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Porcaro AB, Costantino S, Brancelli C, Baielli A, Artoni F, Montanaro F, Gallina S, Bianchi A, Serafin E, Veccia A, Franceschini A, Rizzetto R, Brunelli M, Migliorini F, Bertolo RG, Cerruto MA, Antonelli A. 2012 Briganti nomogram predict prostate cancer progression in EAU intermediate risk with unfavorable tumor grade: A single center experience. Urologia 2024:3915603241252911. [PMID: 38780183 DOI: 10.1177/03915603241252911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
BACKGROUND To investigate the potential prognostic impact of Briganti's 2012 nomogram in EAU intermediate-risk patients presenting with an unfavorable tumor grade and treated with robot-assisted radical prostatectomy, eventually associated with extended pelvic lymph node dissection. MATERIALS AND METHODS From January 2013 to December 2021, the study included 179 EAU intermediate-risk patients presenting with an unfavorable tumor grade (ISUP 3), eventually associated with a PSA of 10-20 ng/ml and/or cT-2b. Briganti's 2012 nomogram was assessed as both a continuous and dichotomous variable, categorized according to the median (risk score ⩾7% vs <7%). Disease progression, defined as biochemical recurrence and/or metastatic progression, was evaluated using Cox proportional hazards in both univariate and multivariate analyses. RESULTS Disease progression occurred in 43 (24%) patients after a median (95% CI) follow-up of 78 (65.7-88.4) months. The nomogram risk score predicted disease progression, evaluated both as a continuous variable (hazard ratio, HR = 1.064; 95% CI: 1.035-1.093; p < 0.0001) and as a categorical variable (HR = 3.399; 95% CI: 1.740-6.638; p < 0.0001). This association was confirmed in multivariate analysis, where hazard ratios remained consistent even after adjusting for clinical and pathological factors. CONCLUSIONS In EAU intermediate-risk PCa cases presenting with an unfavorable tumor grade and treated surgically, Briganti's 2012 nomogram was associated with disease progression after surgery. Consequently, as the nomogram risk score increased, patients were more likely to experience PCa progression, facilitating the stratification of the patient population into distinct prognostic subgroups.
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Affiliation(s)
- Antonio Benito Porcaro
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Sonia Costantino
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Claudio Brancelli
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Alberto Baielli
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Francesco Artoni
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Francesca Montanaro
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Sebastian Gallina
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Alberto Bianchi
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Emanuele Serafin
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Alessandro Veccia
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Andrea Franceschini
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Riccardo Rizzetto
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Matteo Brunelli
- Department of Pathology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Filippo Migliorini
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Riccardo Giuseppe Bertolo
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Maria Angela Cerruto
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Alessandro Antonelli
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
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Zattoni F, Matrone F, Bortolus R, Giannarini G. Navigating the evolving diagnostic and therapeutic landscape of low- and intermediate-risk prostate cancer. Asian J Androl 2024:00129336-990000000-00183. [PMID: 38738954 DOI: 10.4103/aja20249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 02/08/2024] [Indexed: 05/14/2024] Open
Abstract
ABSTRACT In this nonsystematic review of the literature, we explored the changing landscape of detection and treatment of low- and intermediate-risk prostate cancer (PCa). Through emphasizing improved cancer assessment with histology classification and genomics, we investigated key developments in PCa detection and risk stratification. The pivotal role of prostate magnetic resonance imaging (MRI) in the novel diagnostic pathway is examined, alongside the benefits and drawbacks of MRI-targeted biopsies for detection and tumor characterization. We also delved into treatment options, particularly active surveillance for intermediate-risk PCa. Outcomes are compared between intermediate- and low-risk patients, offering insights into tailored management. Surgical techniques, including Retzius-sparing surgery, precision prostatectomy, and partial prostatectomy for anterior cancer, are appraised. Each technique has the potential to enhance outcomes and minimize complications. Advancements in technology and radiobiology, including computed tomography (CT)/MRI imaging and positron emission tomography (PET) fusion, allow for precise dose adjustment and daily target monitoring with imaging-guided radiotherapy, opening new ways of tailoring patients' treatments. Finally, experimental therapeutic approaches such as focal therapy open new treatment frontiers, although they create new needs in tumor identification and tracking during and after the procedure.
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Affiliation(s)
- Fabio Zattoni
- Urologic Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padua, Italy
| | - Fabio Matrone
- Department of Radiotherapy, National Cancer Institute (CRO), Aviano 33081, Italy
| | - Roberto Bortolus
- Department of Radiotherapy, National Cancer Institute (CRO), Aviano 33081, Italy
| | - Gianluca Giannarini
- Urology Unit, Santa Maria Della Misericordia University Hospital, Udine 33100, Italy
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Cornford P, van den Bergh RCN, Briers E, Van den Broeck T, Brunckhorst O, Darraugh J, Eberli D, De Meerleer G, De Santis M, Farolfi A, Gandaglia G, Gillessen S, Grivas N, Henry AM, Lardas M, van Leenders GJLH, Liew M, Linares Espinos E, Oldenburg J, van Oort IM, Oprea-Lager DE, Ploussard G, Roberts MJ, Rouvière O, Schoots IG, Schouten N, Smith EJ, Stranne J, Wiegel T, Willemse PPM, Tilki D. EAU-EANM-ESTRO-ESUR-ISUP-SIOG Guidelines on Prostate Cancer-2024 Update. Part I: Screening, Diagnosis, and Local Treatment with Curative Intent. Eur Urol 2024:S0302-2838(24)02254-1. [PMID: 38614820 DOI: 10.1016/j.eururo.2024.03.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Revised: 03/14/2024] [Accepted: 03/27/2024] [Indexed: 04/15/2024]
Abstract
BACKGROUND AND OBJECTIVE The European Association of Urology (EAU)-European Association of Nuclear Medicine (EANM)-European Society for Radiotherapy and Oncology (ESTRO)-European Society of Urogenital Radiology (ESUR)-International Society of Urological Pathology (ISUP)-International Society of Geriatric Oncology (SIOG) guidelines provide recommendations for the management of clinically localised prostate cancer (PCa). This paper aims to present a summary of the 2024 version of the EAU-EANM-ESTRO-ESUR-ISUP-SIOG guidelines on the screening, diagnosis, and treatment of clinically localised PCa. METHODS The panel performed a literature review of all new data published in English, covering the time frame between May 2020 and 2023. The guidelines were updated, and a strength rating for each recommendation was added based on a systematic review of the evidence. KEY FINDINGS AND LIMITATIONS A risk-adapted strategy for identifying men who may develop PCa is advised, generally commencing at 50 yr of age and based on individualised life expectancy. The use of multiparametric magnetic resonance imaging in order to avoid unnecessary biopsies is recommended. When a biopsy is considered, a combination of targeted and regional biopsies should be performed. Prostate-specific membrane antigen positron emission tomography imaging is the most sensitive technique for identifying metastatic spread. Active surveillance is the appropriate management for men with low-risk PCa, as well as for selected favourable intermediate-risk patients with International Society of Urological Pathology grade group 2 lesions. Local therapies are addressed, as well as the management of persistent prostate-specific antigen after surgery. A recommendation to consider hypofractionation in intermediate-risk patients is provided. Patients with cN1 PCa should be offered a local treatment combined with long-term intensified hormonal treatment. CONCLUSIONS AND CLINICAL IMPLICATIONS The evidence in the field of diagnosis, staging, and treatment of localised PCa is evolving rapidly. These PCa guidelines reflect the multidisciplinary nature of PCa management. PATIENT SUMMARY This article is the summary of the guidelines for "curable" prostate cancer. Prostate cancer is "found" through a multistep risk-based screening process. The objective is to find as many men as possible with a curable cancer. Prostate cancer is curable if it resides in the prostate; it is then classified into low-, intermediary-, and high-risk localised and locally advanced prostate cancer. These risk classes are the basis of the treatments. Low-risk prostate cancer is treated with "active surveillance", a treatment with excellent prognosis. For low-intermediary-risk active surveillance should also be discussed as an option. In other cases, active treatments, surgery, or radiation treatment should be discussed along with the potential side effects to allow shared decision-making.
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Affiliation(s)
- Philip Cornford
- Department of Urology, Liverpool University Hospitals NHS Trust, Liverpool, UK.
| | | | | | | | | | - Julie Darraugh
- European Association of Urology, Arnhem, The Netherlands
| | - Daniel Eberli
- Department of Urology, University Hospital Zurich, Zurich, Switzerland
| | - Gert De Meerleer
- Department of Radiation Oncology, University Hospital Leuven, Leuven, Belgium
| | - Maria De Santis
- Department of Urology, Universitätsmedizin Berlin, Berlin, Germany; Department of Urology, Medical University of Vienna, Vienna, Austria
| | - Andrea Farolfi
- Nuclear Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Giorgio Gandaglia
- Division of Oncology/Unit of Urology, Soldera Prostate Cancer Laboratory, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Silke Gillessen
- Oncology Institute of Southern Switzerland (IOSI), EOC, Bellinzona, Switzerland; Faculty of Biomedical Sciences, USI, Lugano, Switzerland
| | - Nikolaos Grivas
- Department of Urology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Ann M Henry
- Leeds Cancer Centre, St. James's University Hospital and University of Leeds, Leeds, UK
| | - Michael Lardas
- Department of Urology, Metropolitan General Hospital, Athens, Greece
| | | | - Matthew Liew
- Department of Urology, Liverpool University Hospitals NHS Trust, Liverpool, UK
| | | | - Jan Oldenburg
- Akershus University Hospital (Ahus), Lørenskog, Norway; Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Inge M van Oort
- Department of Urology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Daniela E Oprea-Lager
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, VU Medical Center, Amsterdam, The Netherlands
| | | | - Matthew J Roberts
- Department of Urology, Royal Brisbane and Women's Hospital, Brisbane, Australia; Faculty of Medicine, The University of Queensland Centre for Clinical Research, Herston, QLD, Australia
| | - Olivier Rouvière
- Department of Imaging, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France; Université de Lyon, Université Lyon 1, UFR Lyon-Est, Lyon, France
| | - Ivo G Schoots
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Radiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | - Emma J Smith
- European Association of Urology, Arnhem, The Netherlands
| | - Johan Stranne
- Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Urology, Sahlgrenska University Hospital-Västra Götaland, Gothenburg, Sweden
| | - Thomas Wiegel
- Department of Radiation Oncology, University Hospital Ulm, Ulm, Germany
| | - Peter-Paul M Willemse
- Department of Urology, Cancer Center University Medical Center Utrecht, Utrecht, The Netherlands
| | - Derya Tilki
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg Eppendorf, Hamburg, Germany; Department of Urology, University Hospital Hamburg-Eppendorf, Hamburg, Germany; Department of Urology, Koc University Hospital, Istanbul, Turkey
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4
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Porcaro AB, Orlando R, Panunzio A, Tafuri A, Baielli A, Artoni F, Montanaro F, Gallina S, Bianchi A, Mazzucato G, Serafin E, Veccia A, Boldini M, Treccani LP, Rizzetto R, Brunelli M, Migliorini F, Bertolo R, Cerruto MA, Antonelli A. The 2012 Briganti nomogram predicts disease progression in surgically treated intermediate-risk prostate cancer patients with favorable tumor grade group eventually associated with some adverse factors. J Robot Surg 2024; 18:134. [PMID: 38520651 DOI: 10.1007/s11701-024-01886-x] [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: 12/27/2023] [Accepted: 02/26/2024] [Indexed: 03/25/2024]
Abstract
To evaluate the prognostic potential of the 2012 Briganti nomogram for pelvic lymph node invasion on disease progression after surgery in intermediate-risk (IR) prostate cancer (PCa) patients with favorable tumor grade (International Society of Urological Pathology grade group 1 or 2), eventually associated with adverse clinical features as PSA between 10 and 20 ng/mL and/or clinical stage T2b. All IR PCa patients treated with robot-assisted radical prostatectomy and eventually extended pelvic lymph node dissection at the Department of Urology of the Integrated University Hospital of Verona between 2013 and 2021, with the abovementioned features, and available follow-up were considered. The 2012 Briganti nomogram score was assessed both as a continuous and dichotomous variable, where a mean risk score of 4% was used a threshold. The independent predictor status of the nomogram score on disease progression defined as the occurrence of biochemical recurrence and/or metastatic progression was evaluated using the Cox regression analysis. Overall, 348 patients were enrolled in the study. Median (interquartile range) follow-up was 98 (83.5-112.4) months. At multivariable Cox regression analysis, PCa progression, which occurred in 65 (18.7%) cases, was independently predicted only by the 2012 Briganti nomogram score evaluated as a continuous variable, among all considered clinical features (HR 1.16; 95%CI 1.08-1.24; p < 0.001). In addition, patients presenting with a nomogram score ≥ 4% were more likely to experience disease progression even after adjustment for clinical (HR 2.22, 95%CI 1.02-4.79; p = 0.043) and pathological (HR 1.80; 95%CI 1.06-3.05; p = 0.031) factors. In the examined patient population, the 2012 Briganti nomogram predicted PCa progression after surgery. Accordingly, as the risk score increased, patients were more likely to progress, independently by the occurrence of adverse pathology in the surgical specimen. The 2012 Briganti nomogram score categorized according to the mean value allowed to identify prognostic subgroups.
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Affiliation(s)
- Antonio Benito Porcaro
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126, Verona, Italy.
| | - Rossella Orlando
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126, Verona, Italy
| | | | | | - Alberto Baielli
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126, Verona, Italy
| | - Francesco Artoni
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126, Verona, Italy
| | - Francesca Montanaro
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126, Verona, Italy
| | - Sebastian Gallina
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126, Verona, Italy
| | - Alberto Bianchi
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126, Verona, Italy
| | - Giovanni Mazzucato
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126, Verona, Italy
| | - Emanuele Serafin
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126, Verona, Italy
| | - Alessandro Veccia
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126, Verona, Italy
| | - Michele Boldini
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126, Verona, Italy
| | - Lorenzo Pierangelo Treccani
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126, Verona, Italy
| | - Riccardo Rizzetto
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126, Verona, Italy
| | - Matteo Brunelli
- Department of Pathology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Filippo Migliorini
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126, Verona, Italy
| | - Riccardo Bertolo
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126, Verona, Italy
| | - Maria Angela Cerruto
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126, Verona, Italy
| | - Alessandro Antonelli
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126, Verona, Italy
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Dearnaley D, Griffin CL, Silva P, Wilkins A, Stuttle C, Syndikus I, Hassan S, Pugh J, Cruickshank C, Hall E, Corbishley CM. International Society of Urological Pathology (ISUP) Gleason Grade Groups stratify outcomes in the CHHiP Phase 3 prostate radiotherapy trial. BJU Int 2024; 133:179-187. [PMID: 37463104 DOI: 10.1111/bju.16133] [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] [Indexed: 07/20/2023]
Abstract
OBJECTIVES To compare the results of Gleason Grade Group (GGG) classification following central pathology review with previous local pathology assessment, and to examine the difference between using overall and worst GGG in a large patient cohort treated with radiotherapy and short-course hormone therapy. PATIENTS AND METHODS Patients with low- to high-risk localized prostate cancer were randomized into the multicentre CHHiP fractionation trial between 2002 and 2011. Patients received short-course hormone therapy (≤6 month) and radical intensity-modulated radiotherapy (IMRT). Of 2749 consented patients, 1875 had adequate diagnostic biopsy tissue for blinded central pathology review. The median follow-up was 9.3 years. Agreement between local pathology and central pathology-derived GGG and between central pathology-derived overall and worst GGG was assessed using kappa (κ) statistics. Multivariate Cox regression and Kaplan-Meier methods were used to compare the biochemical/clinical failure (BCF) and distant metastases (DM) outcomes of patients with GGG 1-5. RESULTS There was poor agreement between local pathology- and central pathology-derived GGG (κ = 0.19) but good agreement between overall and worst GGG on central pathology review (κ = 0.89). Central pathology-derived GGG stratified BCF and DM outcomes better than local pathology, while overall and worst GGG on central pathology review performed similarly. GGG 3 segregated with GGG 4 for BCF, with BCF-free rates of 90%, 82%, 74%, 71% and 58% for GGGs 1-5, respectively, at 8 years when assessed using overall GGG. There was a progressive decrease in DM-free rates from 98%, 96%, 92%, 88% and 83% for GGGs 1-5, respectively, at 8 years with overall GGG. Patients (n = 57) who were upgraded from GGG 2-3 using worst GS had BCF-free and DM-free rates of 74% and 92% at 8 years. CHHiP eligibility criteria limit the interpretation of these results. CONCLUSION Contemporary review of International Society of Urological Pathology GGG successfully stratified patients treated with short-course hormone therapy and IMRT with regard to both BCF-free and DM-free outcomes. Patients upgraded from GGG 2 to GGG 3 using worst biopsy GS segregate with GGG 3 on long-term follow-up. We recommend that both overall and worst GS be used to derive GGG.
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Affiliation(s)
- David Dearnaley
- The Institute of Cancer Research, London, UK
- Royal Marsden Hospital NHS Foundation Trust, Sutton, UK
| | - Clare L Griffin
- Clinical Trials and Statistics Unit at the Institute of Cancer Research, London, UK
| | - Pedro Silva
- The Institute of Cancer Research, London, UK
- Royal Marsden Hospital NHS Foundation Trust, Sutton, UK
| | - Anna Wilkins
- The Institute of Cancer Research, London, UK
- Royal Marsden Hospital NHS Foundation Trust, Sutton, UK
| | | | | | - Shama Hassan
- Clinical Trials and Statistics Unit at the Institute of Cancer Research, London, UK
| | - Julia Pugh
- Clinical Trials and Statistics Unit at the Institute of Cancer Research, London, UK
| | - Clare Cruickshank
- Clinical Trials and Statistics Unit at the Institute of Cancer Research, London, UK
| | - Emma Hall
- Clinical Trials and Statistics Unit at the Institute of Cancer Research, London, UK
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6
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Parry MG, Sujenthiran A, Nossiter J, Morris M, Berry B, Nathan A, Aggarwal A, Payne H, van der Meulen J, Clarke NW. Prostate cancer outcomes following whole-gland and focal high-intensity focused ultrasound. BJU Int 2023; 132:568-574. [PMID: 37422679 DOI: 10.1111/bju.16122] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/10/2023]
Abstract
OBJECTIVE To report the 5-year failure-free survival (FFS) following high-intensity focused ultrasound (HIFU). PATIENTS AND METHODS This observational cohort study used linked National Cancer Registry data, radiotherapy data, administrative hospital data and mortality records of 1381 men treated with HIFU for clinically localised prostate cancer in England. The primary outcome, FFS, was defined as freedom from local salvage treatment and cancer-specific mortality. Secondary outcomes were freedom from repeat HIFU, prostate cancer-specific survival (CSS) and overall survival (OS). Cox regression was used to determine whether baseline characteristics, including age, treatment year, T stage and International Society of Urological Pathology (ISUP) Grade Group were associated with FFS. RESULTS The median (interquartile range [IQR]) follow-up was 37 (20-62) months. The median (IQR) age was 65 (59-70) years and 81% had an ISUP Grade Group of 1-2. The FFS was 96.5% (95% confidence interval [CI] 95.4%-97.4%) at 1 year, 86.0% (95% CI 83.7%-87.9%) at 3 years and 77.5% (95% CI 74.4%-80.3%) at 5 years. The 5-year FFS for ISUP Grade Groups 1-5 was 82.9%, 76.6%, 72.2%, 52.3% and 30.8%, respectively (P < 0.001). Freedom from repeat HIFU was 79.1% (95% CI 75.7%-82.1%), CSS was 98.8% (95% CI 97.7%-99.4%) and OS was 95.9% (95% CI 94.2%-97.1%) at 5 years. CONCLUSION Four in five men were free from local salvage treatment at 5 years but treatment failure varied significantly according to ISUP Grade Group. Patients should be appropriately informed with respect to salvage radical treatment following HIFU.
