Can the Use of Serial Multiparametric Magnetic Resonance Imaging During Active Surveillance of Prostate Cancer Avoid the Need for Prostate Biopsies?—A Systematic Diagnostic Test Accuracy Review

Hettiarachchi, Dinul; Geraghty, Rob; Rice, Patrick; Sachdeva, Ashwin; Nambiar, Arjun; Johnson, Mark; Gujadhur, Rahul; McNeill, Michael; Haslam, Philip; Soomro, Naeem; Hameed, B. M. Zeeshan; Somani, Bhaskar; Veeratterapillay, Rajan; Prasad, Bhavan

doi:10.1016/j.euo.2020.09.002

Cited by 25 publications

(38 citation statements)

References 28 publications

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“…In the recent years, mpMRI and mpMRI-targeted biopsies have been increasingly incorporated into AS protocols; however, their optimal used for patient selection and follow-up are yet to be defined 24 , 26 , 27 . In academic AS cohorts including LR and IR patients and median follow-up 4–6.4 years, mpMRI was either irregularly used 15 , 19 , 28 or it replaced repeat biopsies in AS protocol, which were performed in cases of mpMRI, clinical, or PSA progression 28 .…”

Section: Discussionmentioning

confidence: 99%

No significant difference in intermediate key outcomes in men with low- and intermediate-risk prostate cancer managed by active surveillance

Cyll

Löffeler

Carlsen

et al. 2022

Sci Rep

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Active surveillance (AS) is standard of care for patients with low-risk prostate cancer (PCa), but its feasibility in intermediate-risk patients is controversial. We compared outcomes of low- and intermediate-risk patients managed with multiparametric magnetic resonance imaging (mpMRI)-supported AS in a community hospital. Of the 433 patients enrolled in AS between 2009 and 2016, 358 complied with AS inclusion criteria (Cancer of the Prostate Risk Assessment (CAPRA) score ≤ 5, Gleason grade group (GGG) ≤ 2, clinical stage ≤ cT2 and prostate-specific antigen (PSA) ≤ 20 ng/ml) and discontinuation criteria (histological-, PSA-, clinical- or radiological disease reclassification). Of the 358 patients, 177 (49%) were low-risk and 181 (51%) were intermediate-risk. Median follow-up was 4.2 years. The estimated 5-year treatment-free survival (TFS) was 56% (95% confidence interval [CI] 51–62%). Intermediate-risk patients had significantly shorter TFS compared with low-risk patients (hazard ratio 2.01, 95% CI 1.47–2.76, p < 0.001). There were no statistically significant differences in the rate of adverse pathology, biochemical recurrence-free survival and overall survival between low- and intermediate-risk patients. Two patients developed metastatic disease and three died of PCa. These results suggest that selected patients with intermediate-risk PCa may be safely managed by mpMRI-supported AS, but longer follow-up is necessary.

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Section: Discussionmentioning

confidence: 99%

No significant difference in intermediate key outcomes in men with low- and intermediate-risk prostate cancer managed by active surveillance

Cyll

Löffeler

Carlsen

et al. 2022

Sci Rep

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“…MRI performance characteristics remain uncertain with strikingly different profiles of MRI characteristics in diagnostic 5 and AS specific 9,10 populations demonstrating discordant estimates for test sensitivity and specificity. While we found test characteristics to drive uncertainty in the model, MRI triage remained the most cost-effective modality using data derived from either diagnostic 5 or AS specific 9,10 settings.…”

Section: Discussionmentioning

confidence: 99%

“…Long-term data on outcomes for cancers detected by MRI-targeted vs nontargeted TRUS biopsies will not be available for another decade, and our model relies on recent systematic reviews of test performance, 5,9 assuming that only detection and not progression is impacted. Further, use of MRI in diagnosis likely will change AS population risk profiles; fortunately, our model was not sensitive to the proportion of men misclassified on initial diagnosis.…”

Section: Discussionmentioning

confidence: 99%

Cost-Effectiveness Analysis and Microsimulation of Serial Multiparametric Magnetic Resonance Imaging in Active Surveillance of Localized Prostate Cancer

