affiliation(s)
- Giorgio Gandaglia
- Unit of Urology/Division of Oncology; URI, IRCCS Ospedale San Raffaele, Milan, Italy.
- Vita-Salute San Raffaele University, Milan, Italy.
| | - Riccardo Leni
- Unit of Urology/Division of Oncology; URI, IRCCS Ospedale San Raffaele, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | | | - Armando Stabile
- Unit of Urology/Division of Oncology; URI, IRCCS Ospedale San Raffaele, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Francesco Montorsi
- Unit of Urology/Division of Oncology; URI, IRCCS Ospedale San Raffaele, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Alberto Briganti
- Unit of Urology/Division of Oncology; URI, IRCCS Ospedale San Raffaele, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
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Wang M, Lange A, Perlman D, Qi J, George AK, Ferrante S, Semerjian A, Sarle R, Cher ML, Ginsburg KB. Upgrading on Per Protocol versus For Cause surveillance prostate biopsies: An opportunity to decreasing the burden of active surveillance. Prostate 2023. [PMID: 37173808 DOI: 10.1002/pros.24556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 04/03/2023] [Accepted: 05/01/2023] [Indexed: 05/15/2023]
Abstract
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.
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Affiliation(s)
- Michael Wang
- Department of Urology, Wayne State University, Detroit, Michigan, USA
| | - Andrew Lange
- Department of Urology, Wayne State University, Detroit, Michigan, USA
| | - David Perlman
- Department of Urology, Wayne State University, Detroit, Michigan, USA
| | - Ji Qi
- University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Arvin K George
- University of Michigan Medical School, Ann Arbor, Michigan, USA
| | | | - Alice Semerjian
- IHA Urology, St. Joseph Mercy Hospital, Ann Arbor, Michigan, USA
| | - Richard Sarle
- Department of Urology, Sparrow Point Hospitals, Lansing, Michigan, USA
| | - Michael L Cher
- Department of Urology, Wayne State University, Detroit, Michigan, USA
| | - Kevin B Ginsburg
- Department of Urology, Wayne State University, Detroit, Michigan, USA
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Wang M, Qi J, George AK, Semerjian A, Linsell SM, Montie JE, Cher ML, Ginsburg KB. The added influence of genomics and post-MRI confirmatory biopsy results to MRI results alone on medical decision making for men with favorable risk prostate cancer being considered for active surveillance. Prostate 2022; 82:1068-1074. [PMID: 35468226 DOI: 10.1002/pros.24357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 03/16/2022] [Accepted: 04/07/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND We examined how the results of genomic classifier (GC) or post-magnetic resonance imaging confirmatory biopsy (pMRI-CBx) influenced management strategy for men with an MRI considering active surveillance (AS). METHODS We reviewed the Michigan Urological Surgery Improvement Collaborative registry for men with favorable-risk prostate cancer. Among men with an MRI after the diagnostic biopsy (n = 1162) a subset also had GC (n = 126) or pMRI-CBx (n = 309). Results of MRI, GC, and pMRI-CBx were deemed reassuring (RA) or non-reassuring (Non-RA). We assess the association of the combination of test results obtained with the selection of AS. Proportions were compared with the Fisher's exact test. Multivariable logistic regression models were fit for an association of test results with the selection of AS. RESULTS The results of pMRI-CBx tended to influence management decisions greater than that of GC, especially in situation where testing results were discordant with the MRI result. Fewer men with a RA MRI and non-RA pMRI-CBx where managed with AS compared with RA MRI alone (31% vs. 86%, p < 0.001). non-RA genomics did not seem to have the same influence on management as non-RA pMRI-CBx as a similar proportion of men with RA MRI and non-RA genomics were managed with AS compared with RA MRI alone (85% vs. 86%, p = 0.753). More men with non-RA MRI and RA pMRI-CBx were managed with AS compared with non-RA MRI alone (89% vs. 40%, p < 0.001). Alternatively, a similar proportion of men with non-RA MRI and RA genomics were managed with AS compared with non-RA MRI alone (42% vs. 40%, p > 0.999). In the multivariable models, pMRI-CBx results influenced the decision for AS versus treatment. CONCLUSIONS In men with newly diagnosed prostate cancer and an MRI, the additional information provided by pMRI-CBx influenced the decision of AS versus treatment, while the addition of GC results were less influential.