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Affiliation(s)
- Matthew G Parry
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
- The National Prostate Cancer Audit, Clinical Effectiveness Unit, Royal College of Surgeons of UK, London, UK
| | - Arunan Sujenthiran
- The National Prostate Cancer Audit, Clinical Effectiveness Unit, Royal College of Surgeons of UK, London, UK
- Flatiron, London, UK
| | - Julie Nossiter
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
- The National Prostate Cancer Audit, Clinical Effectiveness Unit, Royal College of Surgeons of UK, London, UK
| | - Melanie Morris
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
- The National Prostate Cancer Audit, Clinical Effectiveness Unit, Royal College of Surgeons of UK, London, UK
| | - Brendan Berry
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
- The National Prostate Cancer Audit, Clinical Effectiveness Unit, Royal College of Surgeons of UK, London, UK
| | - Arjun Nathan
- The National Prostate Cancer Audit, Clinical Effectiveness Unit, Royal College of Surgeons of UK, London, UK
- University College London, London, UK
| | - Ajay Aggarwal
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
- Department of Radiotherapy, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Heather Payne
- Department of Oncology, University College London Hospitals, London, UK
| | - Jan van der Meulen
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Noel W Clarke
- Departments of Urology, The Christie and Salford Royal Hospitals, Manchester, UK
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7
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Lophatananon A, Light A, Burns-Cox N, Maccormick A, John J, Otti V, McGrath J, Archer P, Anning J, McCracken S, Page T, Muir K, Gnanapragasam VJ. Re-evaluating the diagnostic efficacy of PSA as a referral test to detect clinically significant prostate cancer in contemporary MRI-based image-guided biopsy pathways. JOURNAL OF CLINICAL UROLOGY 2023; 16:264-273. [PMID: 37614642 PMCID: PMC7614972 DOI: 10.1177/20514158211059057] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/25/2023]
Abstract
Introduction Modern image-guided biopsy pathways at diagnostic centres have greatly refined the investigations of men referred with suspected prostate cancer. However, the referral criteria from primary care are still based on historical prostate-specific antigen (PSA) cut-offs and age-referenced thresholds. Here, we tested whether better contemporary pathways and biopsy methods had improved the predictive utility value of PSA referral thresholds. Methods PSA referral thresholds, age-referenced ranges and PSA density (PSAd) were assessed for positive predictive value (PPV) in detection of clinically significant prostate cancer (csPCa - histological ⩾ Grade Group 2). Data were analysed from men referred to three diagnostics centres who used multi-parametric magnetic resonance imaging (mpMRI)-guided prostate biopsies for disease characterisation. Findings were validated in a separate multicentre cohort. Results: Data from 2767 men were included in this study. The median age, PSA and PSAd were 66.4 years, 7.3 ng/mL and 0.1 ng/mL2, respectively. Biopsy detected csPCa was found in 38.7%. The overall area under the curve (AUC) for PSA was 0.68 which is similar to historical performance. A PSA threshold of ⩾ 3 ng/mL had a PPV of 40.3%, but this was age dependent (PPV: 24.8%, 32.7% and 56.8% in men 50-59 years, 60-69 years and ⩾ 70 years, respectively). Different PSA cut-offs and age-reference ranges failed to demonstrate better performance. PSAd demonstrated improved AUC (0.78 vs 0.68, p < 0.0001) and improved PPV compared to PSA. A PSAd of ⩾ 0.10 had a PPV of 48.2% and similar negative predictive value (NPV) to PSA ⩾ 3 ng/mL and out-performed PSA age-reference ranges. This improved performance was recapitulated in a separate multi-centre cohort (n = 541). Conclusion The introduction of MRI-based image-guided biopsy pathways does not appear to have altered PSA diagnostic test characteristics to positively detect csPCa. We find no added value to PSA age-referenced ranges, while PSAd offers better PPV and the potential for a single clinically useful threshold (⩾0.10) for all age groups. Level of evidence IV.
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Affiliation(s)
- Artitaya Lophatananon
- Division of Population Health, Health Services Research & Primary Care Centre, University of Manchester, UK
| | - Alexander Light
- Division of Urology, Department of Surgery, University of Cambridge, UK
- Department of Urology, Cambridge University Hospitals NHS Foundation Trust, UK
| | | | | | - Joseph John
- Department of Urology, Royal Devon and Exeter NHS Foundation Trust and University of Exeter, UK
| | - Vanessa Otti
- Department of Urology, Royal Devon and Exeter NHS Foundation Trust and University of Exeter, UK
| | - John McGrath
- Department of Urology, Royal Devon and Exeter NHS Foundation Trust and University of Exeter, UK
| | - Pete Archer
- Department of Urology, Southend Hospital, UK
| | | | - Stuart McCracken
- Department of Urology, South Tyneside and Sunderland NHS Trust, UK
| | - Toby Page
- Department of Urology, Newcastle Hospitals NHS Trust, UK
| | - Ken Muir
- Division of Population Health, Health Services Research & Primary Care Centre, University of Manchester, UK
| | - Vincent J Gnanapragasam
- Division of Urology, Department of Surgery, University of Cambridge, UK
- Department of Urology, Cambridge University Hospitals NHS Foundation Trust, UK
- Cambridge Urology Translational Research and Clinical Trials Office, Addenbrooke’s Hospital, UK
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Hamdy FC, Donovan JL, Lane JA, Metcalfe C, Davis M, Turner EL, Martin RM, Young GJ, Walsh EI, Bryant RJ, Bollina P, Doble A, Doherty A, Gillatt D, Gnanapragasam V, Hughes O, Kockelbergh R, Kynaston H, Paul A, Paez E, Powell P, Rosario DJ, Rowe E, Mason M, Catto JWF, Peters TJ, Oxley J, Williams NJ, Staffurth J, Neal DE. Fifteen-Year Outcomes after Monitoring, Surgery, or Radiotherapy for Prostate Cancer. N Engl J Med 2023; 388:1547-1558. [PMID: 36912538 DOI: 10.1056/nejmoa2214122] [Citation(s) in RCA: 156] [Impact Index Per Article: 156.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
BACKGROUND Between 1999 and 2009 in the United Kingdom, 82,429 men between 50 and 69 years of age received a prostate-specific antigen (PSA) test. Localized prostate cancer was diagnosed in 2664 men. Of these men, 1643 were enrolled in a trial to evaluate the effectiveness of treatments, with 545 randomly assigned to receive active monitoring, 553 to undergo prostatectomy, and 545 to undergo radiotherapy. METHODS At a median follow-up of 15 years (range, 11 to 21), we compared the results in this population with respect to death from prostate cancer (the primary outcome) and death from any cause, metastases, disease progression, and initiation of long-term androgen-deprivation therapy (secondary outcomes). RESULTS Follow-up was complete for 1610 patients (98%). A risk-stratification analysis showed that more than one third of the men had intermediate or high-risk disease at diagnosis. Death from prostate cancer occurred in 45 men (2.7%): 17 (3.1%) in the active-monitoring group, 12 (2.2%) in the prostatectomy group, and 16 (2.9%) in the radiotherapy group (P = 0.53 for the overall comparison). Death from any cause occurred in 356 men (21.7%), with similar numbers in all three groups. Metastases developed in 51 men (9.4%) in the active-monitoring group, in 26 (4.7%) in the prostatectomy group, and in 27 (5.0%) in the radiotherapy group. Long-term androgen-deprivation therapy was initiated in 69 men (12.7%), 40 (7.2%), and 42 (7.7%), respectively; clinical progression occurred in 141 men (25.9%), 58 (10.5%), and 60 (11.0%), respectively. In the active-monitoring group, 133 men (24.4%) were alive without any prostate cancer treatment at the end of follow-up. No differential effects on cancer-specific mortality were noted in relation to the baseline PSA level, tumor stage or grade, or risk-stratification score. No treatment complications were reported after the 10-year analysis. CONCLUSIONS After 15 years of follow-up, prostate cancer-specific mortality was low regardless of the treatment assigned. Thus, the choice of therapy involves weighing trade-offs between benefits and harms associated with treatments for localized prostate cancer. (Funded by the National Institute for Health and Care Research; ProtecT Current Controlled Trials number, ISRCTN20141297; ClinicalTrials.gov number, NCT02044172.).
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Affiliation(s)
- Freddie C Hamdy
- From the Nuffield Department of Surgical Sciences, University of Oxford, Oxford (F.C.H., R.J.B., D.E.N.), Population Health Sciences (J.L.D., J.A.L., C.M., M.D., E.L.T., R.M.M., G.J.Y., E.I.W., T.J.P., N.J.W.) and Bristol Trials Centre (J.A.L., C.M., G.J.Y.), Bristol Medical School, University of Bristol, the Department of Urology, Southmead Hospital and Bristol Urological Institute (E.R.), and the Department of Cellular Pathology, North Bristol NHS Trust (J.O.), Bristol, the Department of Urology and Surgery, Western General Hospital, University of Edinburgh, Edinburgh (P.B.), the Department of Urology (A. Doble) and the Division of Urology, Department of Surgery and Cambridge Urology Translational Research and Clinical Trials Office, Cambridge Biomedical Campus (V.G., D.E.N.), Addenbrooke's Hospital, Cambridge, the Department of Urology, Queen Elizabeth Hospital, Birmingham (A. Doherty), the Department of Urology, Cardiff and Vale University Health Board (O.H., H.K.), and the School of Medicine (M.M.) and the Division of Cancer and Genetics (J.S.), Cardiff University, Cardiff, the Department of Urology, University Hospitals of Leicester, Leicester (R.K.), the Department of Urology, Leeds Teaching Hospitals NHS Trust, Leeds (A.P.), the Department of Urology, Freeman Hospital, Newcastle-upon-Tyne (E.P., P.P.), and the Department of Urology, Royal Hallamshire Hospital (D.J.R., J.W.F.C.), and the Academic Urology Unit, Medical School, University of Sheffield (J.W.F.C.), Sheffield - all in the United Kingdom; and the Department of Urological Oncology and Robotic Surgery, Macquarie University, Sydney (D.G.)
| | - Jenny L Donovan
- From the Nuffield Department of Surgical Sciences, University of Oxford, Oxford (F.C.H., R.J.B., D.E.N.), Population Health Sciences (J.L.D., J.A.L., C.M., M.D., E.L.T., R.M.M., G.J.Y., E.I.W., T.J.P., N.J.W.) and Bristol Trials Centre (J.A.L., C.M., G.J.Y.), Bristol Medical School, University of Bristol, the Department of Urology, Southmead Hospital and Bristol Urological Institute (E.R.), and the Department of Cellular Pathology, North Bristol NHS Trust (J.O.), Bristol, the Department of Urology and Surgery, Western General Hospital, University of Edinburgh, Edinburgh (P.B.), the Department of Urology (A. Doble) and the Division of Urology, Department of Surgery and Cambridge Urology Translational Research and Clinical Trials Office, Cambridge Biomedical Campus (V.G., D.E.N.), Addenbrooke's Hospital, Cambridge, the Department of Urology, Queen Elizabeth Hospital, Birmingham (A. Doherty), the Department of Urology, Cardiff and Vale University Health Board (O.H., H.K.), and the School of Medicine (M.M.) and the Division of Cancer and Genetics (J.S.), Cardiff University, Cardiff, the Department of Urology, University Hospitals of Leicester, Leicester (R.K.), the Department of Urology, Leeds Teaching Hospitals NHS Trust, Leeds (A.P.), the Department of Urology, Freeman Hospital, Newcastle-upon-Tyne (E.P., P.P.), and the Department of Urology, Royal Hallamshire Hospital (D.J.R., J.W.F.C.), and the Academic Urology Unit, Medical School, University of Sheffield (J.W.F.C.), Sheffield - all in the United Kingdom; and the Department of Urological Oncology and Robotic Surgery, Macquarie University, Sydney (D.G.)
| | - J Athene Lane
- From the Nuffield Department of Surgical Sciences, University of Oxford, Oxford (F.C.H., R.J.B., D.E.N.), Population Health Sciences (J.L.D., J.A.L., C.M., M.D., E.L.T., R.M.M., G.J.Y., E.I.W., T.J.P., N.J.W.) and Bristol Trials Centre (J.A.L., C.M., G.J.Y.), Bristol Medical School, University of Bristol, the Department of Urology, Southmead Hospital and Bristol Urological Institute (E.R.), and the Department of Cellular Pathology, North Bristol NHS Trust (J.O.), Bristol, the Department of Urology and Surgery, Western General Hospital, University of Edinburgh, Edinburgh (P.B.), the Department of Urology (A. Doble) and the Division of Urology, Department of Surgery and Cambridge Urology Translational Research and Clinical Trials Office, Cambridge Biomedical Campus (V.G., D.E.N.), Addenbrooke's Hospital, Cambridge, the Department of Urology, Queen Elizabeth Hospital, Birmingham (A. Doherty), the Department of Urology, Cardiff and Vale University Health Board (O.H., H.K.), and the School of Medicine (M.M.) and the Division of Cancer and Genetics (J.S.), Cardiff University, Cardiff, the Department of Urology, University Hospitals of Leicester, Leicester (R.K.), the Department of Urology, Leeds Teaching Hospitals NHS Trust, Leeds (A.P.), the Department of Urology, Freeman Hospital, Newcastle-upon-Tyne (E.P., P.P.), and the Department of Urology, Royal Hallamshire Hospital (D.J.R., J.W.F.C.), and the Academic Urology Unit, Medical School, University of Sheffield (J.W.F.C.), Sheffield - all in the United Kingdom; and the Department of Urological Oncology and Robotic Surgery, Macquarie University, Sydney (D.G.)
| | - Chris Metcalfe
- From the Nuffield Department of Surgical Sciences, University of Oxford, Oxford (F.C.H., R.J.B., D.E.N.), Population Health Sciences (J.L.D., J.A.L., C.M., M.D., E.L.T., R.M.M., G.J.Y., E.I.W., T.J.P., N.J.W.) and Bristol Trials Centre (J.A.L., C.M., G.J.Y.), Bristol Medical School, University of Bristol, the Department of Urology, Southmead Hospital and Bristol Urological Institute (E.R.), and the Department of Cellular Pathology, North Bristol NHS Trust (J.O.), Bristol, the Department of Urology and Surgery, Western General Hospital, University of Edinburgh, Edinburgh (P.B.), the Department of Urology (A. Doble) and the Division of Urology, Department of Surgery and Cambridge Urology Translational Research and Clinical Trials Office, Cambridge Biomedical Campus (V.G., D.E.N.), Addenbrooke's Hospital, Cambridge, the Department of Urology, Queen Elizabeth Hospital, Birmingham (A. Doherty), the Department of Urology, Cardiff and Vale University Health Board (O.H., H.K.), and the School of Medicine (M.M.) and the Division of Cancer and Genetics (J.S.), Cardiff University, Cardiff, the Department of Urology, University Hospitals of Leicester, Leicester (R.K.), the Department of Urology, Leeds Teaching Hospitals NHS Trust, Leeds (A.P.), the Department of Urology, Freeman Hospital, Newcastle-upon-Tyne (E.P., P.P.), and the Department of Urology, Royal Hallamshire Hospital (D.J.R., J.W.F.C.), and the Academic Urology Unit, Medical School, University of Sheffield (J.W.F.C.), Sheffield - all in the United Kingdom; and the Department of Urological Oncology and Robotic Surgery, Macquarie University, Sydney (D.G.)
| | - Michael Davis
- From the Nuffield Department of Surgical Sciences, University of Oxford, Oxford (F.C.H., R.J.B., D.E.N.), Population Health Sciences (J.L.D., J.A.L., C.M., M.D., E.L.T., R.M.M., G.J.Y., E.I.W., T.J.P., N.J.W.) and Bristol Trials Centre (J.A.L., C.M., G.J.Y.), Bristol Medical School, University of Bristol, the Department of Urology, Southmead Hospital and Bristol Urological Institute (E.R.), and the Department of Cellular Pathology, North Bristol NHS Trust (J.O.), Bristol, the Department of Urology and Surgery, Western General Hospital, University of Edinburgh, Edinburgh (P.B.), the Department of Urology (A. Doble) and the Division of Urology, Department of Surgery and Cambridge Urology Translational Research and Clinical Trials Office, Cambridge Biomedical Campus (V.G., D.E.N.), Addenbrooke's Hospital, Cambridge, the Department of Urology, Queen Elizabeth Hospital, Birmingham (A. Doherty), the Department of Urology, Cardiff and Vale University Health Board (O.H., H.K.), and the School of Medicine (M.M.) and the Division of Cancer and Genetics (J.S.), Cardiff University, Cardiff, the Department of Urology, University Hospitals of Leicester, Leicester (R.K.), the Department of Urology, Leeds Teaching Hospitals NHS Trust, Leeds (A.P.), the Department of Urology, Freeman Hospital, Newcastle-upon-Tyne (E.P., P.P.), and the Department of Urology, Royal Hallamshire Hospital (D.J.R., J.W.F.C.), and the Academic Urology Unit, Medical School, University of Sheffield (J.W.F.C.), Sheffield - all in the United Kingdom; and the Department of Urological Oncology and Robotic Surgery, Macquarie University, Sydney (D.G.)
| | - Emma L Turner
- From the Nuffield Department of Surgical Sciences, University of Oxford, Oxford (F.C.H., R.J.B., D.E.N.), Population Health Sciences (J.L.D., J.A.L., C.M., M.D., E.L.T., R.M.M., G.J.Y., E.I.W., T.J.P., N.J.W.) and Bristol Trials Centre (J.A.L., C.M., G.J.Y.), Bristol Medical School, University of Bristol, the Department of Urology, Southmead Hospital and Bristol Urological Institute (E.R.), and the Department of Cellular Pathology, North Bristol NHS Trust (J.O.), Bristol, the Department of Urology and Surgery, Western General Hospital, University of Edinburgh, Edinburgh (P.B.), the Department of Urology (A. Doble) and the Division of Urology, Department of Surgery and Cambridge Urology Translational Research and Clinical Trials Office, Cambridge Biomedical Campus (V.G., D.E.N.), Addenbrooke's Hospital, Cambridge, the Department of Urology, Queen Elizabeth Hospital, Birmingham (A. Doherty), the Department of Urology, Cardiff and Vale University Health Board (O.H., H.K.), and the School of Medicine (M.M.) and the Division of Cancer and Genetics (J.S.), Cardiff University, Cardiff, the Department of Urology, University Hospitals of Leicester, Leicester (R.K.), the Department of Urology, Leeds Teaching Hospitals NHS Trust, Leeds (A.P.), the Department of Urology, Freeman Hospital, Newcastle-upon-Tyne (E.P., P.P.), and the Department of Urology, Royal Hallamshire Hospital (D.J.R., J.W.F.C.), and the Academic Urology Unit, Medical School, University of Sheffield (J.W.F.C.), Sheffield - all in the United Kingdom; and the Department of Urological Oncology and Robotic Surgery, Macquarie University, Sydney (D.G.)
| | - Richard M Martin
- From the Nuffield Department of Surgical Sciences, University of Oxford, Oxford (F.C.H., R.J.B., D.E.N.), Population Health Sciences (J.L.D., J.A.L., C.M., M.D., E.L.T., R.M.M., G.J.Y., E.I.W., T.J.P., N.J.W.) and Bristol Trials Centre (J.A.L., C.M., G.J.Y.), Bristol Medical School, University of Bristol, the Department of Urology, Southmead Hospital and Bristol Urological Institute (E.R.), and the Department of Cellular Pathology, North Bristol NHS Trust (J.O.), Bristol, the Department of Urology and Surgery, Western General Hospital, University of Edinburgh, Edinburgh (P.B.), the Department of Urology (A. Doble) and the Division of Urology, Department of Surgery and Cambridge Urology Translational Research and Clinical Trials Office, Cambridge Biomedical Campus (V.G., D.E.N.), Addenbrooke's Hospital, Cambridge, the Department of Urology, Queen Elizabeth Hospital, Birmingham (A. Doherty), the Department of Urology, Cardiff and Vale University Health Board (O.H., H.K.), and the School of Medicine (M.M.) and the Division of Cancer and Genetics (J.S.), Cardiff University, Cardiff, the Department of Urology, University Hospitals of Leicester, Leicester (R.K.), the Department of Urology, Leeds Teaching Hospitals NHS Trust, Leeds (A.P.), the Department of Urology, Freeman Hospital, Newcastle-upon-Tyne (E.P., P.P.), and the Department of Urology, Royal Hallamshire Hospital (D.J.R., J.W.F.C.), and the Academic Urology Unit, Medical School, University of Sheffield (J.W.F.C.), Sheffield - all in the United Kingdom; and the Department of Urological Oncology and Robotic Surgery, Macquarie University, Sydney (D.G.)
| | - Grace J Young
- From the Nuffield Department of Surgical Sciences, University of Oxford, Oxford (F.C.H., R.J.B., D.E.N.), Population Health Sciences (J.L.D., J.A.L., C.M., M.D., E.L.T., R.M.M., G.J.Y., E.I.W., T.J.P., N.J.W.) and Bristol Trials Centre (J.A.L., C.M., G.J.Y.), Bristol Medical School, University of Bristol, the Department of Urology, Southmead Hospital and Bristol Urological Institute (E.R.), and the Department of Cellular Pathology, North Bristol NHS Trust (J.O.), Bristol, the Department of Urology and Surgery, Western General Hospital, University of Edinburgh, Edinburgh (P.B.), the Department of Urology (A. Doble) and the Division of Urology, Department of Surgery and Cambridge Urology Translational Research and Clinical Trials Office, Cambridge Biomedical Campus (V.G., D.E.N.), Addenbrooke's Hospital, Cambridge, the Department of Urology, Queen Elizabeth Hospital, Birmingham (A. Doherty), the Department of Urology, Cardiff and Vale University Health Board (O.H., H.K.), and the School of Medicine (M.M.) and the Division of Cancer and Genetics (J.S.), Cardiff University, Cardiff, the Department of Urology, University Hospitals of Leicester, Leicester (R.K.), the Department of Urology, Leeds Teaching Hospitals NHS Trust, Leeds (A.P.), the Department of Urology, Freeman Hospital, Newcastle-upon-Tyne (E.P., P.P.), and the Department of Urology, Royal Hallamshire Hospital (D.J.R., J.W.F.C.), and the Academic Urology Unit, Medical School, University of Sheffield (J.W.F.C.), Sheffield - all in the United Kingdom; and the Department of Urological Oncology and Robotic Surgery, Macquarie University, Sydney (D.G.)