et al. 2022

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Purpose:Many localized prostate cancers will follow an indolent course. Management has shifted toward active surveillance (AS), yet an optimal regimen remains controversial especially regarding expensive multiparametric magnetic resonance imaging (MRI). We aimed to assess cost-effectiveness of MRI in AS protocols.Materials and Methods:A probabilistic microsimulation modeled individual patient trajectories for men diagnosed with low-risk cancer. We assessed no surveillance, up-front treatment (surgery or radiation), and scheduled AS protocols incorporating transrectal ultrasound-guided (TRUS) biopsy or MRI based regimens at serial intervals. Lifetime quality-adjusted life-years and costs adjusted to 2020 US$ were used to calculate expected net monetary benefit at $50,000/quality-adjusted life-year and incremental cost-effectiveness ratios. Uncertainty was assessed with probabilistic sensitivity analysis and linear regression metamodeling.Results:Conservative management with AS outperformed up-front definitive treatment in a modeled cohort reflecting characteristics from a multi-institutional trial. Biopsy decision conditional on positive imaging (MRI triage) at 2-year intervals provided the highest expected net monetary benefit (incremental cost-effectiveness ratio $44,576). Biopsy after both positive and negative imaging (MRI pathway) and TRUS biopsy based regimens were not cost-effective. MRI triage resulted in fewer biopsies while reducing metastatic disease or cancer death. Results were sensitive to test performance and cost. MRI triage was the most likely cost-effective strategy on probabilistic sensitivity analysis.Conclusions:For men with low-risk prostate cancer, our modeling demonstrated that AS with sequential MRI triage is more cost-effective than biopsy regardless of imaging, TRUS biopsy alone or immediate treatment. AS guidelines should specify the role of imaging, and prospective studies should be encouraged.

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“…Indeed, it was estimated that the adherence rate for prostate biopsies decreases over time (81%, 60%, 53% and 33% at 1, 4, 7 and 10 years, respectively) [2]. mpMRI has been proposed as an alternative for monitoring PCa progression [5,6]. However, conflicting results have previously been observed in several AS cohorts that investigated the reliability of repeat mpMRI over time [7][8][9][10][11][12][13][14][15][16][17].…”

Section: Discussionmentioning

confidence: 99%

“…To reduce the frequency of prostate samplings while simultaneously increasing patient adherence, multiparametric MRI (mpMRI) has been implemented in several AS series [4]. However, it remains unclear whether mpMRI can safely replace repeat biopsies during follow-up [5,6]. To date, conflicting results have been reported in previous analyses that assessed the diagnostic accuracy of serial mpMRI scans in men on AS [7][8][9][10][11][12][13][14][15][16][17].…”

Section: Introductionmentioning

confidence: 99%

Repeat MRI during active surveillance: natural history of prostatic lesions and upgrading rates

et al. 2021

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Objectives To assess upgrading rates in patients on active surveillance (AS) for prostate cancer (PCa) after serial multiparametric magnetic resonance imaging (mpMRI). Methods We conducted a retrospective analysis of 558 patients. Five different criteria for mpMRI progression were used: 1) a Prostate Imaging Reporting and Data System (PI‐RADS) score increase; 2) a lesion size increase; 3) an extraprostatic extension score increase; 4) overall mpMRI progression; and 5) the number of criteria met for mpMRI progression (0 vs 1 vs 2–3). In addition, two definitions of PCa upgrading were evaluated: 1) International Society of Urological Pathology Grade Group (ISUP GG) ≥2 with >10% of pattern 4 and 2) ISUP GG ≥ 3. Estimated annual percent changes methodology was used to show the temporal trends of mpMRI progression criteria. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of mpMRI progression criteria were also analysed. Multivariable logistic regression models tested PCa upgrading rates. Results Lower rates over time for all mpMRI progression criteria were observed. The NPV of serial mpMRI scans ranged from 90.5% to 93.5% (ISUP GG≥2 with >10% of pattern 4 PCa upgrading) and from 98% to 99% (ISUP GG≥3 PCa upgrading), depending on the criteria used for mpMRI progression. A prostate‐specific antigen density (PSAD) threshold of 0.15 ng/mL/mL was used to substratify those patients who would be able to skip a prostate biopsy. In multivariable logistic regression models assessing PCa upgrading rates, all five mpMRI progression criteria achieved independent predictor status. Conclusion During AS, approximately 27% of patients experience mpMRI progression at first repeat MRI. However, the rates of mpMRI progression decrease over time at subsequent mpMRI scans. Patients with stable mpMRI findings and with PSAD < 0.15 ng/mL/mL could safely skip surveillance biopsies. Conversely, patients who experience mpMRI progression should undergo a prostate biopsy.

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Can the Use of Serial Multiparametric Magnetic Resonance Imaging During Active Surveillance of Prostate Cancer Avoid the Need for Prostate Biopsies?—A Systematic Diagnostic Test Accuracy Review

Cited by 25 publications

References 28 publications

No significant difference in intermediate key outcomes in men with low- and intermediate-risk prostate cancer managed by active surveillance

No significant difference in intermediate key outcomes in men with low- and intermediate-risk prostate cancer managed by active surveillance

Cost-Effectiveness Analysis and Microsimulation of Serial Multiparametric Magnetic Resonance Imaging in Active Surveillance of Localized Prostate Cancer

Repeat MRI during active surveillance: natural history of prostatic lesions and upgrading rates

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