TY - JOUR
T1 - Five-year Outcomes of Magnetic Resonance Imaging–based Active Surveillance for Prostate Cancer
T2 - A Large Cohort Study[Formula presented]
AU - Stavrinides, Vasilis
AU - Giganti, Francesco
AU - Trock, Bruce
AU - Punwani, Shonit
AU - Allen, Clare
AU - Kirkham, Alex
AU - Freeman, Alex
AU - Haider, Aiman
AU - Ball, Rhys
AU - McCartan, Neil
AU - Whitaker, Hayley
AU - Orczyk, Clement
AU - Emberton, Mark
AU - Moore, Caroline M.
N1 - Publisher Copyright:
© 2020 The Authors
PY - 2020/9
Y1 - 2020/9
N2 - Background: Although the use of multiparametric magnetic resonance imaging (mpMRI) in active surveillance (AS) for prostate cancer is of increasing interest, existing data are derived from small cohorts. Objective: We describe clinical, histological, and radiological outcomes from an established AS programme, where protocol-based biopsies were omitted in favour of MRI-led monitoring. Design, setting, and participants: Data on 672 men enrolled in AS between August 2004 and November 2017 (inclusion criteria: Gleason 3 + 3 or 3 + 4 localised prostate cancer, presenting prostate-specific antigen <20 ng/ml, and baseline mpMRI) were collected from the University College London Hospital (UCLH) database. Outcome measurements and statistical analysis: Primary outcomes were event-free survival (EFS; event defined as prostate cancer treatment, transition to watchful waiting, or death) and treatment-free survival (TFS). Secondary outcomes included rates of all-cause or prostate cancer–related mortality, metastasis, and upgrading to Gleason ≥4 + 3. Data on radiological and histological progression were also collected. Results and limitations: More than 3800 person-years (py) of follow-up were accrued (median: 58 mo; interquartile range 37–82 mo). Approximately 84.7% (95% confidence interval [CI]: 82.0–87.6) and 71.8% (95% CI: 68.2–75.6) of patients remained on AS at 3 and 5 yr, respectively. EFS and TFS were lower in those with MRI-visible (Likert 4–5) disease or secondary Gleason pattern 4 at baseline (log-rank test; p < 0.001). In total, 216 men were treated. There were 24 deaths, none of which was prostate cancer related (6.3/1000 py; 95% CI: 4.1–9.5). Metastases developed in eight men (2.1 events/1000 py; 95% CI: 1.0–4.3), whereas 27 men upgraded to Gleason ≥4 + 3 on follow-up biopsy (7.7 events/1000 py; 95% CI: 5.2–11.3). Conclusions: The rates of discontinuation, mortality, and metastasis in MRI-led surveillance are comparable with those of standard AS. MRI-visible disease and/or secondary Gleason grade 4 at baseline are associated with a greater likelihood of moving to active treatment at 5 yr. Further research will concentrate on optimising imaging intervals according to baseline risk. Patient summary: In this report, we looked at the outcomes of magnetic resonance imaging (MRI)-based surveillance for prostate cancer in a UK cohort. We found that this strategy could allow routine biopsies to be avoided. Secondary Gleason pattern 4 and MRI visibility are associated with increased rates of treatment. We conclude that MRI-based surveillance should be considered for the monitoring of small prostate tumours. We report excellent clinical outcomes from one of the largest imaging-based active surveillance cohorts to date. Magnetic resonance imaging (MRI)-visible cancer at baseline, along with 3 + 4 Gleason grade, predicts a greater likelihood of treatment at five years. MRI-visible lesions appear to have a distinct clinical trajectory from less conspicuous ones.
AB - Background: Although the use of multiparametric magnetic resonance imaging (mpMRI) in active surveillance (AS) for prostate cancer is of increasing interest, existing data are derived from small cohorts. Objective: We describe clinical, histological, and radiological outcomes from an established AS programme, where protocol-based biopsies were omitted in favour of MRI-led monitoring. Design, setting, and participants: Data on 672 men enrolled in AS between August 2004 and November 2017 (inclusion criteria: Gleason 3 + 3 or 3 + 4 localised prostate cancer, presenting prostate-specific antigen <20 ng/ml, and baseline mpMRI) were collected from the University College London Hospital (UCLH) database. Outcome measurements and statistical analysis: Primary outcomes were event-free survival (EFS; event defined as prostate cancer treatment, transition to watchful waiting, or death) and treatment-free survival (TFS). Secondary outcomes included rates of all-cause or prostate cancer–related mortality, metastasis, and upgrading to Gleason ≥4 + 3. Data on radiological and histological progression were also collected. Results and limitations: More than 3800 person-years (py) of follow-up were accrued (median: 58 mo; interquartile range 37–82 mo). Approximately 84.7% (95% confidence interval [CI]: 82.0–87.6) and 71.8% (95% CI: 68.2–75.6) of patients remained on AS at 3 and 5 yr, respectively. EFS and TFS were lower in those with MRI-visible (Likert 4–5) disease or secondary Gleason pattern 4 at baseline (log-rank test; p < 0.001). In total, 216 men were treated. There were 24 deaths, none of which was prostate cancer related (6.3/1000 py; 95% CI: 4.1–9.5). Metastases developed in eight men (2.1 events/1000 py; 95% CI: 1.0–4.3), whereas 27 men upgraded to Gleason ≥4 + 3 on follow-up biopsy (7.7 events/1000 py; 95% CI: 5.2–11.3). Conclusions: The rates of discontinuation, mortality, and metastasis in MRI-led surveillance are comparable with those of standard AS. MRI-visible disease and/or secondary Gleason grade 4 at baseline are associated with a greater likelihood of moving to active treatment at 5 yr. Further research will concentrate on optimising imaging intervals according to baseline risk. Patient summary: In this report, we looked at the outcomes of magnetic resonance imaging (MRI)-based surveillance for prostate cancer in a UK cohort. We found that this strategy could allow routine biopsies to be avoided. Secondary Gleason pattern 4 and MRI visibility are associated with increased rates of treatment. We conclude that MRI-based surveillance should be considered for the monitoring of small prostate tumours. We report excellent clinical outcomes from one of the largest imaging-based active surveillance cohorts to date. Magnetic resonance imaging (MRI)-visible cancer at baseline, along with 3 + 4 Gleason grade, predicts a greater likelihood of treatment at five years. MRI-visible lesions appear to have a distinct clinical trajectory from less conspicuous ones.
KW - Active surveillance
KW - Magnetic resonance imaging
KW - Prostate cancer
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U2 - 10.1016/j.eururo.2020.03.035
DO - 10.1016/j.eururo.2020.03.035
M3 - Article
C2 - 32360049
AN - SCOPUS:85084093542
SN - 0302-2838
VL - 78
SP - 443
EP - 451
JO - European Urology
JF - European Urology
IS - 3
ER -