| | - Eleanor I Walsh
- From the Nuffield Department of Surgical Sciences, University of Oxford, Oxford (F.C.H., R.J.B., D.E.N.), Population Health Sciences (J.L.D., J.A.L., C.M., M.D., E.L.T., R.M.M., G.J.Y., E.I.W., T.J.P., N.J.W.) and Bristol Trials Centre (J.A.L., C.M., G.J.Y.), Bristol Medical School, University of Bristol, the Department of Urology, Southmead Hospital and Bristol Urological Institute (E.R.), and the Department of Cellular Pathology, North Bristol NHS Trust (J.O.), Bristol, the Department of Urology and Surgery, Western General Hospital, University of Edinburgh, Edinburgh (P.B.), the Department of Urology (A. Doble) and the Division of Urology, Department of Surgery and Cambridge Urology Translational Research and Clinical Trials Office, Cambridge Biomedical Campus (V.G., D.E.N.), Addenbrooke's Hospital, Cambridge, the Department of Urology, Queen Elizabeth Hospital, Birmingham (A. Doherty), the Department of Urology, Cardiff and Vale University Health Board (O.H., H.K.), and the School of Medicine (M.M.) and the Division of Cancer and Genetics (J.S.), Cardiff University, Cardiff, the Department of Urology, University Hospitals of Leicester, Leicester (R.K.), the Department of Urology, Leeds Teaching Hospitals NHS Trust, Leeds (A.P.), the Department of Urology, Freeman Hospital, Newcastle-upon-Tyne (E.P., P.P.), and the Department of Urology, Royal Hallamshire Hospital (D.J.R., J.W.F.C.), and the Academic Urology Unit, Medical School, University of Sheffield (J.W.F.C.), Sheffield - all in the United Kingdom; and the Department of Urological Oncology and Robotic Surgery, Macquarie University, Sydney (D.G.)
| | - Richard J Bryant
- From the Nuffield Department of Surgical Sciences, University of Oxford, Oxford (F.C.H., R.J.B., D.E.N.), Population Health Sciences (J.L.D., J.A.L., C.M., M.D., E.L.T., R.M.M., G.J.Y., E.I.W., T.J.P., N.J.W.) and Bristol Trials Centre (J.A.L., C.M., G.J.Y.), Bristol Medical School, University of Bristol, the Department of Urology, Southmead Hospital and Bristol Urological Institute (E.R.), and the Department of Cellular Pathology, North Bristol NHS Trust (J.O.), Bristol, the Department of Urology and Surgery, Western General Hospital, University of Edinburgh, Edinburgh (P.B.), the Department of Urology (A. Doble) and the Division of Urology, Department of Surgery and Cambridge Urology Translational Research and Clinical Trials Office, Cambridge Biomedical Campus (V.G., D.E.N.), Addenbrooke's Hospital, Cambridge, the Department of Urology, Queen Elizabeth Hospital, Birmingham (A. Doherty), the Department of Urology, Cardiff and Vale University Health Board (O.H., H.K.), and the School of Medicine (M.M.) and the Division of Cancer and Genetics (J.S.), Cardiff University, Cardiff, the Department of Urology, University Hospitals of Leicester, Leicester (R.K.), the Department of Urology, Leeds Teaching Hospitals NHS Trust, Leeds (A.P.), the Department of Urology, Freeman Hospital, Newcastle-upon-Tyne (E.P., P.P.), and the Department of Urology, Royal Hallamshire Hospital (D.J.R., J.W.F.C.), and the Academic Urology Unit, Medical School, University of Sheffield (J.W.F.C.), Sheffield - all in the United Kingdom; and the Department of Urological Oncology and Robotic Surgery, Macquarie University, Sydney (D.G.)
| | - Prasad Bollina
- From the Nuffield Department of Surgical Sciences, University of Oxford, Oxford (F.C.H., R.J.B., D.E.N.), Population Health Sciences (J.L.D., J.A.L., C.M., M.D., E.L.T., R.M.M., G.J.Y., E.I.W., T.J.P., N.J.W.) and Bristol Trials Centre (J.A.L., C.M., G.J.Y.), Bristol Medical School, University of Bristol, the Department of Urology, Southmead Hospital and Bristol Urological Institute (E.R.), and the Department of Cellular Pathology, North Bristol NHS Trust (J.O.), Bristol, the Department of Urology and Surgery, Western General Hospital, University of Edinburgh, Edinburgh (P.B.), the Department of Urology (A. Doble) and the Division of Urology, Department of Surgery and Cambridge Urology Translational Research and Clinical Trials Office, Cambridge Biomedical Campus (V.G., D.E.N.), Addenbrooke's Hospital, Cambridge, the Department of Urology, Queen Elizabeth Hospital, Birmingham (A. Doherty), the Department of Urology, Cardiff and Vale University Health Board (O.H., H.K.), and the School of Medicine (M.M.) and the Division of Cancer and Genetics (J.S.), Cardiff University, Cardiff, the Department of Urology, University Hospitals of Leicester, Leicester (R.K.), the Department of Urology, Leeds Teaching Hospitals NHS Trust, Leeds (A.P.), the Department of Urology, Freeman Hospital, Newcastle-upon-Tyne (E.P., P.P.), and the Department of Urology, Royal Hallamshire Hospital (D.J.R., J.W.F.C.), and the Academic Urology Unit, Medical School, University of Sheffield (J.W.F.C.), Sheffield - all in the United Kingdom; and the Department of Urological Oncology and Robotic Surgery, Macquarie University, Sydney (D.G.)
| | - Andrew Doble
- From the Nuffield Department of Surgical Sciences, University of Oxford, Oxford (F.C.H., R.J.B., D.E.N.), Population Health Sciences (J.L.D., J.A.L., C.M., M.D., E.L.T., R.M.M., G.J.Y., E.I.W., T.J.P., N.J.W.) and Bristol Trials Centre (J.A.L., C.M., G.J.Y.), Bristol Medical School, University of Bristol, the Department of Urology, Southmead Hospital and Bristol Urological Institute (E.R.), and the Department of Cellular Pathology, North Bristol NHS Trust (J.O.), Bristol, the Department of Urology and Surgery, Western General Hospital, University of Edinburgh, Edinburgh (P.B.), the Department of Urology (A. Doble) and the Division of Urology, Department of Surgery and Cambridge Urology Translational Research and Clinical Trials Office, Cambridge Biomedical Campus (V.G., D.E.N.), Addenbrooke's Hospital, Cambridge, the Department of Urology, Queen Elizabeth Hospital, Birmingham (A. Doherty), the Department of Urology, Cardiff and Vale University Health Board (O.H., H.K.), and the School of Medicine (M.M.) and the Division of Cancer and Genetics (J.S.), Cardiff University, Cardiff, the Department of Urology, University Hospitals of Leicester, Leicester (R.K.), the Department of Urology, Leeds Teaching Hospitals NHS Trust, Leeds (A.P.), the Department of Urology, Freeman Hospital, Newcastle-upon-Tyne (E.P., P.P.), and the Department of Urology, Royal Hallamshire Hospital (D.J.R., J.W.F.C.), and the Academic Urology Unit, Medical School, University of Sheffield (J.W.F.C.), Sheffield - all in the United Kingdom; and the Department of Urological Oncology and Robotic Surgery, Macquarie University, Sydney (D.G.)
| | - Alan Doherty
- From the Nuffield Department of Surgical Sciences, University of Oxford, Oxford (F.C.H., R.J.B., D.E.N.), Population Health Sciences (J.L.D., J.A.L., C.M., M.D., E.L.T., R.M.M., G.J.Y., E.I.W., T.J.P., N.J.W.) and Bristol Trials Centre (J.A.L., C.M., G.J.Y.), Bristol Medical School, University of Bristol, the Department of Urology, Southmead Hospital and Bristol Urological Institute (E.R.), and the Department of Cellular Pathology, North Bristol NHS Trust (J.O.), Bristol, the Department of Urology and Surgery, Western General Hospital, University of Edinburgh, Edinburgh (P.B.), the Department of Urology (A. Doble) and the Division of Urology, Department of Surgery and Cambridge Urology Translational Research and Clinical Trials Office, Cambridge Biomedical Campus (V.G., D.E.N.), Addenbrooke's Hospital, Cambridge, the Department of Urology, Queen Elizabeth Hospital, Birmingham (A. Doherty), the Department of Urology, Cardiff and Vale University Health Board (O.H., H.K.), and the School of Medicine (M.M.) and the Division of Cancer and Genetics (J.S.), Cardiff University, Cardiff, the Department of Urology, University Hospitals of Leicester, Leicester (R.K.), the Department of Urology, Leeds Teaching Hospitals NHS Trust, Leeds (A.P.), the Department of Urology, Freeman Hospital, Newcastle-upon-Tyne (E.P., P.P.), and the Department of Urology, Royal Hallamshire Hospital (D.J.R., J.W.F.C.), and the Academic Urology Unit, Medical School, University of Sheffield (J.W.F.C.), Sheffield - all in the United Kingdom; and the Department of Urological Oncology and Robotic Surgery, Macquarie University, Sydney (D.G.)
| | - David Gillatt
- From the Nuffield Department of Surgical Sciences, University of Oxford, Oxford (F.C.H., R.J.B., D.E.N.), Population Health Sciences (J.L.D., J.A.L., C.M., M.D., E.L.T., R.M.M., G.J.Y., E.I.W., T.J.P., N.J.W.) and Bristol Trials Centre (J.A.L., C.M., G.J.Y.), Bristol Medical School, University of Bristol, the Department of Urology, Southmead Hospital and Bristol Urological Institute (E.R.), and the Department of Cellular Pathology, North Bristol NHS Trust (J.O.), Bristol, the Department of Urology and Surgery, Western General Hospital, University of Edinburgh, Edinburgh (P.B.), the Department of Urology (A. Doble) and the Division of Urology, Department of Surgery and Cambridge Urology Translational Research and Clinical Trials Office, Cambridge Biomedical Campus (V.G., D.E.N.), Addenbrooke's Hospital, Cambridge, the Department of Urology, Queen Elizabeth Hospital, Birmingham (A. Doherty), the Department of Urology, Cardiff and Vale University Health Board (O.H., H.K.), and the School of Medicine (M.M.) and the Division of Cancer and Genetics (J.S.), Cardiff University, Cardiff, the Department of Urology, University Hospitals of Leicester, Leicester (R.K.), the Department of Urology, Leeds Teaching Hospitals NHS Trust, Leeds (A.P.), the Department of Urology, Freeman Hospital, Newcastle-upon-Tyne (E.P., P.P.), and the Department of Urology, Royal Hallamshire Hospital (D.J.R., J.W.F.C.), and the Academic Urology Unit, Medical School, University of Sheffield (J.W.F.C.), Sheffield - all in the United Kingdom; and the Department of Urological Oncology and Robotic Surgery, Macquarie University, Sydney (D.G.)
| | - Vincent Gnanapragasam
- From the Nuffield Department of Surgical Sciences, University of Oxford, Oxford (F.C.H., R.J.B., D.E.N.), Population Health Sciences (J.L.D., J.A.L., C.M., M.D., E.L.T., R.M.M., G.J.Y., E.I.W., T.J.P., N.J.W.) and Bristol Trials Centre (J.A.L., C.M., G.J.Y.), Bristol Medical School, University of Bristol, the Department of Urology, Southmead Hospital and Bristol Urological Institute (E.R.), and the Department of Cellular Pathology, North Bristol NHS Trust (J.O.), Bristol, the Department of Urology and Surgery, Western General Hospital, University of Edinburgh, Edinburgh (P.B.), the Department of Urology (A. Doble) and the Division of Urology, Department of Surgery and Cambridge Urology Translational Research and Clinical Trials Office, Cambridge Biomedical Campus (V.G., D.E.N.), Addenbrooke's Hospital, Cambridge, the Department of Urology, Queen Elizabeth Hospital, Birmingham (A. Doherty), the Department of Urology, Cardiff and Vale University Health Board (O.H., H.K.), and the School of Medicine (M.M.) and the Division of Cancer and Genetics (J.S.), Cardiff University, Cardiff, the Department of Urology, University Hospitals of Leicester, Leicester (R.K.), the Department of Urology, Leeds Teaching Hospitals NHS Trust, Leeds (A.P.), the Department of Urology, Freeman Hospital, Newcastle-upon-Tyne (E.P., P.P.), and the Department of Urology, Royal Hallamshire Hospital (D.J.R., J.W.F.C.), and the Academic Urology Unit, Medical School, University of Sheffield (J.W.F.C.), Sheffield - all in the United Kingdom; and the Department of Urological Oncology and Robotic Surgery, Macquarie University, Sydney (D.G.)
| | - Owen Hughes
- From the Nuffield Department of Surgical Sciences, University of Oxford, Oxford (F.C.H., R.J.B., D.E.N.), Population Health Sciences (J.L.D., J.A.L., C.M., M.D., E.L.T., R.M.M., G.J.Y., E.I.W., T.J.P., N.J.W.) and Bristol Trials Centre (J.A.L., C.M., G.J.Y.), Bristol Medical School, University of Bristol, the Department of Urology, Southmead Hospital and Bristol Urological Institute (E.R.), and the Department of Cellular Pathology, North Bristol NHS Trust (J.O.), Bristol, the Department of Urology and Surgery, Western General Hospital, University of Edinburgh, Edinburgh (P.B.), the Department of Urology (A. Doble) and the Division of Urology, Department of Surgery and Cambridge Urology Translational Research and Clinical Trials Office, Cambridge Biomedical Campus (V.G., D.E.N.), Addenbrooke's Hospital, Cambridge, the Department of Urology, Queen Elizabeth Hospital, Birmingham (A. Doherty), the Department of Urology, Cardiff and Vale University Health Board (O.H., H.K.), and the School of Medicine (M.M.) and the Division of Cancer and Genetics (J.S.), Cardiff University, Cardiff, the Department of Urology, University Hospitals of Leicester, Leicester (R.K.), the Department of Urology, Leeds Teaching Hospitals NHS Trust, Leeds (A.P.), the Department of Urology, Freeman Hospital, Newcastle-upon-Tyne (E.P., P.P.), and the Department of Urology, Royal Hallamshire Hospital (D.J.R., J.W.F.C.), and the Academic Urology Unit, Medical School, University of Sheffield (J.W.F.C.), Sheffield - all in the United Kingdom; and the Department of Urological Oncology and Robotic Surgery, Macquarie University, Sydney (D.G.)
| | - Roger Kockelbergh
- From the Nuffield Department of Surgical Sciences, University of Oxford, Oxford (F.C.H., R.J.B., D.E.N.), Population Health Sciences (J.L.D., J.A.L., C.M., M.D., E.L.T., R.M.M., G.J.Y., E.I.W., T.J.P., N.J.W.) and Bristol Trials Centre (J.A.L., C.M., G.J.Y.), Bristol Medical School, University of Bristol, the Department of Urology, Southmead Hospital and Bristol Urological Institute (E.R.), and the Department of Cellular Pathology, North Bristol NHS Trust (J.O.), Bristol, the Department of Urology and Surgery, Western General Hospital, University of Edinburgh, Edinburgh (P.B.), the Department of Urology (A. Doble) and the Division of Urology, Department of Surgery and Cambridge Urology Translational Research and Clinical Trials Office, Cambridge Biomedical Campus (V.G., D.E.N.), Addenbrooke's Hospital, Cambridge, the Department of Urology, Queen Elizabeth Hospital, Birmingham (A. Doherty), the Department of Urology, Cardiff and Vale University Health Board (O.H., H.K.), and the School of Medicine (M.M.) and the Division of Cancer and Genetics (J.S.), Cardiff University, Cardiff, the Department of Urology, University Hospitals of Leicester, Leicester (R.K.), the Department of Urology, Leeds Teaching Hospitals NHS Trust, Leeds (A.P.), the Department of Urology, Freeman Hospital, Newcastle-upon-Tyne (E.P., P.P.), and the Department of Urology, Royal Hallamshire Hospital (D.J.R., J.W.F.C.), and the Academic Urology Unit, Medical School, University of Sheffield (J.W.F.C.), Sheffield - all in the United Kingdom; and the Department of Urological Oncology and Robotic Surgery, Macquarie University, Sydney (D.G.)
| | - Howard Kynaston
- From the Nuffield Department of Surgical Sciences, University of Oxford, Oxford (F.C.H., R.J.B., D.E.N.), Population Health Sciences (J.L.D., J.A.L., C.M., M.D., E.L.T., R.M.M., G.J.Y., E.I.W., T.J.P., N.J.W.) and Bristol Trials Centre (J.A.L., C.M., G.J.Y.), Bristol Medical School, University of Bristol, the Department of Urology, Southmead Hospital and Bristol Urological Institute (E.R.), and the Department of Cellular Pathology, North Bristol NHS Trust (J.O.), Bristol, the Department of Urology and Surgery, Western General Hospital, University of Edinburgh, Edinburgh (P.B.), the Department of Urology (A. Doble) and the Division of Urology, Department of Surgery and Cambridge Urology Translational Research and Clinical Trials Office, Cambridge Biomedical Campus (V.G., D.E.N.), Addenbrooke's Hospital, Cambridge, the Department of Urology, Queen Elizabeth Hospital, Birmingham (A. Doherty), the Department of Urology, Cardiff and Vale University Health Board (O.H., H.K.), and the School of Medicine (M.M.) and the Division of Cancer and Genetics (J.S.), Cardiff University, Cardiff, the Department of Urology, University Hospitals of Leicester, Leicester (R.K.), the Department of Urology, Leeds Teaching Hospitals NHS Trust, Leeds (A.P.), the Department of Urology, Freeman Hospital, Newcastle-upon-Tyne (E.P., P.P.), and the Department of Urology, Royal Hallamshire Hospital (D.J.R., J.W.F.C.), and the Academic Urology Unit, Medical School, University of Sheffield (J.W.F.C.), Sheffield - all in the United Kingdom; and the Department of Urological Oncology and Robotic Surgery, Macquarie University, Sydney (D.G.)
| | - Alan Paul
- From the Nuffield Department of Surgical Sciences, University of Oxford, Oxford (F.C.H., R.J.B., D.E.N.), Population Health Sciences (J.L.D., J.A.L., C.M., M.D., E.L.T., R.M.M., G.J.Y., E.I.W., T.J.P., N.J.W.) and Bristol Trials Centre (J.A.L., C.M., G.J.Y.), Bristol Medical School, University of Bristol, the Department of Urology, Southmead Hospital and Bristol Urological Institute (E.R.), and the Department of Cellular Pathology, North Bristol NHS Trust (J.O.), Bristol, the Department of Urology and Surgery, Western General Hospital, University of Edinburgh, Edinburgh (P.B.), the Department of Urology (A. Doble) and the Division of Urology, Department of Surgery and Cambridge Urology Translational Research and Clinical Trials Office, Cambridge Biomedical Campus (V.G., D.E.N.), Addenbrooke's Hospital, Cambridge, the Department of Urology, Queen Elizabeth Hospital, Birmingham (A. Doherty), the Department of Urology, Cardiff and Vale University Health Board (O.H., H.K.), and the School of Medicine (M.M.) and the Division of Cancer and Genetics (J.S.), Cardiff University, Cardiff, the Department of Urology, University Hospitals of Leicester, Leicester (R.K.), the Department of Urology, Leeds Teaching Hospitals NHS Trust, Leeds (A.P.), the Department of Urology, Freeman Hospital, Newcastle-upon-Tyne (E.P., P.P.), and the Department of Urology, Royal Hallamshire Hospital (D.J.R., J.W.F.C.), and the Academic Urology Unit, Medical School, University of Sheffield (J.W.F.C.), Sheffield - all in the United Kingdom; and the Department of Urological Oncology and Robotic Surgery, Macquarie University, Sydney (D.G.)
| | - Edgar Paez
- From the Nuffield Department of Surgical Sciences, University of Oxford, Oxford (F.C.H., R.J.B., D.E.N.), Population Health Sciences (J.L.D., J.A.L., C.M., M.D., E.L.T., R.M.M., G.J.Y., E.I.W., T.J.P., N.J.W.) and Bristol Trials Centre (J.A.L., C.M., G.J.Y.), Bristol Medical School, University of Bristol, the Department of Urology, Southmead Hospital and Bristol Urological Institute (E.R.), and the Department of Cellular Pathology, North Bristol NHS Trust (J.O.), Bristol, the Department of Urology and Surgery, Western General Hospital, University of Edinburgh, Edinburgh (P.B.), the Department of Urology (A. Doble) and the Division of Urology, Department of Surgery and Cambridge Urology Translational Research and Clinical Trials Office, Cambridge Biomedical Campus (V.G., D.E.N.), Addenbrooke's Hospital, Cambridge, the Department of Urology, Queen Elizabeth Hospital, Birmingham (A. Doherty), the Department of Urology, Cardiff and Vale University Health Board (O.H., H.K.), and the School of Medicine (M.M.) and the Division of Cancer and Genetics (J.S.), Cardiff University, Cardiff, the Department of Urology, University Hospitals of Leicester, Leicester (R.K.), the Department of Urology, Leeds Teaching Hospitals NHS Trust, Leeds (A.P.), the Department of Urology, Freeman Hospital, Newcastle-upon-Tyne (E.P., P.P.), and the Department of Urology, Royal Hallamshire Hospital (D.J.R., J.W.F.C.), and the Academic Urology Unit, Medical School, University of Sheffield (J.W.F.C.), Sheffield - all in the United Kingdom; and the Department of Urological Oncology and Robotic Surgery, Macquarie University, Sydney (D.G.)