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Affiliation(s)
- Michael Wang
- Department of Urology, Wayne State University, Detroit, Michigan, USA
| | - Ji Qi
- University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Arvin K George
- University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Alice Semerjian
- IHA Urology, St. Joseph Mercy Hospital, Ann Arbor, Michigan, USA
| | - Susan M Linsell
- University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - James E Montie
- University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Michael L Cher
- Department of Urology, Wayne State University, Detroit, Michigan, USA
| | - Kevin B Ginsburg
- Department of Urology, Wayne State University, Detroit, Michigan, USA
- Department of Surgical Oncology, Division of Urologic Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA
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Versalle D, Qi J, Noyes S, Moriarity A, George A, Cher M. Practice-level variation in the decision to biopsy PI-RADS 3 lesions in favorable-risk prostate cancer patients. Urology 2022; 164:191-196. [DOI: 10.1016/j.urology.2022.01.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 12/26/2021] [Accepted: 01/11/2022] [Indexed: 11/17/2022]
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Ginsburg KB, Johnson K, Moldovan T, Peabody H, Qi J, Dunn RL, Rogers C, Weizer A, Kaul S, Johnson A, Traver M, Lane BR. A Statewide Quality Improvement Collaborative's Adherence to the 2017 American Urological Association Guidelines Regarding Initial Evaluation of Patients With Clinical T1 Renal Masses. Urology 2021; 158:117-124. [PMID: 34499969 DOI: 10.1016/j.urology.2021.08.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 08/03/2021] [Accepted: 08/22/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To evaluate MUSIC-KIDNEY's adherence to the American Urological Association (AUA) guidelines regarding the initial evaluation of patient's with clinical T1 (cT1) renal masses. METHODS We reviewed MUSIC-KIDNEY registry data for patients with newly diagnosed cT1 renal masses to assess for adherence with the 2017 AUA guideline statements regarding recommendations to obtain (1) CMP, (2) CBC, (3) UA, (4) abdominal cross-sectional imaging, and (5) chest imaging. An evaluation consisting of all 5 guideline measures was considered "complete compliance." Variation with guideline adherence was assessed by contributing practice, management strategy, and renal mass size. RESULTS We identified 1808 patients with cT1 renal masses in the MUSIC-KIDNEY registry, of which 30% met the definition of complete compliance. Most patients received care that was compliant with recommendations to obtain laboratory testing with 1448 (80%), 1545 (85%), and 1472 (81%) patients obtaining a CMP, CBC, and UA respectively. Only 862 (48%) patients underwent chest imaging. Significant variation exists in complete guideline compliance for contributing practices, ranging from 0% to 45% as well as for patients which underwent immediate intervention compared with initial observation (37% vs 23%) and patients with cT1b masses compared with cT1a masses (36% vs 28%). CONCLUSION Complete guideline compliance in the initial evaluation of patients with cT1 renal masses is poor, which is mainly driven by omission of chest imaging. Significant variation in guideline adherence is seen across practices, as well as patients undergoing an intervention vs observation, and cT1a vs cT1b masses. There are ample quality improvement opportunities to increase adherence and decrease variability with guideline recommendations.
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Affiliation(s)
- Kevin B Ginsburg
- Wayne State University, School of Medicine, Detroit, MI; Department of Surgical Oncology, Fox Chase Cancer Center, Division of Urology and Urologic Oncology, Philadelphia, PA.
| | | | - Tudor Moldovan
- Michigan State University, College of Human Medicine, Grand Rapids, MI
| | | | - Ji Qi
- Michigan Medicine, Ann Arbor, MI
| | | | | | | | - Sanjeev Kaul
- Comprehensive Urology, William Beaumont Hospital, Royal Oak, MI
| | | | | | - Brian R Lane
- Michigan State University, College of Human Medicine, Grand Rapids, MI; Spectrum Health Hospital System, Grand Rapids, MI
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Paudel R, Ferrante S, Qi J, Dunn RL, Berry DL, Semerjian A, Brede CM, George AK, Lane BR, Ginsburg KB, Montie JE, Lane GI. Patient Preferences and Treatment Decisions for Prostate Cancer: Results From A Statewide Urological Quality Improvement Collaborative. Urology 2021; 155:55-61. [PMID: 33933504 DOI: 10.1016/j.urology.2021.04.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 04/13/2021] [Accepted: 04/15/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To examine the relationship between influential factors and treatment decisions among men with newly diagnosed prostate cancer (PCa). METHODS We identified men in the Michigan Urological Surgery Improvement Collaborative registry diagnosed with localized PCa between 2018-2020 who completed Personal Patient Profile-Prostate. We analyzed the proportion of active surveillance (AS) between men who stated future bladder, bowel, and sexual problems (termed influential factors) had "a lot of influence" on their treatment decisions versus other responses. We also assessed the relationship between influential factors, confirmatory testing results and choice of AS. RESULTS A total of 509 men completed Personal Patient Profile-Prostate. Treatment decisions aligned with influential factors for 88% of men with favorable risk and 49% with unfavorable risk PCa. A higher proportion of men who identified bladder, bowel and sexual concerns as having "a lot of influence" on their treatment decision chose AS, compared with men with other influential factors, although not statistically significant (44% vs 35%, P = .11). Similar results were also found when men were stratified based on PCa risk groups (favorable risk: 78% vs 67%; unfavorable risk: 17% vs 9%, respectively). Despite a small sample size, a higher proportion of men with non-reassuring confirmatory testing selected AS if influential factors had "a lot of influence" compared to "no influence" on their treatment decisions. CONCLUSION Men's concerns for future bladder, bowel, and sexual function problems, as elicited by a decision aid, may help explain treatment selection that differs from traditional clinical recommendation.
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Affiliation(s)
- Roshan Paudel
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI.
| | | | - Ji Qi
- Michigan Urological Surgery Improvement Collaborative, Ann Arbor, MI
| | - Rodney L Dunn
- Michigan Urological Surgery Improvement Collaborative, Ann Arbor, MI
| | - Donna L Berry
- Biobehavioral Nursing and Health Informatics, University of Washington, Seattle, WA
| | - Alice Semerjian
- Michigan Urological Surgery Improvement Collaborative, Ann Arbor, MI; IHA Urology, St. Joseph Mercy Health System, Ypsilanti, MI
| | | | - Arvin K George
- Michigan Urological Surgery Improvement Collaborative, Ann Arbor, MI; Department of Urology, University of Michigan, Ann Arbor, MI
| | | | - Kevin B Ginsburg
- Department of Urology, Wayne State University School of Medicine, Detroit, MI; Department of Surgical Oncology, Division of Urologic Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - James E Montie
- Michigan Urological Surgery Improvement Collaborative, Ann Arbor, MI; Department of Urology, University of Michigan, Ann Arbor, MI
| | - Giulia I Lane
- Department of Urology, University of Michigan, Ann Arbor, MI
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