| | - Philip Powell
- From the Nuffield Department of Surgical Sciences, University of Oxford, Oxford (F.C.H., R.J.B., D.E.N.), Population Health Sciences (J.L.D., J.A.L., C.M., M.D., E.L.T., R.M.M., G.J.Y., E.I.W., T.J.P., N.J.W.) and Bristol Trials Centre (J.A.L., C.M., G.J.Y.), Bristol Medical School, University of Bristol, the Department of Urology, Southmead Hospital and Bristol Urological Institute (E.R.), and the Department of Cellular Pathology, North Bristol NHS Trust (J.O.), Bristol, the Department of Urology and Surgery, Western General Hospital, University of Edinburgh, Edinburgh (P.B.), the Department of Urology (A. Doble) and the Division of Urology, Department of Surgery and Cambridge Urology Translational Research and Clinical Trials Office, Cambridge Biomedical Campus (V.G., D.E.N.), Addenbrooke's Hospital, Cambridge, the Department of Urology, Queen Elizabeth Hospital, Birmingham (A. Doherty), the Department of Urology, Cardiff and Vale University Health Board (O.H., H.K.), and the School of Medicine (M.M.) and the Division of Cancer and Genetics (J.S.), Cardiff University, Cardiff, the Department of Urology, University Hospitals of Leicester, Leicester (R.K.), the Department of Urology, Leeds Teaching Hospitals NHS Trust, Leeds (A.P.), the Department of Urology, Freeman Hospital, Newcastle-upon-Tyne (E.P., P.P.), and the Department of Urology, Royal Hallamshire Hospital (D.J.R., J.W.F.C.), and the Academic Urology Unit, Medical School, University of Sheffield (J.W.F.C.), Sheffield - all in the United Kingdom; and the Department of Urological Oncology and Robotic Surgery, Macquarie University, Sydney (D.G.)
| | - Derek J Rosario
- From the Nuffield Department of Surgical Sciences, University of Oxford, Oxford (F.C.H., R.J.B., D.E.N.), Population Health Sciences (J.L.D., J.A.L., C.M., M.D., E.L.T., R.M.M., G.J.Y., E.I.W., T.J.P., N.J.W.) and Bristol Trials Centre (J.A.L., C.M., G.J.Y.), Bristol Medical School, University of Bristol, the Department of Urology, Southmead Hospital and Bristol Urological Institute (E.R.), and the Department of Cellular Pathology, North Bristol NHS Trust (J.O.), Bristol, the Department of Urology and Surgery, Western General Hospital, University of Edinburgh, Edinburgh (P.B.), the Department of Urology (A. Doble) and the Division of Urology, Department of Surgery and Cambridge Urology Translational Research and Clinical Trials Office, Cambridge Biomedical Campus (V.G., D.E.N.), Addenbrooke's Hospital, Cambridge, the Department of Urology, Queen Elizabeth Hospital, Birmingham (A. Doherty), the Department of Urology, Cardiff and Vale University Health Board (O.H., H.K.), and the School of Medicine (M.M.) and the Division of Cancer and Genetics (J.S.), Cardiff University, Cardiff, the Department of Urology, University Hospitals of Leicester, Leicester (R.K.), the Department of Urology, Leeds Teaching Hospitals NHS Trust, Leeds (A.P.), the Department of Urology, Freeman Hospital, Newcastle-upon-Tyne (E.P., P.P.), and the Department of Urology, Royal Hallamshire Hospital (D.J.R., J.W.F.C.), and the Academic Urology Unit, Medical School, University of Sheffield (J.W.F.C.), Sheffield - all in the United Kingdom; and the Department of Urological Oncology and Robotic Surgery, Macquarie University, Sydney (D.G.)
| | - Edward Rowe
- From the Nuffield Department of Surgical Sciences, University of Oxford, Oxford (F.C.H., R.J.B., D.E.N.), Population Health Sciences (J.L.D., J.A.L., C.M., M.D., E.L.T., R.M.M., G.J.Y., E.I.W., T.J.P., N.J.W.) and Bristol Trials Centre (J.A.L., C.M., G.J.Y.), Bristol Medical School, University of Bristol, the Department of Urology, Southmead Hospital and Bristol Urological Institute (E.R.), and the Department of Cellular Pathology, North Bristol NHS Trust (J.O.), Bristol, the Department of Urology and Surgery, Western General Hospital, University of Edinburgh, Edinburgh (P.B.), the Department of Urology (A. Doble) and the Division of Urology, Department of Surgery and Cambridge Urology Translational Research and Clinical Trials Office, Cambridge Biomedical Campus (V.G., D.E.N.), Addenbrooke's Hospital, Cambridge, the Department of Urology, Queen Elizabeth Hospital, Birmingham (A. Doherty), the Department of Urology, Cardiff and Vale University Health Board (O.H., H.K.), and the School of Medicine (M.M.) and the Division of Cancer and Genetics (J.S.), Cardiff University, Cardiff, the Department of Urology, University Hospitals of Leicester, Leicester (R.K.), the Department of Urology, Leeds Teaching Hospitals NHS Trust, Leeds (A.P.), the Department of Urology, Freeman Hospital, Newcastle-upon-Tyne (E.P., P.P.), and the Department of Urology, Royal Hallamshire Hospital (D.J.R., J.W.F.C.), and the Academic Urology Unit, Medical School, University of Sheffield (J.W.F.C.), Sheffield - all in the United Kingdom; and the Department of Urological Oncology and Robotic Surgery, Macquarie University, Sydney (D.G.)
| | - Malcolm Mason
- From the Nuffield Department of Surgical Sciences, University of Oxford, Oxford (F.C.H., R.J.B., D.E.N.), Population Health Sciences (J.L.D., J.A.L., C.M., M.D., E.L.T., R.M.M., G.J.Y., E.I.W., T.J.P., N.J.W.) and Bristol Trials Centre (J.A.L., C.M., G.J.Y.), Bristol Medical School, University of Bristol, the Department of Urology, Southmead Hospital and Bristol Urological Institute (E.R.), and the Department of Cellular Pathology, North Bristol NHS Trust (J.O.), Bristol, the Department of Urology and Surgery, Western General Hospital, University of Edinburgh, Edinburgh (P.B.), the Department of Urology (A. Doble) and the Division of Urology, Department of Surgery and Cambridge Urology Translational Research and Clinical Trials Office, Cambridge Biomedical Campus (V.G., D.E.N.), Addenbrooke's Hospital, Cambridge, the Department of Urology, Queen Elizabeth Hospital, Birmingham (A. Doherty), the Department of Urology, Cardiff and Vale University Health Board (O.H., H.K.), and the School of Medicine (M.M.) and the Division of Cancer and Genetics (J.S.), Cardiff University, Cardiff, the Department of Urology, University Hospitals of Leicester, Leicester (R.K.), the Department of Urology, Leeds Teaching Hospitals NHS Trust, Leeds (A.P.), the Department of Urology, Freeman Hospital, Newcastle-upon-Tyne (E.P., P.P.), and the Department of Urology, Royal Hallamshire Hospital (D.J.R., J.W.F.C.), and the Academic Urology Unit, Medical School, University of Sheffield (J.W.F.C.), Sheffield - all in the United Kingdom; and the Department of Urological Oncology and Robotic Surgery, Macquarie University, Sydney (D.G.)
| | - James W F Catto
- From the Nuffield Department of Surgical Sciences, University of Oxford, Oxford (F.C.H., R.J.B., D.E.N.), Population Health Sciences (J.L.D., J.A.L., C.M., M.D., E.L.T., R.M.M., G.J.Y., E.I.W., T.J.P., N.J.W.) and Bristol Trials Centre (J.A.L., C.M., G.J.Y.), Bristol Medical School, University of Bristol, the Department of Urology, Southmead Hospital and Bristol Urological Institute (E.R.), and the Department of Cellular Pathology, North Bristol NHS Trust (J.O.), Bristol, the Department of Urology and Surgery, Western General Hospital, University of Edinburgh, Edinburgh (P.B.), the Department of Urology (A. Doble) and the Division of Urology, Department of Surgery and Cambridge Urology Translational Research and Clinical Trials Office, Cambridge Biomedical Campus (V.G., D.E.N.), Addenbrooke's Hospital, Cambridge, the Department of Urology, Queen Elizabeth Hospital, Birmingham (A. Doherty), the Department of Urology, Cardiff and Vale University Health Board (O.H., H.K.), and the School of Medicine (M.M.) and the Division of Cancer and Genetics (J.S.), Cardiff University, Cardiff, the Department of Urology, University Hospitals of Leicester, Leicester (R.K.), the Department of Urology, Leeds Teaching Hospitals NHS Trust, Leeds (A.P.), the Department of Urology, Freeman Hospital, Newcastle-upon-Tyne (E.P., P.P.), and the Department of Urology, Royal Hallamshire Hospital (D.J.R., J.W.F.C.), and the Academic Urology Unit, Medical School, University of Sheffield (J.W.F.C.), Sheffield - all in the United Kingdom; and the Department of Urological Oncology and Robotic Surgery, Macquarie University, Sydney (D.G.)
| | - Tim J Peters
- From the Nuffield Department of Surgical Sciences, University of Oxford, Oxford (F.C.H., R.J.B., D.E.N.), Population Health Sciences (J.L.D., J.A.L., C.M., M.D., E.L.T., R.M.M., G.J.Y., E.I.W., T.J.P., N.J.W.) and Bristol Trials Centre (J.A.L., C.M., G.J.Y.), Bristol Medical School, University of Bristol, the Department of Urology, Southmead Hospital and Bristol Urological Institute (E.R.), and the Department of Cellular Pathology, North Bristol NHS Trust (J.O.), Bristol, the Department of Urology and Surgery, Western General Hospital, University of Edinburgh, Edinburgh (P.B.), the Department of Urology (A. Doble) and the Division of Urology, Department of Surgery and Cambridge Urology Translational Research and Clinical Trials Office, Cambridge Biomedical Campus (V.G., D.E.N.), Addenbrooke's Hospital, Cambridge, the Department of Urology, Queen Elizabeth Hospital, Birmingham (A. Doherty), the Department of Urology, Cardiff and Vale University Health Board (O.H., H.K.), and the School of Medicine (M.M.) and the Division of Cancer and Genetics (J.S.), Cardiff University, Cardiff, the Department of Urology, University Hospitals of Leicester, Leicester (R.K.), the Department of Urology, Leeds Teaching Hospitals NHS Trust, Leeds (A.P.), the Department of Urology, Freeman Hospital, Newcastle-upon-Tyne (E.P., P.P.), and the Department of Urology, Royal Hallamshire Hospital (D.J.R., J.W.F.C.), and the Academic Urology Unit, Medical School, University of Sheffield (J.W.F.C.), Sheffield - all in the United Kingdom; and the Department of Urological Oncology and Robotic Surgery, Macquarie University, Sydney (D.G.)
| | - Jon Oxley
- From the Nuffield Department of Surgical Sciences, University of Oxford, Oxford (F.C.H., R.J.B., D.E.N.), Population Health Sciences (J.L.D., J.A.L., C.M., M.D., E.L.T., R.M.M., G.J.Y., E.I.W., T.J.P., N.J.W.) and Bristol Trials Centre (J.A.L., C.M., G.J.Y.), Bristol Medical School, University of Bristol, the Department of Urology, Southmead Hospital and Bristol Urological Institute (E.R.), and the Department of Cellular Pathology, North Bristol NHS Trust (J.O.), Bristol, the Department of Urology and Surgery, Western General Hospital, University of Edinburgh, Edinburgh (P.B.), the Department of Urology (A. Doble) and the Division of Urology, Department of Surgery and Cambridge Urology Translational Research and Clinical Trials Office, Cambridge Biomedical Campus (V.G., D.E.N.), Addenbrooke's Hospital, Cambridge, the Department of Urology, Queen Elizabeth Hospital, Birmingham (A. Doherty), the Department of Urology, Cardiff and Vale University Health Board (O.H., H.K.), and the School of Medicine (M.M.) and the Division of Cancer and Genetics (J.S.), Cardiff University, Cardiff, the Department of Urology, University Hospitals of Leicester, Leicester (R.K.), the Department of Urology, Leeds Teaching Hospitals NHS Trust, Leeds (A.P.), the Department of Urology, Freeman Hospital, Newcastle-upon-Tyne (E.P., P.P.), and the Department of Urology, Royal Hallamshire Hospital (D.J.R., J.W.F.C.), and the Academic Urology Unit, Medical School, University of Sheffield (J.W.F.C.), Sheffield - all in the United Kingdom; and the Department of Urological Oncology and Robotic Surgery, Macquarie University, Sydney (D.G.)
| | - Naomi J Williams
- From the Nuffield Department of Surgical Sciences, University of Oxford, Oxford (F.C.H., R.J.B., D.E.N.), Population Health Sciences (J.L.D., J.A.L., C.M., M.D., E.L.T., R.M.M., G.J.Y., E.I.W., T.J.P., N.J.W.) and Bristol Trials Centre (J.A.L., C.M., G.J.Y.), Bristol Medical School, University of Bristol, the Department of Urology, Southmead Hospital and Bristol Urological Institute (E.R.), and the Department of Cellular Pathology, North Bristol NHS Trust (J.O.), Bristol, the Department of Urology and Surgery, Western General Hospital, University of Edinburgh, Edinburgh (P.B.), the Department of Urology (A. Doble) and the Division of Urology, Department of Surgery and Cambridge Urology Translational Research and Clinical Trials Office, Cambridge Biomedical Campus (V.G., D.E.N.), Addenbrooke's Hospital, Cambridge, the Department of Urology, Queen Elizabeth Hospital, Birmingham (A. Doherty), the Department of Urology, Cardiff and Vale University Health Board (O.H., H.K.), and the School of Medicine (M.M.) and the Division of Cancer and Genetics (J.S.), Cardiff University, Cardiff, the Department of Urology, University Hospitals of Leicester, Leicester (R.K.), the Department of Urology, Leeds Teaching Hospitals NHS Trust, Leeds (A.P.), the Department of Urology, Freeman Hospital, Newcastle-upon-Tyne (E.P., P.P.), and the Department of Urology, Royal Hallamshire Hospital (D.J.R., J.W.F.C.), and the Academic Urology Unit, Medical School, University of Sheffield (J.W.F.C.), Sheffield - all in the United Kingdom; and the Department of Urological Oncology and Robotic Surgery, Macquarie University, Sydney (D.G.)
| | - John Staffurth
- From the Nuffield Department of Surgical Sciences, University of Oxford, Oxford (F.C.H., R.J.B., D.E.N.), Population Health Sciences (J.L.D., J.A.L., C.M., M.D., E.L.T., R.M.M., G.J.Y., E.I.W., T.J.P., N.J.W.) and Bristol Trials Centre (J.A.L., C.M., G.J.Y.), Bristol Medical School, University of Bristol, the Department of Urology, Southmead Hospital and Bristol Urological Institute (E.R.), and the Department of Cellular Pathology, North Bristol NHS Trust (J.O.), Bristol, the Department of Urology and Surgery, Western General Hospital, University of Edinburgh, Edinburgh (P.B.), the Department of Urology (A. Doble) and the Division of Urology, Department of Surgery and Cambridge Urology Translational Research and Clinical Trials Office, Cambridge Biomedical Campus (V.G., D.E.N.), Addenbrooke's Hospital, Cambridge, the Department of Urology, Queen Elizabeth Hospital, Birmingham (A. Doherty), the Department of Urology, Cardiff and Vale University Health Board (O.H., H.K.), and the School of Medicine (M.M.) and the Division of Cancer and Genetics (J.S.), Cardiff University, Cardiff, the Department of Urology, University Hospitals of Leicester, Leicester (R.K.), the Department of Urology, Leeds Teaching Hospitals NHS Trust, Leeds (A.P.), the Department of Urology, Freeman Hospital, Newcastle-upon-Tyne (E.P., P.P.), and the Department of Urology, Royal Hallamshire Hospital (D.J.R., J.W.F.C.), and the Academic Urology Unit, Medical School, University of Sheffield (J.W.F.C.), Sheffield - all in the United Kingdom; and the Department of Urological Oncology and Robotic Surgery, Macquarie University, Sydney (D.G.)
| | - David E Neal
- From the Nuffield Department of Surgical Sciences, University of Oxford, Oxford (F.C.H., R.J.B., D.E.N.), Population Health Sciences (J.L.D., J.A.L., C.M., M.D., E.L.T., R.M.M., G.J.Y., E.I.W., T.J.P., N.J.W.) and Bristol Trials Centre (J.A.L., C.M., G.J.Y.), Bristol Medical School, University of Bristol, the Department of Urology, Southmead Hospital and Bristol Urological Institute (E.R.), and the Department of Cellular Pathology, North Bristol NHS Trust (J.O.), Bristol, the Department of Urology and Surgery, Western General Hospital, University of Edinburgh, Edinburgh (P.B.), the Department of Urology (A. Doble) and the Division of Urology, Department of Surgery and Cambridge Urology Translational Research and Clinical Trials Office, Cambridge Biomedical Campus (V.G., D.E.N.), Addenbrooke's Hospital, Cambridge, the Department of Urology, Queen Elizabeth Hospital, Birmingham (A. Doherty), the Department of Urology, Cardiff and Vale University Health Board (O.H., H.K.), and the School of Medicine (M.M.) and the Division of Cancer and Genetics (J.S.), Cardiff University, Cardiff, the Department of Urology, University Hospitals of Leicester, Leicester (R.K.), the Department of Urology, Leeds Teaching Hospitals NHS Trust, Leeds (A.P.), the Department of Urology, Freeman Hospital, Newcastle-upon-Tyne (E.P., P.P.), and the Department of Urology, Royal Hallamshire Hospital (D.J.R., J.W.F.C.), and the Academic Urology Unit, Medical School, University of Sheffield (J.W.F.C.), Sheffield - all in the United Kingdom; and the Department of Urological Oncology and Robotic Surgery, Macquarie University, Sydney (D.G.)
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Thankapannair V, Keates A, Barrett T, Gnanapragasam VJ. Prospective Implementation and Early Outcomes of a Risk-stratified Prostate Cancer Active Surveillance Follow-up Protocol. EUR UROL SUPPL 2023; 49:15-22. [PMID: 36874604 PMCID: PMC9975013 DOI: 10.1016/j.euros.2022.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2022] [Indexed: 01/26/2023] Open
Abstract
Background Active surveillance (AS) is a major management option for men with early prostate cancer. Current guidelines however advocate identical AS follow-up for all without considering different disease trajectories. We previously proposed a pragmatic three-tier STRATified CANcer Surveillance (STRATCANS) follow-up strategy based on different progression risks from clinic-pathological and imaging features. Objective To report early outcomes from the implementation of the STRATCANS protocol in our centre. Design setting and participants Men on AS were enrolled into a prospective stratified follow-up programme. Intervention Three tiers of increasing follow-up intensity based on National Institute for Health and Care Excellence (NICE): Cambridge Prognostic Group (CPG) 1 or 2, prostate-specific antigen density, and magnetic resonance imaging (MRI) Likert score at entry. Outcome measurements and statistical analysis Rates of progression to CPG ≥3, any pathological progression, AS attrition, and patient choice for treatment were assessed. Differences in progression were compared with chi-square statistics. Results and limitations Data from 156 men (median age 67.3 yr) were analysed. Of these, 38.4% had CPG2 disease and 27.5% had grade group 2 disease at diagnosis. The median time on AS was 4 yr (interquartile range 3.2-4.9) and 1.5 yr on STRATCANS. Overall, 135/156 (86.5%) men remained on AS or converted to watchful waiting and 6/156 (3.8%) stopped AS by choice by the end of the evaluation period. Of the 156 patients, 66 (42.3%) were allocated to STRATCANS 1 (least intense follow-up), 61 (39.1%) to STRATCANS 2, and 29 (18.6%) to STRATCANS 3 (highest intensity). By increasing STRATCANS tier, progression rates to CPG ≥3 and any progression events were 0% and 4.6%, 3.4% and 8.6%, and 7.4% and 22.2%, respectively (p = 0.019). Modelling resource usage suggested potential reductions in appointments by 22% and MRI by 42% compared with current NICE guideline recommendations (first 12 months of AS). The study is limited by short follow-up, a relatively small cohort, and being single centre. Conclusions A simple risk-tiered AS strategy is possible with early outcomes supporting stratified follow-up intensity. STRATCANS implementation could de-escalate follow-up in men at a low risk of progression while husbanding resources for those who need closer follow-up. Patient summary We report a practical way to personalise follow-up for men on active surveillance for early prostate cancer. Our method may allow reductions in the follow-up burden for men at a low risk of disease change while maintaining vigilance for those at a higher risk.
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Affiliation(s)
- Vineetha Thankapannair
- Department of Urology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Alexandra Keates
- Cambridge Urology Translational Research and Clinical Trials Office, Cambridge Biomedical Campus, Addenbrooke's Hospital, Cambridge, UK
| | - Tristan Barrett
- Department of Radiology, University of Cambridge, Cambridge, UK
| | - Vincent J Gnanapragasam
- Department of Urology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.,Cambridge Urology Translational Research and Clinical Trials Office, Cambridge Biomedical Campus, Addenbrooke's Hospital, Cambridge, UK.,Division of Urology, Department of Surgery, University of Cambridge, Cambridge, UK
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10
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El‐Taji O, Evans H, Arora V, Amin S, Kumar M, Rajan TN. Diagnostic and cost‐effectiveness of axial skeleton MRI in staging high‐risk prostate cancer. BJUI COMPASS 2023; 4:346-351. [PMID: 37025475 PMCID: PMC10071081 DOI: 10.1002/bco2.210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 11/24/2022] [Accepted: 12/04/2022] [Indexed: 02/04/2023] Open
Abstract
Introduction Current literature suggests that axial skeleton magnetic resonance imaging (AS-MRI) is more sensitive than Tc 99m bone scintigraphy (BS) for detecting bone metastases (BM) in high-risk prostate cancer (PCa). However, BS is still widely performed. Its diagnostic accuracy has been studied; however, its feasibility and cost implications are yet to be examined. Methods We reviewed all patients with high risk PCa undergoing AS-MRI over a 5-year period. AS-MRI was performed on patients with histologically confirmed PCa and either PSA > 20 ng/ml, Gleason ≥8, or TNM Stage ≥T3 or N1 disease. All AS-MRI studies were obtained using a 1.5-T AchievaPhilips™MRI scanner. We compared the AS-MRI positivity and equivocal rate with that of BS. Data were analysed according to Gleason score, T-stage and PSA. Multivariate logistic regression analyses were used to quantify the strength of association between positive scans and clinical variables. Feasibility and burden of expenditure was also evaluated. Results Five hundred three patients with a median age of 72 and a mean PSA of 34.8 ng/ml were analysed. Eighty-eight patients (17.5%) were positive for BM on AS-MRI (mean PSA 99 [95% CI 69.1-129.9]). Comparatively 409 patients (81.3%) were negative for BM on AS-MRI (mean PSA 24.7 (95% CI [21.7-27.7]) (p = 0.007); 1.2% (n = 6) of patients had equivocal results (mean PSA 33.4 [95% CI 10.5-56.3]). There was no significant difference in age (p = 0.122) between this group and patients with a positive scan, but there was a significant difference in PSA (p = 0.028), T stage (p = 0.006) and Gleason score (p = 0.023). In comparison with BS, AS-MRI detection rate was equivalent or higher compared with the literature. Based on NHS tariff calculations, there would be a minimum cost saving of £8406.89. All patients underwent AS-MRI within 14 days. Conclusion The use of AS-MRI to stage BM in high-risk PCa is both feasible and results in a reduced burden of expenditure.
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Affiliation(s)
- Omar El‐Taji
- Department of Urology Wirral University Teaching Hospitals Wirral UK
| | - Hannah Evans
- Department of Urology Wirral University Teaching Hospitals Wirral UK
| | - Vandan Arora
- Department of Radiology Wirral University Teaching Hospitals Wirral UK
- School of Medicine University of Bolton Bolton United Kingdom
| | - Suzanne Amin
- Department of Radiology Wirral University Teaching Hospitals Wirral UK
| | - Manal Kumar
- Department of Urology Wirral University Teaching Hospitals Wirral UK
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11
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Ikromjanov K, Bhattacharjee S, Sumon RI, Hwang YB, Rahman H, Lee MJ, Kim HC, Park E, Cho NH, Choi HK. Region Segmentation of Whole-Slide Images for Analyzing Histological Differentiation of Prostate Adenocarcinoma Using Ensemble EfficientNetB2 U-Net with Transfer Learning Mechanism. Cancers (Basel) 2023; 15:cancers15030762. [PMID: 36765719 PMCID: PMC9913745 DOI: 10.3390/cancers15030762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 01/18/2023] [Accepted: 01/23/2023] [Indexed: 01/28/2023] Open
Abstract
Recent advances in computer-aided detection via deep learning (DL) now allow for prostate cancer to be detected automatically and recognized with extremely high accuracy, much like other medical diagnoses and prognoses. However, researchers are still limited by the Gleason scoring system. The histopathological analysis involved in assigning the appropriate score is a rigorous, time-consuming manual process that is constrained by the quality of the material and the pathologist's level of expertise. In this research, we implemented a DL model using transfer learning on a set of histopathological images to segment cancerous and noncancerous areas in whole-slide images (WSIs). In this approach, the proposed Ensemble U-net model was applied for the segmentation of stroma, cancerous, and benign areas. The WSI dataset of prostate cancer was collected from the Kaggle repository, which is publicly available online. A total of 1000 WSIs were used for region segmentation. From this, 8100 patch images were used for training, and 900 for testing. The proposed model demonstrated an average dice coefficient (DC), intersection over union (IoU), and Hausdorff distance of 0.891, 0.811, and 15.9, respectively, on the test set, with corresponding masks of patch images. The manipulation of the proposed segmentation model improves the ability of the pathologist to predict disease outcomes, thus enhancing treatment efficacy by isolating the cancerous regions in WSIs.
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Affiliation(s)
- Kobiljon Ikromjanov
- Department of Digital Anti-Aging Healthcare, u-AHRC, Inje University, Gimhae 50834, Republic of Korea
| | - Subrata Bhattacharjee
- Department of Computer Engineering, u-AHRC, Inje University, Gimhae 50834, Republic of Korea
| | - Rashadul Islam Sumon
- Department of Digital Anti-Aging Healthcare, u-AHRC, Inje University, Gimhae 50834, Republic of Korea
| | - Yeong-Byn Hwang
- Department of Digital Anti-Aging Healthcare, u-AHRC, Inje University, Gimhae 50834, Republic of Korea
| | - Hafizur Rahman
- Department of Digital Anti-Aging Healthcare, u-AHRC, Inje University, Gimhae 50834, Republic of Korea
| | - Myung-Jae Lee
- JLK Artificial Intelligence R&D Center, Seoul 06141, Republic of Korea
| | - Hee-Cheol Kim
- Department of Digital Anti-Aging Healthcare, u-AHRC, Inje University, Gimhae 50834, Republic of Korea
| | - Eunhyang Park
- Department of Pathology, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Nam-Hoon Cho
- Department of Pathology, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Heung-Kook Choi
- Department of Computer Engineering, u-AHRC, Inje University, Gimhae 50834, Republic of Korea
- JLK Artificial Intelligence R&D Center, Seoul 06141, Republic of Korea
- Correspondence: ; Tel.: +82-10-6733-3437
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12
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Heritage S, Sundaram S, Kirkby NF, Kirkby KJ, Mee T, Jena R. An Update to the Malthus Model for Radiotherapy Utilisation in England. Clin Oncol (R Coll Radiol) 2023; 35:e1-e9. [PMID: 35835634 DOI: 10.1016/j.clon.2022.06.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 05/17/2022] [Accepted: 06/16/2022] [Indexed: 01/05/2023]
Abstract
AIMS The Malthus Programme predicts national and local radiotherapy demand by combining cancer incidence data with decision trees detailing the indications, and appropriate dose fractionation, for radiotherapy. Since the last model update in 2017, technological advancements and the COVID-19 pandemic have led to increasing hypofractionation of radiotherapy schedules. Indications for radiotherapy have also evolved, particularly in the context of oligometastatic disease. Here we present a brief update on the model for 2021. We have updated the decision trees for breast, prostate, lung and head and neck cancers, and incorporated recent cancer incidence data into our model, generating a current estimate of fraction demand for these four cancer sites across England. MATERIALS AND METHODS The decision tree update was based on evidence from practice-changing randomised controlled trials, published guidelines, audit data and expert opinion. Site- and stage-specific incidence data were taken from the National Disease Registration Service. We used the updated model to estimate the proportion of patients who would receive radiotherapy (appropriate rate of radiotherapy) and the fraction demand per million population at a national and Clinical Commissioning Group level in 2021. RESULTS The total predicted fraction demand has decreased by 11.4% across all four cancer sites in our new model, compared with the 2017 version. This reduction can be explained primarily by greater use of hypofractionated treatments (including stereotactic ablative radiotherapy) and a shift towards earlier stage presentation. The only large change in appropriate rate of radiotherapy was an absolute decrease of 3% for lung cancer. CONCLUSIONS Compared with our previous model, the current version predicts a reduction in fraction demand across England. This is driven principally by hypofractionation of radiotherapy regimens, using technology that requires increasingly complex planning. Treatment complexity and local service factors need to be taken into account when translating fraction burden into linear accelerator demand or throughput.
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Affiliation(s)
- S Heritage
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - S Sundaram
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - N F Kirkby
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK; The Christie NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - K J Kirkby
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK; The Christie NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - T Mee
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK; The Christie NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - R Jena
- Department of Oncology, University of Cambridge, Cambridge, UK.
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13
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Light A, Lophatananon A, Keates A, Thankappannair V, Barrett T, Dominguez-Escrig J, Rubio-Briones J, Benheddi T, Olivier J, Villers A, Babureddy K, Abdelmoteleb H, Gnanapragasam VJ. Development and External Validation of the STRATified CANcer Surveillance (STRATCANS) Multivariable Model for Predicting Progression in Men with Newly Diagnosed Prostate Cancer Starting Active Surveillance. J Clin Med 2022; 12:jcm12010216. [PMID: 36615017 PMCID: PMC9821695 DOI: 10.3390/jcm12010216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 12/06/2022] [Accepted: 12/25/2022] [Indexed: 12/29/2022] Open
Abstract
For men with newly diagnosed prostate cancer, we aimed to develop and validate a model to predict the risk of progression on active surveillance (AS), which could inform more personalised AS strategies. In total, 883 men from 3 European centres were used for model development and internal validation, and 151 men from a fourth European centre were used for external validation. Men with Cambridge Prognostic Group (CPG) 1-2 disease at diagnosis were eligible. The endpoint was progression to the composite endpoint of CPG3 disease or worse (≥CPG3). Model performance at 4 years was evaluated through discrimination (C-index), calibration plots, and decision curve analysis. The final multivariable model incorporated prostate-specific antigen (PSA), Grade Group, magnetic resonance imaging (MRI) score (Prostate Imaging Reporting & Data System (PI-RADS) or Likert), and prostate volume. Calibration and discrimination were good in both internal validation (C-index 0.742, 95% CI 0.694-0.793) and external validation (C-index 0.845, 95% CI 0.712-0.958). In decision curve analysis, the model offered net benefit compared to a 'follow-all' strategy at risk thresholds of ≥0.08 and ≥0.04 in development and external validation, respectively. In conclusion, our model demonstrated good accuracy and clinical utility in predicting the progression on AS at 4 years post-diagnosis. Men with lower risk predictions could subsequently be offered less-intense surveillance. Further external validation in larger cohorts is now required.
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Affiliation(s)
- Alexander Light
- Division of Urology, Department of Surgery, University of Cambridge, Cambridge CB2 0QQ, UK
- Department of Urology, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK
- Cambridge Urology Translational Research and Clinical Trials Office, Cambridge Biomedical Campus, University of Cambridge, Cambridge CB2 0QQ, UK
| | - Artitaya Lophatananon
- Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester M13 9PL, UK
| | - Alexandra Keates
- Department of Urology, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK
- Cambridge Urology Translational Research and Clinical Trials Office, Cambridge Biomedical Campus, University of Cambridge, Cambridge CB2 0QQ, UK
| | - Vineetha Thankappannair
- Department of Urology, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK
| | - Tristan Barrett
- Department of Radiology, University of Cambridge, Cambridge CB2 0QQ, UK
- Department of Radiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK
| | - Jose Dominguez-Escrig
- Department of Urology, Fundación Instituto Valenciano de Oncología, 46009 Valencia, Spain
| | - Jose Rubio-Briones
- Department of Urology, Fundación Instituto Valenciano de Oncología, 46009 Valencia, Spain
| | - Toufik Benheddi
- Department of Urology, Lille University, 59000 Lille, France
| | - Jonathan Olivier
- Department of Urology, Lille University, 59000 Lille, France
- UMR8161, CNRS-Institut de Biologie de Lille, 59800 Lille, France
| | - Arnauld Villers
- Department of Urology, Lille University, 59000 Lille, France
- UMR8161, CNRS-Institut de Biologie de Lille, 59800 Lille, France
| | - Kirthana Babureddy
- Department of Urology, University Hospital of Wales, Cardiff and Vale University Health Board, Cardiff CF14 4XW, UK
| | - Haitham Abdelmoteleb
- Department of Urology, University Hospital of Wales, Cardiff and Vale University Health Board, Cardiff CF14 4XW, UK
| | - Vincent J. Gnanapragasam
- Division of Urology, Department of Surgery, University of Cambridge, Cambridge CB2 0QQ, UK
- Department of Urology, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK
- Cambridge Urology Translational Research and Clinical Trials Office, Cambridge Biomedical Campus, University of Cambridge, Cambridge CB2 0QQ, UK
- Correspondence: ; Tel.: +44-1223245151
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14
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Wang C, Liu G, Liu Y, Yang Z, Xin W, Wang M, Li Y, Yang L, Mu H, Zhou C. Novel serum proteomic biomarkers for early diagnosis and aggressive grade identification of prostate cancer. Front Oncol 2022; 12:1004015. [PMID: 36276156 PMCID: PMC9582260 DOI: 10.3389/fonc.2022.1004015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 09/20/2022] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND Prostate cancer (PCa) is one of the most common tumors and the second leading cause of cancer-related death in men. The discovery of novel biomarkers for PCa diagnosis in the early stage, as well as discriminating aggressive PCa from non-aggressive PCa continue to pose a challenge. The aim of this study was to identify serum proteins that were sensitive and specific enough to detect early-stage and aggressive PCa. METHODS The serum proteomic profiling of patients with PCa and benign prostatic hyperplasia (BPH) was comprehensively analyzed using data-independent acquisition mass spectrometry (DIA-MS), and the bioinformatics analysis was performed. The differentially expressed proteins (DEPs) of interest were further verified by enzyme-linked immunosorbent assay (ELISA) and immunoturbidimetry assay. RESULTS Statistically significant difference in abundance showed 56 DEPs between early-stage PCa and BPH and 47 DEPs between aggressive and non-aggressive PCa patients. In addition, the verification results showed that serum L-selectin concentration was significantly higher (p<0.05) in Gleason 6 PCa when compared with BPH, and the concentration of osteopontin (SPP1) and ceruloplasmin (CP) increased with higher Gleason score. CONCLUSIONS DIA-MS has great potential in cancer-related biomarker screening. Our data demonstrated that adding SPP1 and CP to PSA improved the separation of Gleason 7 (4 + 3) or above from Gleason 7 (3 + 4) or below compared with PSA diagnosis alone. Serum SPP1 and CP could be effective biomarkers to differentiate aggressive PCa (especially Gleason 7 (4 + 3) or above) from non-aggressive disease.
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Affiliation(s)
- Ce Wang
- Department of Clinical Laboratory, Tianjin First Central Hospital, School of Medicine, Nankai University, Tianjin, China
| | - Guangming Liu
- Department of Urology Surgery, Tianjin First Central Hospital, School of Medicine, Nankai University, Tianjin, China
| | - Yehua Liu
- Department of Clinical Laboratory, Tianjin First Central Hospital, School of Medicine, Nankai University, Tianjin, China
| | - Zhanpo Yang
- Department of Urology Surgery, Tianjin First Central Hospital, School of Medicine, Nankai University, Tianjin, China
| | - Weiwei Xin
- Department of Pathology, Tianjin First Central Hospital, School of Medicine, Nankai University, Tianjin, China
| | - Meng Wang
- Department of Clinical Laboratory, Tianjin First Central Hospital, School of Medicine, Nankai University, Tianjin, China
| | - Yang Li
- Department of Clinical Laboratory, Tianjin First Central Hospital, School of Medicine, Nankai University, Tianjin, China
| | - Lan Yang
- Department of Clinical Laboratory, Tianjin First Central Hospital, School of Medicine, Nankai University, Tianjin, China
| | - Hong Mu
- Department of Clinical Laboratory, Tianjin First Central Hospital, School of Medicine, Nankai University, Tianjin, China
| | - Chunlei Zhou
- Department of Clinical Laboratory, Tianjin First Central Hospital, School of Medicine, Nankai University, Tianjin, China
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15
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Lophatananon A, Byrne MHV, Barrett T, Warren A, Muir K, Dokubo I, Georgiades F, Sheba M, Bibby L, Gnanapragasam VJ. Assessing the impact of MRI based diagnostics on pre-treatment disease classification and prognostic model performance in men diagnosed with new prostate cancer from an unscreened population. BMC Cancer 2022; 22:878. [PMID: 35953766 PMCID: PMC9367076 DOI: 10.1186/s12885-022-09955-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 07/31/2022] [Indexed: 11/30/2022] Open
Abstract
Introduction Pre-treatment risk and prognostic groups are the cornerstone for deciding management in non-metastatic prostate cancer. All however, were developed in the pre-MRI era. Here we compared categorisation of cancers using either only clinical parameters or with MRI enhanced information in men referred for suspected prostate cancer from an unscreened population. Patient and methods Data from men referred from primary care to our diagnostic service and with both clinical (digital rectal examination [DRE] and systematic biopsies) and MRI enhanced attributes (MRI stage and combined systematic/targeted biopsies) were used for this study. Clinical vs MRI data were contrasted for clinico-pathological and risk group re-distribution using the European Association of Urology (EAU), American Urological Association (AUA) and UK National Institute for Health Care Excellence (NICE) Cambridge Prognostic Group (CPG) models. Differences were retrofitted to a population cohort with long-term prostate cancer mortality (PCM) outcomes to simulate impact on model performance. We further contrasted individualised overall survival (OS) predictions using the Predict Prostate algorithm. Results Data from 370 men were included (median age 66y). Pre-biopsy MRI stage reassignments occurred in 7.8% (versus DRE). Image-guided biopsies increased Grade Group 2 and ≥ Grade Group 3 assignments in 2.7% and 2.9% respectively. The main change in risk groups was more high-risk cancers (6.2% increase in the EAU and AUA system, 4.3% increase in CPG4 and 1.9% CPG5). When extrapolated to a historical population-based cohort (n = 10,139) the redistribution resulted in generally lower concordance indices for PCM. The 5-tier NICE-CPG system outperformed the 4-tier AUA and 3-tier EAU models (C Index 0.70 versus 0.65 and 0.64). Using an individualised prognostic model, changes in predicted OS were small (median difference 1% and 2% at 10- and 15-years’ respectively). Similarly, estimated treatment survival benefit changes were minimal (1% at both 10- and 15-years’ time frame). Conclusion MRI guided diagnostics does change pre-treatment risk groups assignments but the overall prognostic impact appears modest in men referred from unscreened populations. Particularly, when using more granular tiers or individualised prognostic models. Existing risk and prognostic models can continue to be used to counsel men about treatment option until long term survival outcomes are available.
Supplementary Information The online version contains supplementary material available at 10.1186/s12885-022-09955-w.
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Affiliation(s)
- Artitaya Lophatananon
- Division of Population Health, Health Services Research & Primary Care Centre, University of Manchester, Manchester, UK
| | - Matthew H V Byrne
- Department of Urology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Tristan Barrett
- Department of Radiology, University of Cambridge, Cambridge, UK
| | - Anne Warren
- Department of Pathology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Kenneth Muir
- Division of Population Health, Health Services Research & Primary Care Centre, University of Manchester, Manchester, UK
| | - Ibifuro Dokubo
- Department of Urology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Fanos Georgiades
- Department of Urology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.,Division of Urology, Department of Surgery, University of Cambridge, Cambridge, UK
| | - Mostafa Sheba
- Kasr Al Any School of Medicine, Cairo University, Giza, Egypt
| | - Lisa Bibby
- Department of Urology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Vincent J Gnanapragasam
- Department of Urology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK. .,Division of Urology, Department of Surgery, University of Cambridge, Cambridge, UK. .,Cambridge Urology Translational Research and Clinical Trials Office, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, UK.
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16
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Bratt O, Carlsson S, Fransson P, Thellenberg Karlsson C, Stranne J, Kindblom J. The Swedish national guidelines on prostate cancer, part 1: early detection, diagnostics, staging, patient support and primary management of non-metastatic disease. Scand J Urol 2022; 56:265-273. [PMID: 35811480 DOI: 10.1080/21681805.2022.2094462] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVE There is now an unprecedented amount of evidence to consider when revising prostate cancer guidelines. We believe that there is a value in publishing summaries of national clinical guidelines in English for others to read and comment on. METHODS This is part 1 of a summary of the Swedish prostate cancer guidelines that were published in June 2022. It covers the early detection, diagnostics, staging, patient support and management of the non-metastatic disease. Part 2 covers recurrence after local treatment and management of the metastatic disease. RESULTS The 2022 Swedish guidelines include several new recommendations: rectal iodine-povidone to reduce post-biopsy infections, external beam radiation with focal boost to the tumour, use of a pre-rectal spacer to reduce rectal side effects after external beam radiotherapy in some expert centres, 6 months' concomitant and adjuvant rather than neoadjuvant and concomitant hormonal treatment together with radiotherapy for unfavourable intermediate and high-risk disease, and adjuvant abiraterone plus prednisolone together with a GnRH agonist for a subgroup of men with very high-risk disease. The Swedish guidelines differ from the European by having more restrictive recommendations regarding genetic testing and pelvic lymph node dissection, the risk group classification, recommending ultra-hypofractionated (7 fractions) external radiotherapy for intermediate and selected high-risk cancers, by not recommending any hormonal treatment together with radiotherapy for favourable intermediate-risk disease, and by recommending bicalutamide monotherapy instead of a GnRH agonist for some patient groups. CONCLUSIONS The 2022 Swedish prostate cancer guidelines include several new recommendations and some that differ from the European guidelines.
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Affiliation(s)
- Ola Bratt
- Department of Urology, Sahlgrenska University Hospital, Göteborg, Sweden.,Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Göteborg, Sweden
| | - Stefan Carlsson
- Section of Urology, Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - Per Fransson
- Department of Nursing, Umeå University, Umeå, Sweden
| | | | - Johan Stranne
- Department of Urology, Sahlgrenska University Hospital, Göteborg, Sweden.,Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Göteborg, Sweden
| | - Jon Kindblom
- Department of Oncology, Sahlgrenska University Hospital, Göteborg, Sweden
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17
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Stenman C, Abrahamsson E, Redsäter M, Gnanapragasam VJ, Bratt O. Rates of Positive Abdominal Computed Tomography and Bone Scan Findings Among Men with Cambridge Prognostic Group 4 or 5 prostate cancer: A Nationwide Registry Study. EUR UROL SUPPL 2022; 41:123-125. [PMID: 35722245 PMCID: PMC9198361 DOI: 10.1016/j.euros.2022.05.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/27/2022] [Indexed: 12/16/2022] Open
Abstract
European and American guidelines recommend abdominal computed tomography (CT) and bone scans for staging of high-risk prostate cancer (PC). To improve clinical risk stratification of nonmetastatic PC a new, five-tier risk classification system has been developed, the Cambridge Prognostic Groups (CPG), in which “high-risk” PC is divided into favourable CPG 4 and unfavourable CPG 5. We used the National Prostate Cancer Register of Sweden (NPCR) to define the rates of positive CT and bone scan findings among men with CPG 4 or 5 cancer. Among men with CPG 4 and prostate-specific antigen (PSA) <50 ng/ml, only 3.6% (95% confidence interval 2.9–4.5%) of the CT scans showed regional lymph-node metastasis (N1M0), while 6.2% (95% confidence interval 5.4–7.0%) of the bone scans were positive. Rates for both were higher in the subgroups with PSA 50–99 ng/ml (10% and 15%) and with CPG 5 disease. The low positivity rate questions routine use of CT for men with CPG 4 cancer and PSA <50 ng/ml, particularly considering the poor sensitivity and specificity for detection of lymph node metastasis. The positivity rate was higher for bone scans, and as current clinical practice relies on trials using bone scans for staging (eg, to define low- versus high-volume metastatic disease), continued routine use of bone scans seems justified. Patient summary Our analysis of data from the National Prostate Cancer Register of Sweden showed that for men with favourable high-risk prostate cancer (Cambridge Prognostic Group 4), the rate of positive computed tomography (CT) scans was low. This result suggests that CT scans may not be necessary for detecting cancer spread in men with Cambridge Prognostic Group 4 prostate cancer .
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Affiliation(s)
- Caroline Stenman
- Department of Urology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | | | | | - Ola Bratt
- Department of Urology, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Urology, Sahlgrenska Academy, Gothenburg University, Sweden
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18
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Parry MG, Nossiter J, Morris M, Sujenthiran A, Skolarus TA, Berry B, Nathan A, Cathcart P, Aggarwal A, van der Meulen J, Trinh QD, Payne H, Clarke NW. Comparison of the treatment of men with prostate cancer between the US and England: an international population-based study. Prostate Cancer Prostatic Dis 2022:10.1038/s41391-021-00482-6. [PMID: 35001083 DOI: 10.1038/s41391-021-00482-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 11/24/2021] [Accepted: 11/26/2021] [Indexed: 11/09/2022]
Abstract
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.
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Affiliation(s)
- Matthew G Parry
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK. .,Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK.
| | - Julie Nossiter
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK.,Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
| | - Melanie Morris
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK.,Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
| | - Arunan Sujenthiran
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK.,Flatiron, London, UK
| | - Ted A Skolarus
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, University of Michigan, Ann Arbor, MI, USA.,Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - Brendan Berry
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK.,Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
| | - Arjun Nathan
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK.,Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK.,University College London, London, UK
| | - Paul Cathcart
- Department of Urology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Ajay Aggarwal
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK.,Department of Radiotherapy, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Jan van der Meulen
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Quoc-Dien Trinh
- Harvard Medical School, Boston, USA.,Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Heather Payne
- Department of Oncology, University College London Hospitals, London, UK
| | - Noel W Clarke
- Department of Urology, The Christie NHS Foundation Trust, Manchester, UK.,Department of Urology, Salford Royal NHS Foundation Trust, Salford, UK
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19
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Hjälm-Eriksson M, Nilsson S, Brandberg Y, Johansson H, Lennernäs B, Lundell G, Castellanos E, Ullén A. High rate of local control and cure at 10 years after treatment of prostate cancer with external beam radiotherapy and high-dose-rate brachytherapy: a single centre experience. Acta Oncol 2021; 60:1301-1307. [PMID: 34498986 DOI: 10.1080/0284186x.2021.1953706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND AND PURPOSE To analyse the cumulative incidence of any failure (AF), prostate cancer-specific failure (PCSF), any death (AD), prostate cancer-specific death (PCSD), and local control in 2387 men with prostate cancer (PC), consecutively treated with combined high-dose-rate brachytherapy (HDRBT) and external beam radiotherapy (EBRT) from 1998 to 2010. MATERIAL AND METHODS A retrospective, single-institution study of men with localised PC. The mean age was 66 years and 54.7% had high-risk PC according to the Cambridge prognostic group (CPG) classification. The treatment was delivered as EBRT (2 Gy × 25) and HDRBT (10 Gy × 2) with combined androgen blockade (CAB). The median follow-up was 10.2 years. RESULTS The cumulative incidence of PCSD at 10 years was 5% [CI 95% 0.04-0.06]. The 10 years PCSD per risk group were: low (L) 0.4%, intermediate favourable (IF) 1%, intermediate unfavourable (IU) 4.3%, high-risk favourable (HF) 5.8%, and high-risk unfavourable (HU) 13.9%. The PCSF rate at 10 years was 16.5% [CI 95% 0.15-0.18]. The PCSF per risk group at 10 years were: L 2.5%, IF 5.5%, IU 15.9%, HF 15.6%, and HU 38.99%. PCSF occurred in 399 men, of whom 15% were found to have local failure. The estimated frequency of local failure in the entire cohort was 1.2%. CONCLUSIONS HDRBT combined with EBRT is an effective treatment with long-term overall survival and excellent local control for patients with PC. The low rate of local recurrence among men with relapse suggests that these patients were micro metastasised at time of treatment, which calls for improved methods to detect disseminated disease.
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Affiliation(s)
- Marie Hjälm-Eriksson
- Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden
- Department of Oncology, Capio S:t Göran’s Hospital, Stockholm, Sweden
| | - Sten Nilsson
- Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden
- Department of Pelvic Cancer, Genitourinary Oncology and Urology Unit, Karolinska University Hospital, Stockholm, Sweden
| | - Yvonne Brandberg
- Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden
- Department of Pelvic Cancer, Psychosocial Unit, Karolinska University Hospital, Stockholm, Sweden
| | - Hemming Johansson
- Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden
| | - Bo Lennernäs
- Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden
| | - Göran Lundell
- Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden
| | - Enrique Castellanos
- Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden
- Department of Pelvic Cancer, Genitourinary Oncology and Urology Unit, Karolinska University Hospital, Stockholm, Sweden
| | - Anders Ullén
- Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden
- Department of Pelvic Cancer, Genitourinary Oncology and Urology Unit, Karolinska University Hospital, Stockholm, Sweden
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20
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Bajeot AS, Covin B, Meyrignac O, Pericart S, Aziza R, Portalez D, Graff-Cailleaud P, Ploussard G, Roumiguié M, Malavaud B. Managing Discordant Findings Between Multiparametric Magnetic Resonance Imaging and Transrectal Magnetic Resonance Imaging-directed Prostate Biopsy-The Key Role of Magnetic Resonance Imaging-directed Transperineal Biopsy. Eur Urol Oncol 2021; 5:296-303. [PMID: 34154979 DOI: 10.1016/j.euo.2021.06.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 03/30/2021] [Accepted: 06/01/2021] [Indexed: 01/12/2023]
Abstract
BACKGROUND Discordant findings between multiparametric magnetic resonance imaging (mpMRI) and transrectal image-guided biopsies of the prostate (TRUS-P) may result in inadequate risk stratification of localized prostate cancer. OBJECTIVE To assess transperineal image-guided biopsies of the index target (TPER-IT) in terms of disease reclassification and treatment recommendations. DESIGN, SETTING, AND PARTICIPANTS Cases referred for suspicion or treatment of localized prostate cancer were reviewed in a multidisciplinary setting, and discordance was characterized into three scenarios: type I-negative biopsies or International Society of Urological Pathology (ISUP) grade 1 cancer in Prostate Imaging Reporting and Data System (PI-RADS) ≥4 index target (IT); type II-negative biopsies or ISUP grade 1 cancer in anterior IT; and type III-<3 mm stretch of cancer in PI-RADS ≥3 IT. Discordant findings were characterized in 132/558 (23.7%) patients after TRUS-P. Of these patients, 102 received reassessment TPER-IT. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The primary objective was to report changes in treatment recommendations after TPER-IT. Therefore, cores obtained by primary TRUS-P and TPER-IT were analyzed in terms of cancer detection, ISUP grade, and Cambridge Prognostic Group classification using descriptive statistics. RESULTS AND LIMITATIONS TPER-IT biopsies that consisted of fewer cores than the initial TRUS-P (seven vs 14, p < 0.0001) resulted in more cancer tissue materials for analysis (56 vs 42.5 mm, p = 0.0003). As a result, 40% of patients initially considered for follow-up (12/30) and 49% for active surveillance (30/61) were reassigned after TPER-IT to surgery or intensity-modulated radiotherapy. CONCLUSIONS Nonconcordance between pathology and imaging was observed in a significant proportion of patients receiving TRUS-P. TPER-IT better informed the presence and grade of cancer, resulting in a significant impact on treatment recommendations. A multidisciplinary review of mpMRI and TRUS-P findings and reassessment TPER-IT in type I-II discordances is recommended. PATIENT SUMMARY In this report, patients with suspicious imaging of the prostate, but no or well-differentiated cancer on transrectal image-guided -biopsies, were offered transperineal image-guided biopsies for reassessment. We found that a large share of these had a more aggressive cancer than initially suspected. We conclude that discordant results warrant reassessment transperineal image-guided biopsies as these may impact disease risk classification and treatment recommendations.
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Affiliation(s)
- Anne-Sophie Bajeot
- Department of Urology, Toulouse Cancer Institute, Toulouse, France; Department of Urology, Toulouse University Hospital, Toulouse, France
| | - Bertrand Covin
- Department of Urology, Toulouse Cancer Institute, Toulouse, France
| | - Oliver Meyrignac
- Department of Radiology, Toulouse Cancer Institute, Toulouse, France
| | - Sarah Pericart
- Department of Pathology, Toulouse Cancer Institute, Toulouse, France
| | - Richard Aziza
- Department of Radiology, Toulouse Cancer Institute, Toulouse, France
| | - Daniel Portalez
- Department of Radiology, Toulouse Cancer Institute, Toulouse, France
| | | | - Guillaume Ploussard
- Department of Urology, Toulouse Cancer Institute, Toulouse, France; Department of Urology, La Croix du Sud Hospital, Toulouse, France
| | - Mathieu Roumiguié
- Department of Urology, Toulouse Cancer Institute, Toulouse, France; Department of Urology, Toulouse University Hospital, Toulouse, France
| | - Bernard Malavaud
- Department of Urology, Toulouse Cancer Institute, Toulouse, France.
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21
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Caglic I, Sushentsev N, Gnanapragasam VJ, Sala E, Shaida N, Koo BC, Kozlov V, Warren AY, Kastner C, Barrett T. MRI-derived PRECISE scores for predicting pathologically-confirmed radiological progression in prostate cancer patients on active surveillance. Eur Radiol 2021; 31:2696-2705. [PMID: 33196886 PMCID: PMC8043947 DOI: 10.1007/s00330-020-07336-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 06/16/2020] [Accepted: 07/23/2020] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To assess the predictive value and correlation to pathological progression of the Prostate Cancer Radiological Estimation of Change in Sequential Evaluation (PRECISE) scoring system in the follow-up of prostate cancer (PCa) patients on active surveillance (AS). METHODS A total of 295 men enrolled on an AS programme between 2011 and 2018 were included. Baseline multiparametric magnetic resonance imaging (mpMRI) was performed at AS entry to guide biopsy. The follow-up mpMRI studies were prospectively reported by two sub-specialist uroradiologists with 10 years and 13 years of experience. PRECISE scores were dichotomized at the cut-off value of 4, and the sensitivity, specificity, positive predictive value and negative predictive value were calculated. Diagnostic performance was further quantified by using area under the receiver operating curve (AUC) which was based on the results of targeted MRI-US fusion biopsy. Univariate analysis using Cox regression was performed to assess which baseline clinical and mpMRI parameters were related to disease progression on AS. RESULTS Progression rate of the cohort was 13.9% (41/295) over a median follow-up of 52 months. With a cut-off value of category ≥ 4, the PRECISE scoring system showed sensitivity, specificity, PPV and NPV for predicting progression on AS of 0.76, 0.89, 0.52 and 0.96, respectively. The AUC was 0.82 (95% CI = 0.74-0.90). Prostate-specific antigen density (PSA-D), Likert lesion score and index lesion size were the only significant baseline predictors of progression (each p < 0.05). CONCLUSION The PRECISE scoring system showed good overall performance, and the high NPV may help limit the number of follow-up biopsies required in patients on AS. KEY POINTS • PRECISE scores 1-3 have high NPV which could reduce the need for re-biopsy during active surveillance. • PRECISE scores 4-5 have moderate PPV and should trigger either close monitoring or re-biopsy. • Three baseline predictors (PSA density, lesion size and Likert score) have a significant impact on the progression-free survival (PFS) time.
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Affiliation(s)
- Iztok Caglic
- CamPARI Prostate Cancer Group, Addenbrooke's Hospital and University of Cambridge, Cambridge, UK
- Department of Radiology, Addenbrooke's Hospital and University of Cambridge, Cambridge, UK
| | - Nikita Sushentsev
- Department of Radiology, Addenbrooke's Hospital and University of Cambridge, Cambridge, UK
| | - Vincent J Gnanapragasam
- Department of Urology, Addenbrooke's Hospital, Cambridge, UK
- Academic Urology Group, Department of Surgery, University of Cambridge, Cambridge, UK
- Cambridge Urology Translational Research and Clinical Trials Office, University of Cambridge, Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - Evis Sala
- CamPARI Prostate Cancer Group, Addenbrooke's Hospital and University of Cambridge, Cambridge, UK
- Department of Radiology, Addenbrooke's Hospital and University of Cambridge, Cambridge, UK
| | - Nadeem Shaida
- CamPARI Prostate Cancer Group, Addenbrooke's Hospital and University of Cambridge, Cambridge, UK
- Department of Radiology, Addenbrooke's Hospital and University of Cambridge, Cambridge, UK
| | - Brendan C Koo
- CamPARI Prostate Cancer Group, Addenbrooke's Hospital and University of Cambridge, Cambridge, UK
- Department of Radiology, Addenbrooke's Hospital and University of Cambridge, Cambridge, UK
| | - Vasily Kozlov
- Department of Public Health and Healthcare Organisation, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Anne Y Warren
- CamPARI Prostate Cancer Group, Addenbrooke's Hospital and University of Cambridge, Cambridge, UK
- Department of Pathology, Addenbrooke's Hospital, Cambridge, UK
| | - Christof Kastner
- CamPARI Prostate Cancer Group, Addenbrooke's Hospital and University of Cambridge, Cambridge, UK
- Department of Urology, Addenbrooke's Hospital, Cambridge, UK
| | - Tristan Barrett
- CamPARI Prostate Cancer Group, Addenbrooke's Hospital and University of Cambridge, Cambridge, UK.
- Department of Radiology, Addenbrooke's Hospital and University of Cambridge, Cambridge, UK.
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22
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Salvi M, Bosco M, Molinaro L, Gambella A, Papotti M, Acharya UR, Molinari F. A hybrid deep learning approach for gland segmentation in prostate histopathological images. Artif Intell Med 2021; 115:102076. [PMID: 34001325 DOI: 10.1016/j.artmed.2021.102076] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 04/08/2021] [Accepted: 04/10/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND In digital pathology, the morphology and architecture of prostate glands have been routinely adopted by pathologists to evaluate the presence of cancer tissue. The manual annotations are operator-dependent, error-prone and time-consuming. The automated segmentation of prostate glands can be very challenging too due to large appearance variation and serious degeneration of these histological structures. METHOD A new image segmentation method, called RINGS (Rapid IdentificatioN of Glandural Structures), is presented to segment prostate glands in histopathological images. We designed a novel glands segmentation strategy using a multi-channel algorithm that exploits and fuses both traditional and deep learning techniques. Specifically, the proposed approach employs a hybrid segmentation strategy based on stroma detection to accurately detect and delineate the prostate glands contours. RESULTS Automated results are compared with manual annotations and seven state-of-the-art techniques designed for glands segmentation. Being based on stroma segmentation, no performance degradation is observed when segmenting healthy or pathological structures. Our method is able to delineate the prostate gland of the unknown histopathological image with a dice score of 90.16 % and outperforms all the compared state-of-the-art methods. CONCLUSIONS To the best of our knowledge, the RINGS algorithm is the first fully automated method capable of maintaining a high sensitivity even in the presence of severe glandular degeneration. The proposed method will help to detect the prostate glands accurately and assist the pathologists to make accurate diagnosis and treatment. The developed model can be used to support prostate cancer diagnosis in polyclinics and community care centres.
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Affiliation(s)
- Massimo Salvi
- Politecnico di Torino, PoliTo(BIO)Med Lab, Biolab, Department of Electronics and Telecommunications, Corso Duca degli Abruzzi 24, Turin, 10129, Italy.
| | - Martino Bosco
- San Lazzaro Hospital, Department of Pathology, Via Petrino Belli 26, Alba, 12051, Italy
| | - Luca Molinaro
- A.O.U. Città della Salute e della Scienza Hospital, Division of Pathology, Corso Bramante 88, Turin, 10126, Italy
| | - Alessandro Gambella
- A.O.U. Città della Salute e della Scienza Hospital, Division of Pathology, Corso Bramante 88, Turin, 10126, Italy
| | - Mauro Papotti
- University of Turin, Division of Pathology, Department of Oncology, Via Santena 5, Turin, 10126, Italy
| | - U Rajendra Acharya
- Department of Electronics and Computer Engineering, Ngee Ann Polytechnic, Singapore; Department of Biomedical Engineering, School of Science and Technology, SUSS University, Clementi, 599491, Singapore; Department of Bioinformatics and Medical Engineering, Asia University, Taiwan
| | - Filippo Molinari
- Politecnico di Torino, PoliTo(BIO)Med Lab, Biolab, Department of Electronics and Telecommunications, Corso Duca degli Abruzzi 24, Turin, 10129, Italy
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23
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Xie M, Gao XS, Ma MW, Gu XB, Li HZ, Lyu F, Bai Y, Chen JY, Ren XY, Liu MZ. Population-Based Comparison of Different Risk Stratification Systems Among Prostate Cancer Patients. Front Oncol 2021; 11:646073. [PMID: 33928035 PMCID: PMC8076565 DOI: 10.3389/fonc.2021.646073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 03/16/2021] [Indexed: 11/16/2022] Open
Abstract
Background It is not known which risk stratification system has the best discrimination ability for predicting prostate cancer death. Methods We identified patients with non-metastatic primary prostate adenocarcinoma diagnosis between 2004 and 2015 using the Surveillance, Epidemiology, and End Results database. Patients were categorized in different risk groups using the three frequently used risk stratification systems of the National Comprehensive Cancer Network guideline (NCCN-g), American Urological Association guideline (AUA-g), and European Association of Urology guideline (EAU-g), respectively. Associations between risk classification and prostate cancer-specific mortality (PCSM) were determined using Kaplan–Meier analyses and multivariable regression with Cox proportional hazards model. Area under the receiver operating characteristics curve (AUC) analyses were used to test the discrimination ability of the three risk grouping systems. Results We analyzed 310,062 patients with a median follow-up of 61 months. A total of 36,368 deaths occurred, including 6,033 prostate cancer deaths. For all the three risk stratification systems, the risk groups were significantly associated with PCSM. The AUC of the model relying on NCCN-g, AUA-g, and EAU-g risk stratification systems for PCSM at specifically 8 years were 0.818, 0.793, and 0.689 in the entire population; 0.819, 0.795, and 0.691 in Whites; 0.802, 0.777, and 0.681 in Blacks; 0.862, 0.818, and 0.714 in Asians; 0.845, 0.806, and 0.728 in Chinese patients. Regardless of the age, marital status, socioeconomic status, and treatment modality, AUC of the model relying on NCCN-g and AUA-g for PCSM was greater than that relying on EAU-g; AUC of the model relying on NCCN-g system was greater than that of the AUA-g system. Conclusions The NCCN-g and AUA-g risk stratification systems perform better in discriminating PCSM compared to the EAU-g system. The discrimination ability of the NCCN-g system was better than that of the AUA-g system. It is recommended to use NCCN-g to evaluate risk groups for prostate cancer patients and then provide more appropriate corresponding treatment recommendations.
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Affiliation(s)
- Mu Xie
- Department of Radiation Oncology, Peking University First Hospital, Beijing, China
| | - Xian-Shu Gao
- Department of Radiation Oncology, Peking University First Hospital, Beijing, China
| | - Ming-Wei Ma
- Department of Radiation Oncology, Peking University First Hospital, Beijing, China
| | - Xiao-Bin Gu
- Department of Radiation Oncology, Zhengzhou University First Affiliated Hospital, Zhengzhou, China
| | - Hong-Zhen Li
- Department of Radiation Oncology, Peking University First Hospital, Beijing, China
| | - Feng Lyu
- Department of Radiation Oncology, Peking University First Hospital, Beijing, China
| | - Yun Bai
- Department of Radiation Oncology, Peking University First Hospital, Beijing, China
| | - Jia-Yan Chen
- Department of Radiation Oncology, Peking University First Hospital, Beijing, China
| | - Xue-Ying Ren
- Department of Radiation Oncology, Peking University First Hospital, Beijing, China
| | - Ming-Zhu Liu
- Department of Radiation Oncology, Peking University First Hospital, Beijing, China
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24
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Liu S, Shen M, Hsu EC, Zhang CA, Garcia-Marques F, Nolley R, Koul K, Rice MA, Aslan M, Pitteri SJ, Massie C, George A, Brooks JD, Gnanapragasam VJ, Stoyanova T. Discovery of PTN as a serum-based biomarker of pro-metastatic prostate cancer. Br J Cancer 2021; 124:896-900. [PMID: 33288843 PMCID: PMC7921397 DOI: 10.1038/s41416-020-01200-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 11/02/2020] [Accepted: 11/12/2020] [Indexed: 01/31/2023] Open
Abstract
Distinguishing clinically significant from indolent prostate cancer (PC) is a major clinical challenge. We utilised targeted protein biomarker discovery approach to identify biomarkers specific for pro-metastatic PC. Serum samples from the cancer-free group; Cambridge Prognostic Group 1 (CPG1, low risk); CPG5 (high risk) and metastatic disease were analysed using Olink Proteomics panels. Tissue validation was performed by immunohistochemistry in a radical prostatectomy cohort (n = 234). We discovered that nine proteins (pleiotrophin (PTN), MK, PVRL4, EPHA2, TFPI-2, hK11, SYND1, ANGPT2, and hK14) were elevated in metastatic PC patients when compared to other groups. PTN levels were increased in serum from men with CPG5 compared to benign and CPG1. High tissue PTN level was an independent predictor of biochemical recurrence and metastatic progression in low- and intermediate-grade disease. These findings suggest that PTN may represent a novel biomarker for the presence of poor prognosis local disease with the potential to metastasise warranting further investigation.
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Affiliation(s)
- Shiqin Liu
- Department of Radiology, Stanford University, Stanford, CA, USA
- Canary Center at Stanford for Cancer Early Detection, Stanford University, Palo Alto, CA, USA
| | - Michelle Shen
- Department of Radiology, Stanford University, Stanford, CA, USA
- Canary Center at Stanford for Cancer Early Detection, Stanford University, Palo Alto, CA, USA
| | - En-Chi Hsu
- Department of Radiology, Stanford University, Stanford, CA, USA
- Canary Center at Stanford for Cancer Early Detection, Stanford University, Palo Alto, CA, USA
| | | | - Fernando Garcia-Marques
- Department of Radiology, Stanford University, Stanford, CA, USA
- Canary Center at Stanford for Cancer Early Detection, Stanford University, Palo Alto, CA, USA
| | - Rosalie Nolley
- Department of Urology, Stanford University, Stanford, CA, USA
| | - Kashyap Koul
- Department of Radiology, Stanford University, Stanford, CA, USA
- Canary Center at Stanford for Cancer Early Detection, Stanford University, Palo Alto, CA, USA
| | - Meghan A Rice
- Department of Radiology, Stanford University, Stanford, CA, USA
- Canary Center at Stanford for Cancer Early Detection, Stanford University, Palo Alto, CA, USA
| | - Merve Aslan
- Department of Radiology, Stanford University, Stanford, CA, USA
- Canary Center at Stanford for Cancer Early Detection, Stanford University, Palo Alto, CA, USA
| | - Sharon J Pitteri
- Department of Radiology, Stanford University, Stanford, CA, USA
- Canary Center at Stanford for Cancer Early Detection, Stanford University, Palo Alto, CA, USA
| | - Charlie Massie
- Cambridge Urology Translational Research and Clinical Trials, Cambridge University Hospitals NHS Trust & University of Cambridge, Cambridge, UK
- Urological Malignancies Programme, CRUK Cambridge Cancer Centre, Cambridge, UK
- Early Detection Programme, CRUK Cambridge Cancer Centre, Cambridge, UK
| | - Anne George
- Urological Malignancies Programme, CRUK Cambridge Cancer Centre, Cambridge, UK
| | - James D Brooks
- Canary Center at Stanford for Cancer Early Detection, Stanford University, Palo Alto, CA, USA
- Department of Urology, Stanford University, Stanford, CA, USA
| | - Vincent J Gnanapragasam
- Cambridge Urology Translational Research and Clinical Trials, Cambridge University Hospitals NHS Trust & University of Cambridge, Cambridge, UK.
- Academic Urology Group, Department of Surgery, University of Cambridge, Cambridge, UK.
| | - Tanya Stoyanova
- Department of Radiology, Stanford University, Stanford, CA, USA.
- Canary Center at Stanford for Cancer Early Detection, Stanford University, Palo Alto, CA, USA.
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25
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Deek M, Lilleby W, Vaage V, Hole KH, DeWeese T, Stensvold A, Tran P, Seierstad T. Impact of radiation dose on recurrence in high-risk prostate cancer patients. Prostate 2020; 80:1322-1327. [PMID: 33258482 DOI: 10.1002/pros.24059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 08/04/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND Dose escalated radiation therapy (RT) combined with long-term androgen deprivation therapy (ADT) is a standard of care option for men with high-risk and locally advanced prostate cancer (PCa). However, the optimal dose of escalated RT and ADT is not known. Here we assessed the impact of radiation dose and length of ADT on biochemical recurrence in a multi-institutional cohort stratified by the Cambridge prognostic group (CPG). We hypothesized that radiation dose and length of ADT would impact outcome in similar risk groups of our patients. METHODS Two-hundred and forty-four patients were included, 132 from Oslo University Hospital, Department of Oncology and 112 from Johns Hopkins Hospital, Department of Radiation Oncology. Biochemical recurrence was defined as prostate-specific antigen (PSA) nadir +2 ng/mL. Time to recurrence was estimated using Kaplan-Meier analysis and when stratified by CPG the log-rank test was used. Cox regression analysis was performed to identify factors associated with risk of recurrence. Site of recurrence was investigated. RESULTS The median follow-up time was 7.4 years. The vast majority (71%) of patients were classified as high-risk (CPG 4) or very high-risk features (CPG 5). Significantly more PSA recurrences occurred in CPG 5 (41%) compared with CPG 4 (25%) (P = .04) and five-year cumulative recurrence-free survival was lower for CPG 4 and 5 (89% and 68%) compared with CPG 1, 2, and 3 (100%, 100%, and 93%). The recurrence-free survival for CPG 5 was significantly higher for prostate irradiation of 80 Gy as compared with 74 Gy (P = .011). For CPG 4 and 5 no local recurrences were detected in patients receiving 80 Gy. On stepwise Cox regression analysis neither age nor length of ADT were independent prognostic factors for recurrence free survival. CONCLUSION Prostate dose escalation from 74 to 80 Gy decreases risk of recurrence in high-risk PCa. Further studies are needed to identify the optimal combination of ADT and RT.
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Affiliation(s)
- Matthew Deek
- Department of Radiation Oncology, Johns Hopkins Hospital, Baltimore, Maryland
| | - Wolfgang Lilleby
- Department of Oncology, Oslo University Hospital-Radium Hospital, Oslo, Norway
| | - Victoria Vaage
- Department of Oncology, Oslo University Hospital-Radium Hospital, Oslo, Norway
| | - Knut H Hole
- Department of Radiology, Oslo University Hospital-Radium Hospital, Oslo, Norway
- Faculty of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Theodore DeWeese
- Department of Radiation Oncology, Johns Hopkins Hospital, Baltimore, Maryland
| | - Andreas Stensvold
- Department of Oncology, Østfold Hospital Trust, Kalnes, Østfold, Norway
| | - Phuoc Tran
- Department of Radiation Oncology, Johns Hopkins Hospital, Baltimore, Maryland
| | - Therese Seierstad
- Division for Radiology and Nuclear Medicine, Department of Research and Development, Oslo University Hospital, Oslo, Norway
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Identification and Validation of Leucine-rich α-2-glycoprotein 1 as a Noninvasive Biomarker for Improved Precision in Prostate Cancer Risk Stratification. EUR UROL SUPPL 2020; 21:51-60. [PMID: 34337468 PMCID: PMC8317831 DOI: 10.1016/j.euros.2020.08.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2020] [Indexed: 12/24/2022] Open
Abstract
Background More accurate risk assessments are needed to improve prostate cancer management. Objective To identify blood-based protein biomarkers that provided prognostic information for risk stratification. Design, setting, and participants Mass spectrometry was used to identify biomarker candidates from blood, and validation studies were performed in four independent cohorts retrospectively collected between 1988 and 2015. Outcome measurements and statistical analysis The primary outcome objectives were progression-free survival, prostate cancer–specific survival (PCSS), and overall survival. Statistical analyses to assess survival and model performance were performed. Results and limitation Serum leucine-rich α-2-glycoprotein 1 (LRG1) was found to be elevated in fatal prostate cancer. LRG1 provided prognostic information independent of metastasis and increased the accuracy in predicting PCSS, particularly in the first 3 yr. A high LRG1 level is associated with an average of two-fold higher risk of disease-progression and mortality in both high-risk and metastatic patients. However, our study design, with a retrospective analysis of samples spanning several decades back, limits the assessment of the clinical utility of LRG1 in today’s clinical practice. Thus, independent prospective studies are needed to establish LRG1 as a clinically useful biomarker for patient management. Conclusions High blood levels of LRG1 are unfavourable in newly diagnosed high-risk and metastatic prostate cancer, and LRG1 increased the accuracy of risk stratification of prostate cancer patients. Patient summary High blood levels of leucine-rich α-2-glycoprotein 1 are unfavourable in newly diagnosed high-risk and metastatic prostate cancer.
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27
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Fosbøl MØ, Kurbegovic S, Johannesen HH, Røder MA, Hansen AE, Mortensen J, Loft A, Petersen PM, Madsen J, Brasso K, Kjaer A. Urokinase-Type Plasminogen Activator Receptor (uPAR) PET/MRI of Prostate Cancer for Noninvasive Evaluation of Aggressiveness: Comparison with Gleason Score in a Prospective Phase 2 Clinical Trial. J Nucl Med 2020; 62:354-359. [PMID: 32764119 DOI: 10.2967/jnumed.120.248120] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 06/30/2020] [Indexed: 02/06/2023] Open
Abstract
The aim of this study was to evaluate the correlation between uptake of the PET ligand 68Ga-NOTA-AE105, targeting the urokinase-type plasminogen activator receptor (uPAR), and Gleason score in patients undergoing prostate biopsy. Methods: Patients with clinical suspicion of prostate cancer (PCa) or previously diagnosed with PCa were prospectively enrolled in this phase 2 trial. A combination of uPAR PET and multiparametric MRI (mpMRI) was performed, and the SUV in the primary tumor, as delineated by mpMRI, was measured by 2 independent readers. The correlation between the SUV and the Gleason score obtained by biopsy was assessed. Results: A total of 27 patients had histologically verified PCa visible on mpMRI and constituted the study population. There was a positive correlation between the SUVmax and the Gleason score (Spearman ρ = 0.55; P = 0.003). Receiver operating characteristic analysis showed an area under the curve of 0.88 (95% CI, 0.67-1.00) for discriminating a Gleason score of greater than or equal to 3 + 4 from a Gleason score of less than or equal to 3 + 3. A cutoff for the tumor SUVmax could be established with a sensitivity of 96% (79%-99%) and a specificity of 75% (30%-95%) for detecting a Gleason score of greater than or equal to 3 + 4. For discriminating a Gleason score of greater than or equal to 4 + 3 from a Gleason score of less than or equal to 3 + 4, a cutoff could be established for detecting a Gleason score of greater than or equal to 4 + 3 with a sensitivity of 93% (69%-99%) and a specificity of 62% (36%-82%). Conclusion: SUV measurements from uPAR PET in primary tumors, as delineated by mpMRI, showed a significant correlation with the Gleason score, and the tumor SUVmax was able to discriminate between low-risk Gleason score profiles and intermediate risk Gleason score profiles with a high diagnostic accuracy. Consequently, uPAR PET/MRI could be a promising method for the noninvasive evaluation of PCa and might reduce the need for repeated biopsies (e.g., in active surveillance).
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Affiliation(s)
- Marie Øbro Fosbøl
- Department of Clinical Physiology, Nuclear Medicine & PET and Cluster for Molecular Imaging, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark
| | - Sorel Kurbegovic
- Department of Clinical Physiology, Nuclear Medicine & PET and Cluster for Molecular Imaging, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark
| | - Helle Hjorth Johannesen
- Department of Clinical Physiology, Nuclear Medicine & PET and Cluster for Molecular Imaging, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark
| | - Martin Andreas Røder
- Copenhagen Prostate Cancer Center, Department of Urology, Rigshospitalet, Copenhagen, Denmark; and
| | - Adam Espe Hansen
- Department of Clinical Physiology, Nuclear Medicine & PET and Cluster for Molecular Imaging, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark
| | - Jann Mortensen
- Department of Clinical Physiology, Nuclear Medicine & PET and Cluster for Molecular Imaging, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark
| | - Annika Loft
- Department of Clinical Physiology, Nuclear Medicine & PET and Cluster for Molecular Imaging, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark
| | | | - Jacob Madsen
- Department of Clinical Physiology, Nuclear Medicine & PET and Cluster for Molecular Imaging, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark
| | - Klaus Brasso
- Copenhagen Prostate Cancer Center, Department of Urology, Rigshospitalet, Copenhagen, Denmark; and
| | - Andreas Kjaer
- Department of Clinical Physiology, Nuclear Medicine & PET and Cluster for Molecular Imaging, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark
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Parry MG, Cowling TE, Sujenthiran A, Nossiter J, Berry B, Cathcart P, Aggarwal A, Payne H, van der Meulen J, Clarke NW, Gnanapragasam VJ. Risk stratification for prostate cancer management: value of the Cambridge Prognostic Group classification for assessing treatment allocation. BMC Med 2020; 18:114. [PMID: 32460859 PMCID: PMC7254634 DOI: 10.1186/s12916-020-01588-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 04/07/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The five-tiered Cambridge Prognostic Group (CPG) classification is a better predictor of prostate cancer-specific mortality than the traditional three-tiered classification (low, intermediate, and high risk). We investigated radical treatment rates according to CPG in men diagnosed with non-metastatic prostate cancer in England between 2014 and 2017. METHODS Patients diagnosed with non-metastatic prostate cancer were identified from the National Prostate Cancer Audit database. Men were risk stratified according to the CPG classification. Risk ratios (RR) were estimated for undergoing radical treatment according to CPG and for receiving radiotherapy for those treated radically. Funnel plots were used to display variation in radical treatment rates across hospitals. RESULTS A total of 61,999 men were included with 10,963 (17.7%) in CPG1 (lowest risk group), 13,588 (21.9%) in CPG2, 9452 (15.2%) in CPG3, 12,831 (20.7%) in CPG4, and 15,165 (24.5%) in CPG5 (highest risk group). The proportion of men receiving radical treatment increased from 11.3% in CPG1 to 78.8% in CGP4, and 73.3% in CPG5. Men in CPG3 were more likely to receive radical treatment than men in CPG2 (66.3% versus 48.4%; adjusted RR 1.44; 95% CI 1.36-1.53; P < 0.001). Radically treated men in CPG3 were also more likely to receive radiotherapy than men in CPG2 (59.2% versus 43.9%; adjusted RR, 1.18; 95% CI 1.10-1.26). Although radical treatment rates were similar in CPG4 and CPG5 (78.8% versus 73.3%; adjusted RR 1.01; 95% CI 0.98-1.04), more men in CPG5 had radiotherapy than men in CPG4 (79.9% versus 59.1%, adjusted RR 1.26; 95% CI 1.12-1.40). CONCLUSIONS The CPG classification distributes men in five risk groups that are about equal in size. It reveals differences in treatment practices in men with intermediate-risk disease (CPG2 and CPG3) and in men with high-risk disease (CPG4 and CPGP5) that are not visible when using the traditional three-tiered risk classification.
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Affiliation(s)
- M G Parry
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK. .,Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, England.
| | - T E Cowling
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - A Sujenthiran
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, England
| | - J Nossiter
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, England
| | - B Berry
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK.,Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, England
| | - P Cathcart
- Department of Urology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - A Aggarwal
- Department of Cancer Epidemiology, Population, and Global Health, King's College London, London, UK.,Department of Radiotherapy, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - H Payne
- Department of Oncology, University College London Hospitals, London, UK
| | - J van der Meulen
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - N W Clarke
- Department of Urology, The Christie NHS Foundation Trust, Manchester, UK.,Department of Urology, Salford Royal NHS Foundation Trust, Salford, UK
| | - V J Gnanapragasam
- Academic Urology Group, Department of Surgery, University of Cambridge, Cambridge, UK.,Department of Urology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.,Cambridge Urology Translational Research and Clinical Trials Office, Cambridge Biomedical Campus, Cambridge, UK
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29
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Kim L, Boxall N, George A, Burling K, Acher P, Aning J, McCracken S, Page T, Gnanapragasam VJ. Clinical utility and cost modelling of the phi test to triage referrals into image-based diagnostic services for suspected prostate cancer: the PRIM (Phi to RefIne Mri) study. BMC Med 2020; 18:95. [PMID: 32299423 PMCID: PMC7164355 DOI: 10.1186/s12916-020-01548-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Accepted: 03/03/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The clinical pathway to detect and diagnose prostate cancer has been revolutionised by the use of multiparametric MRI (mpMRI pre-biopsy). mpMRI however remains a resource-intensive test and is highly operator dependent with variable effectiveness with regard to its negative predictive value. Here we tested the use of the phi assay in standard clinical practice to pre-select men at the highest risk of harbouring significant cancer and hence refine the use of mpMRI and biopsies. METHODS A prospective five-centre study recruited men being investigated through an mpMRI-based prostate cancer diagnostic pathway. Test statistics for PSA, PSA density (PSAd) and phi were assessed for detecting significant cancers using 2 definitions: ≥ Grade Group (GG2) and ≥ Cambridge Prognostic Groups (CPG) 3. Cost modelling and decision curve analysis (DCA) was simultaneously performed. RESULTS A total of 545 men were recruited and studied with a median age, PSA and phi of 66 years, 8.0 ng/ml and 44 respectively. Overall, ≥ GG2 and ≥ CPG3 cancer detection rates were 64% (349/545), 47% (256/545) and 32% (174/545) respectively. There was no difference across centres for patient demographics or cancer detection rates. The overall area under the curve (AUC) for predicting ≥ GG2 cancers was 0.70 for PSA and 0.82 for phi. AUCs for ≥ CPG3 cancers were 0.81 and 0.87 for PSA and phi respectively. AUC values for phi did not differ between centres suggesting reliability of the test in different diagnostic settings. Pre-referral phi cut-offs between 20 and 30 had NPVs of 0.85-0.90 for ≥ GG2 cancers and 0.94-1.0 for ≥ CPG3 cancers. A strategy of mpMRI in all and biopsy only positive lesions reduced unnecessary biopsies by 35% but missed 9% of ≥ GG2 and 5% of ≥ CPG3 cancers. Using PH ≥ 30 to rule out referrals missed 8% and 5% of ≥ GG2 and ≥ CPG3 cancers (and reduced unnecessary biopsies by 40%). This was achieved however with 25% fewer mpMRI. Pathways incorporating PSAd missed fewer cancers but necessitated more unnecessary biopsies. The phi strategy had the lowest mean costs with DCA demonstrating net clinical benefit over a range of thresholds. CONCLUSION phi as a triaging test may be an effective way to reduce mpMRI and biopsies without compromising detection of significant prostate cancers.
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Affiliation(s)
- Lois Kim
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Nicholas Boxall
- Department of Urology, Cambridge University Hospitals Trust, Cambridge, UK
| | - Anne George
- Urological Malignancies Programme CRUK & Cambridge Urology Translational Research and Clinical Trials Office, University of Cambridge Box 193, Cambridge Biomedical Campus Cambridge CB20QQ, Cambridge, UK
| | - Keith Burling
- NIHR Cambridge Biomedical Research Centre, Core Biochemical Assay Laboratory, University of Cambridge, Cambridge, UK
| | - Pete Acher
- Department of Urology, Southend Hospital, Essex, UK
| | - Jonathan Aning
- Department of Urology, North Bristol NHS Trust, Bristol, UK
| | - Stuart McCracken
- Department of Urology, South Tyneside and Sunderland NHS Trust, Sunderland, UK
| | - Toby Page
- Department of Urology, Newcastle Hospitals NHS Trust, Newcastle upon Tyne, UK
| | - Vincent J Gnanapragasam
- Department of Urology, Cambridge University Hospitals Trust, Cambridge, UK. .,Urological Malignancies Programme CRUK & Cambridge Urology Translational Research and Clinical Trials Office, University of Cambridge Box 193, Cambridge Biomedical Campus Cambridge CB20QQ, Cambridge, UK. .,Academic Urology Group, Department of Surgery, University of Cambridge, Cambridge, UK.
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30
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Neal DE, Metcalfe C, Donovan JL, Lane JA, Davis M, Young GJ, Dutton SJ, Walsh EI, Martin RM, Peters TJ, Turner EL, Mason M, Bryant R, Bollina P, Catto J, Doherty A, Gillatt D, Gnanapragasam V, Holding P, Hughes O, Kockelbergh R, Kynaston H, Oxley J, Paul A, Paez E, Rosario DJ, Rowe E, Staffurth J, Altman DG, Hamdy FC. Ten-year Mortality, Disease Progression, and Treatment-related Side Effects in Men with Localised Prostate Cancer from the ProtecT Randomised Controlled Trial According to Treatment Received. Eur Urol 2020; 77:320-330. [PMID: 31771797 DOI: 10.1016/j.eururo.2019.10.030] [Citation(s) in RCA: 89] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 10/30/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND The ProtecT trial reported intention-to-treat analysis of men with localised prostate cancer (PCa) randomly allocated to active monitoring (AM), radical prostatectomy, and external beam radiotherapy. OBJECTIVE To determine report outcomes according to treatment received in men in randomised and treatment choice cohorts. DESIGN, SETTING, AND PARTICIPANTS This study focuses on secondary care. Men with clinically localised prostate cancer at one of nine UK centres were invited to participate in the treatment trial comparing AM, radical prostatectomy, and radiotherapy. INTERVENTION Two cohorts included 1643 men who agreed to be randomised; 997 declined randomisation and chose treatment. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Health-related quality of life impacts on urinary, bowel, and sexual function were assessed using patient-reported outcome measures. Analysis was carried out based on treatment received for each cohort and on pooled estimates using meta-analysis. Differences were estimated with adjustment for known prognostic factors using propensity scores. RESULTS AND LIMITATIONS According to treatment received, more men receiving AM died of PCa (AM 1.85%, surgery 0.67%, radiotherapy 0.73%), whilst this difference remained consistent with chance in the randomised cohort (p=0.08); stronger evidence was found in the exploratory analyses (randomised plus choice cohort) when AM was compared with the combined radical treatment group (p=0.003). There was also strong evidence that metastasis (AM 5.6%, surgery 2.4%, radiotherapy 2.7%) and disease progression (AM 20.35%, surgery 5.87%, radiotherapy 6.62%) were more common in the AM group. Compared with AM, there were higher risks of sexual dysfunction (95% at 6mo) and urinary incontinence (55% at 6mo) after surgery, and of sexual dysfunction (88% at 6mo) and bowel dysfunction (5% at 6mo) after radiotherapy. The key limitations are the potential for bias when comparing groups defined by treatment received and outdating of the interventions being evaluated during the lengthy follow-up required in trials of screen-detected PCa. CONCLUSIONS Analyses according to treatment received showed increased rates of disease-related events and lower rates of patient-reported harms in men managed by AM compared with men managed by radical treatment, and stronger evidence of greater PCa mortality in the AM group. PATIENT SUMMARY More than 90 out of every 100 men with localised prostate cancer do not die of prostate cancer within 10yr, irrespective of whether treatment is by means of monitoring, surgery, or radiotherapy. Side effects on sexual and bladder function are much better after active monitoring, but the risks of spreading of prostate cancer are more common.
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Affiliation(s)
- David E Neal
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK.
| | - Chris Metcalfe
- Bristol Randomised Trials Collaboration (BRTC), Bristol Trials Centre, University of Bristol, Bristol, UK
| | | | - J Athene Lane
- Bristol Randomised Trials Collaboration (BRTC), Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Michael Davis
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Grace J Young
- Bristol Randomised Trials Collaboration (BRTC), Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Susan J Dutton
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | | | | | - Tim J Peters
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Emma L Turner
- Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Richard Bryant
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Prasad Bollina
- Department of Urology & Surgery, Western General Hospital, University of Edinburgh, Edinburgh, UK
| | - James Catto
- Academic Urology Unit, University of Sheffield, Sheffield, UK
| | - Alan Doherty
- Department of Urology, Queen Elizabeth Hospital, Birmingham, UK
| | - David Gillatt
- Department of Urology, Southmead Hospital and Bristol Urological Institute, Bristol, UK
| | - Vincent Gnanapragasam
- Academic Urology Group, Department of Surgery & Cambridge Urology Translational Research and Clinical Trials, Cambridge Biomedical Campus, University of Cambridge, Cambridge, UK
| | - Peter Holding
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Owen Hughes
- Department of Urology, Cardiff and Vale University Health Board, Cardiff, UK
| | - Roger Kockelbergh
- Department of Urology, University Hospitals of Leicester, Leicester, UK
| | - Howard Kynaston
- Division of Cancer and Genetics, School of Medicine, Cardiff University, Cardiff, UK
| | - Jon Oxley
- Department of Cellular Pathology, North Bristol NHS Trust, Bristol, UK
| | - Alan Paul
- Department of Urology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Edgar Paez
- Department of Urology, Freeman Hospital, Newcastle-upon-Tyne, UK
| | - Derek J Rosario
- Department of Urology, Royal Hallamshire Hospital, Sheffield, UK
| | - Edward Rowe
- Department of Urology, Southmead Hospital and Bristol Urological Institute, Bristol, UK
| | - John Staffurth
- Division of Cancer and Genetics, School of Medicine, Cardiff University, Cardiff, UK
| | - Doug G Altman
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Freddie C Hamdy
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
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31
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Zelic R, Garmo H, Zugna D, Stattin P, Richiardi L, Akre O, Pettersson A. Predicting Prostate Cancer Death with Different Pretreatment Risk Stratification Tools: A Head-to-head Comparison in a Nationwide Cohort Study. Eur Urol 2019; 77:180-188. [PMID: 31606332 DOI: 10.1016/j.eururo.2019.09.027] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 09/20/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Numerous pretreatment risk classification tools are available for prostate cancer. Which tool is best in predicting prostate cancer death is unclear. OBJECTIVE To systematically compare the prognostic performance of the most commonly used pretreatment risk stratification tools for prostate cancer. DESIGN, SETTING, AND PARTICIPANTS A nationwide cohort study was conducted, including 154 811 men in Prostate Cancer data Base Sweden (PCBaSe) 4.0 diagnosed with nonmetastatic prostate cancer during 1998-2016 and followed through 2016. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS We compared the D'Amico, National Institute for Health and Care Excellence (NICE), European Association of Urology (EAU), Genito-Urinary Radiation Oncologists of Canada (GUROC), American Urological Association (AUA), National Comprehensive Cancer Network (NCCN), and Cambridge Prognostic Groups (CPG) risk group systems; the Cancer of the Prostate Risk Assessment (CAPRA) score; and the Memorial Sloan Kettering Cancer Center (MSKCC) nomogram in predicting prostate cancer death by estimating the concordance index (C-index) and the observed versus predicted cumulative incidences at different follow-up times. RESULTS AND LIMITATIONS A total of 139 515 men were included in the main analysis, of whom 15 961 died from prostate cancer during follow-up. The C-index at 10 yr of follow-up ranged from 0.73 (95% confidence interval [CI]: 0.72-0.73) to 0.81 (95% CI: 0.80-0.81) across the compared tools. The MSKCC nomogram (C-index: 0.81, 95% CI: 0.80-0.81), CAPRA score (C-index: 0.80, 95% CI: 0.79-0.81), and CPG system (C-index: 0.78, 95% CI: 0.78-0.79) performed the best. The order of performance between the tools remained in analyses stratified by primary treatment and year of diagnosis. The predicted cumulative incidences were close to the observed ones, with some underestimation at 5 yr. It is a limitation that the study was conducted solely in a Swedish setting (ie, case mix). CONCLUSIONS The MSKCC nomogram, CAPRA score, and CPG risk grouping system performed better in discriminating prostate cancer death than the D'Amico and D'Amico-derived systems (NICE, GUROC, EAU, AUA, and NCCN). Use of these tools may improve clinical decision making. PATIENT SUMMARY There are numerous pretreatment risk classification tools that can aid treatment decision for prostate cancer. We systematically compared the prognostic performance of the most commonly used tools in a large cohort of Swedish men with prostate cancer. The Memorial Sloan Kettering Cancer Center nomogram, Cancer of the Prostate Risk Assessment score, and Cambridge Prognostic Groups performed best in predicting prostate cancer death. The use of these tools may improve treatment decisions.
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Affiliation(s)
- Renata Zelic
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.
| | - Hans Garmo
- Division of Cancer Studies, Translational Oncology & Urology Research (TOUR), King's College London, London, UK; Akademiska Sjukhuset, Regional Cancer Centre, Uppsala, Sweden
| | - Daniela Zugna
- Cancer Epidemiology Unit, Department of Medical Sciences, University of Turin, and CPO-Piemonte, Turin, Italy
| | - Pär Stattin
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Lorenzo Richiardi
- Cancer Epidemiology Unit, Department of Medical Sciences, University of Turin, and CPO-Piemonte, Turin, Italy
| | - Olof Akre
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Urology, Karolinska University Hospital, Stockholm, Sweden
| | - Andreas Pettersson
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
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32
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Neal D. Precision prostatectomy: reconciling functional and oncological outcomes. BMJ SURGERY, INTERVENTIONS, & HEALTH TECHNOLOGIES 2019; 1:e000015. [PMID: 35047778 PMCID: PMC8647570 DOI: 10.1136/bmjsit-2019-000015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 07/11/2019] [Indexed: 11/15/2022] Open
Affiliation(s)
- David Neal
- Nuffield Department of Surgical Sciences, Oxford University, Oxford, UK
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Thurtle D, Rossi SH, Berry B, Pharoah P, Gnanapragasam VJ. Models predicting survival to guide treatment decision-making in newly diagnosed primary non-metastatic prostate cancer: a systematic review. BMJ Open 2019; 9:e029149. [PMID: 31230029 PMCID: PMC6596988 DOI: 10.1136/bmjopen-2019-029149] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES Men diagnosed with non-metastatic prostate cancer require standardised and robust long-term prognostic information to help them decide on management. Most currently-used tools use short-term and surrogate outcomes. We explored the evidence base in the literature on available pre-treatment, prognostic models built around long-term survival and assess the accuracy, generalisability and clinical availability of these models. DESIGN Systematic literature review, pre-specified and registered on PROSPERO (CRD42018086394). DATA SOURCES MEDLINE, Embase and The Cochrane Library were searched from January 2000 through February 2018, using previously-tested search terms. ELIGIBILITY CRITERIA Inclusion required a multivariable model prognostic model for non-metastatic prostate cancer, using long-term survival data (defined as ≥5 years), which was not treatment-specific and usable at the point of diagnosis. DATA EXTRACTION AND SYNTHESIS Title, abstract and full-text screening were sequentially performed by three reviewers. Data extraction was performed for items in the CHecklist for critical Appraisal and data extraction for systematic Reviews of prediction Modelling Studies checklist. Individual studies were assessed using the new Prediction model Risk Of Bias ASsessment Tool. RESULTS Database searches yielded 6581 studies after deduplication. Twelve studies were included in the final review. Nine were model development studies using data from over 231 888 men. However, only six of the nine studies included any conservatively managed cases and only three of the nine included treatment as a predictor variable. Every included study had at least one parameter for which there was high risk of bias, with failure to report accuracy, and inadequate reporting of missing data common failings. Three external validation studies were included, reporting two available models: The University of California San Francisco (UCSF) Cancer of the Prostate Risk Assessment score and the Cambridge Prognostic Groups. Neither included treatment effect, and both had potential flaws in design, but represent the most robust and usable prognostic models currently available. CONCLUSION Few long-term prognostic models exist to inform decision-making at diagnosis of non-metastatic prostate cancer. Improved models are required to inform management and avoid undertreatment and overtreatment of non-metastatic prostate cancer.
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Affiliation(s)
- David Thurtle
- Department of Surgery, University of Cambridge, Cambridge, UK
| | - Sabrina H Rossi
- Department of Surgery, University of Cambridge, Cambridge, UK
- Department of Urology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Brendan Berry
- Department of Surgery, University of Cambridge, Cambridge, UK
| | - Paul Pharoah
- Cancer Epidemiology, University of Cambridge, Cambridge, UK
| | - Vincent J Gnanapragasam
- Department of Surgery, University of Cambridge, Cambridge, UK
- Department of Urology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Gnanapragasam VJ, Barrett T, Thankapannair V, Thurtle D, Rubio-Briones J, Domínguez-Escrig J, Bratt O, Statin P, Muir K, Lophatananon A. Using prognosis to guide inclusion criteria, define standardised endpoints and stratify follow-up in active surveillance for prostate cancer. BJU Int 2019; 124:758-767. [PMID: 31063245 DOI: 10.1111/bju.14800] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To test whether using disease prognosis can inform a rational approach to active surveillance (AS) for early prostate cancer. PATIENTS AND METHODS We previously developed the Cambridge Prognostics Groups (CPG) classification, a five-tiered model that uses prostate-specific antigen (PSA), Grade Group and Stage to predict cancer survival outcomes. We applied the CPG model to a UK and a Swedish prostate cancer cohort to test differences in prostate cancer mortality (PCM) in men managed conservatively or by upfront treatment in CPG2 and 3 (which subdivides the intermediate-risk classification) vs CPG1 (low-risk). We then applied the CPG model to a contemporary UK AS cohort, which was optimally characterised at baseline for disease burden, to identify predictors of true prognostic progression. Results were re-tested in an external AS cohort from Spain. RESULTS In a UK cohort (n = 3659) the 10-year PCM was 2.3% in CPG1, 1.5%/3.5% in treated/untreated CPG2, and 1.9%/8.6% in treated/untreated CPG3. In the Swedish cohort (n = 27 942) the10-year PCM was 1.0% in CPG1, 2.2%/2.7% in treated/untreated CPG2, and 6.1%/12.5% in treated/untreated CPG3. We then tested using progression to CPG3 as a hard endpoint in a modern AS cohort (n = 133). During follow-up (median 3.5 years) only 6% (eight of 133) progressed to CPG3. Predictors of progression were a PSA density ≥0.15 ng/mL/mL and CPG2 at diagnosis. Progression occurred in 1%, 8% and 21% of men with neither factor, only one, or both, respectively. In an independent Spanish AS cohort (n = 143) the corresponding rates were 3%, 10% and 14%, respectively. CONCLUSION Using disease prognosis allows a rational approach to inclusion criteria, discontinuation triggers and risk-stratified management in AS.
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Affiliation(s)
- Vincent J Gnanapragasam
- Academic Urology Group, Department of Surgery, University of Cambridge, Cambridge, UK.,Department of Urology, Cambridge University Hospitals NHS Trust, Cambridge, UK.,Cambridge Urology Translational Research and Clinical Trials Cambridge Biomedical Campus, University of Cambridge, Cambridge, UK
| | - Tristan Barrett
- Department of Radiology, University of Cambridge, Cambridge, UK
| | | | - David Thurtle
- Academic Urology Group, Department of Surgery, University of Cambridge, Cambridge, UK
| | | | | | - Ola Bratt
- Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Par Statin
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Kenneth Muir
- Department of Public Health and Epidemiology, University of Manchester, Manchester, UK
| | - Artitaya Lophatananon
- Department of Public Health and Epidemiology, University of Manchester, Manchester, UK
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Mason RJ, Joniau S, Karnes RJ. Defining "High Risk" for Men with Localized Prostate Cancer: How Close Can Clinical Parameters Get Us? Eur Urol Oncol 2019; 1:149-150. [PMID: 31100239 DOI: 10.1016/j.euo.2018.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 04/16/2018] [Indexed: 11/16/2022]
Affiliation(s)
- Ross J Mason
- Department of Urology, Mayo Clinic, Rochester, MN, USA
| | - Steven Joniau
- Department of Urology, University Hospitals Leuven, Leuven, Belgium
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Gnanapragasam VJ, Barrett T, Massie C, Pacey S, Warren A. Using prognosis to guide early detection and treatment selection in non-metastatic prostate cancer. BJU Int 2019; 123:562-563. [PMID: 30499634 DOI: 10.1111/bju.14637] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Vincent J Gnanapragasam
- Translational Prostate Cancer Group, Cancer Research UK (CRUK) Cambridge Cancer Centre, Cambridge, UK
- Academic Urology Group, Department of Surgery, University of Cambridge, Cambridge, UK
- Urological Malignancies Programme, CRUK Cambridge Cancer Centre, Cambridge, UK
| | - Tristan Barrett
- Translational Prostate Cancer Group, Cancer Research UK (CRUK) Cambridge Cancer Centre, Cambridge, UK
- Urological Malignancies Programme, CRUK Cambridge Cancer Centre, Cambridge, UK
- Department of Radiology, University of Cambridge, Cambridge, UK
| | - Charlie Massie
- Translational Prostate Cancer Group, Cancer Research UK (CRUK) Cambridge Cancer Centre, Cambridge, UK
- Urological Malignancies Programme, CRUK Cambridge Cancer Centre, Cambridge, UK
- Early Detection Programme, CRUK Cambridge Cancer Centre, Cambridge, UK
| | - Simon Pacey
- Translational Prostate Cancer Group, Cancer Research UK (CRUK) Cambridge Cancer Centre, Cambridge, UK
- Urological Malignancies Programme, CRUK Cambridge Cancer Centre, Cambridge, UK
- Department of Oncology, University of Cambridge, Cambridge, UK
| | - Anne Warren
- Translational Prostate Cancer Group, Cancer Research UK (CRUK) Cambridge Cancer Centre, Cambridge, UK
- Urological Malignancies Programme, CRUK Cambridge Cancer Centre, Cambridge, UK
- Department of Pathology, Addenbrooke's Hospital, Cambridge, UK
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Thurtle DR, Greenberg DC, Lee LS, Huang HH, Pharoah PD, Gnanapragasam VJ. Individual prognosis at diagnosis in nonmetastatic prostate cancer: Development and external validation of the PREDICT Prostate multivariable model. PLoS Med 2019; 16:e1002758. [PMID: 30860997 PMCID: PMC6413892 DOI: 10.1371/journal.pmed.1002758] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 02/04/2019] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Prognostic stratification is the cornerstone of management in nonmetastatic prostate cancer (PCa). However, existing prognostic models are inadequate-often using treatment outcomes rather than survival, stratifying by broad heterogeneous groups and using heavily treated cohorts. To address this unmet need, we developed an individualised prognostic model that contextualises PCa-specific mortality (PCSM) against other cause mortality, and estimates the impact of treatment on survival. METHODS AND FINDINGS Using records from the United Kingdom National Cancer Registration and Analysis Service (NCRAS), data were collated for 10,089 men diagnosed with nonmetastatic PCa between 2000 and 2010 in Eastern England. Median follow-up was 9.8 years with 3,829 deaths (1,202 PCa specific). Totals of 19.8%, 14.1%, 34.6%, and 31.5% of men underwent conservative management, prostatectomy, radiotherapy (RT), and androgen deprivation monotherapy, respectively. A total of 2,546 men diagnosed in Singapore over a similar time period represented an external validation cohort. Data were randomly split 70:30 into model development and validation cohorts. Fifteen-year PCSM and non-PCa mortality (NPCM) were explored using separate multivariable Cox models within a competing risks framework. Fractional polynomials (FPs) were utilised to fit continuous variables and baseline hazards. Model accuracy was assessed by discrimination and calibration using the Harrell C-index and chi-squared goodness of fit, respectively, within both validation cohorts. A multivariable model estimating individualised 10- and 15-year survival outcomes was constructed combining age, prostate-specific antigen (PSA), histological grade, biopsy core involvement, stage, and primary treatment, which were each independent prognostic factors for PCSM, and age and comorbidity, which were prognostic for NPCM. The model demonstrated good discrimination, with a C-index of 0.84 (95% CI: 0.82-0.86) and 0.84 (95% CI: 0.80-0.87) for 15-year PCSM in the UK and Singapore validation cohorts, respectively, comparing favourably to international risk-stratification criteria. Discrimination was maintained for overall mortality, with C-index 0.77 (95% CI: 0.75-0.78) and 0.76 (95% CI: 0.73-0.78). The model was well calibrated with no significant difference between predicted and observed PCa-specific (p = 0.19) or overall deaths (p = 0.43) in the UK cohort. Key study limitations were a relatively small external validation cohort, an inability to account for delayed changes to treatment beyond 12 months, and an absence of tumour-stage subclassifications. CONCLUSIONS 'PREDICT Prostate' is an individualised multivariable PCa prognostic model built from baseline diagnostic information and the first to our knowledge that models potential treatment benefits on overall survival. Prognostic power is high despite using only routinely collected clinicopathological information.
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Affiliation(s)
- David R. Thurtle
- Academic Urology Group, Department of Surgery, University of Cambridge, Cambridge, United Kingdom
- Department of Urology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
- * E-mail: (DRT); (VJG)
| | - David C. Greenberg
- National Cancer Registration and Analysis Service (Eastern Region), Fulbourn, Cambridge, United Kingdom
| | - Lui S. Lee
- Department of Urology, Singapore General Hospital, Singapore
| | - Hong H. Huang
- Department of Urology, Singapore General Hospital, Singapore
| | - Paul D. Pharoah
- Centre for Cancer Genetic Epidemiology, Department of Oncology, University of Cambridge, Cambridge, United Kingdom
| | - Vincent J. Gnanapragasam
- Academic Urology Group, Department of Surgery, University of Cambridge, Cambridge, United Kingdom
- Department of Urology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
- Cambridge Urology Translational Research and Clinical Trials, Cambridge, United Kingdom
- * E-mail: (DRT); (VJG)
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