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AUA 2020

AUA 2020: Does Inclusion of MRI in Active Surveillance Decrease The Rate Of Discontinuation? A Reflection Of The Use of MRI in the PRIAS Study

(UroToday.com) Active surveillance aims to reduce overtreatment in patients with low-risk prostate cancer and has, as initial treatment, excellent prostate cancer-specific survival.1-2 The reduction of overtreatment is, however, limited due to a high rate of discontinuation.3 Magnetic resonance imaging (MRI) enables a more accurate sampling of prostate cancer, and the use of MRI before inclusion in active surveillance should, therefore, reduce lead to less discontinuation of active surveillance. Furthermore, the use of MRI in active surveillance algorithms is strongly supported by the European Association of Urology.4  At the American Urological Association (AUA) 2020 virtual annual meeting, Dr. Monique Roobol and colleagues presented results of their study comparing the rate of active surveillance discontinuation of men included with and without MRI information at inclusion. 

The PRIAS study, Prostate Cancer Research International Active Surveillance (PRIAS), is a prospective observational study, providing data of real-life clinical practice. Patients with Grade Group 1 prostate cancer, included in the PRIAS study before the MRI era (Group A, n=500), included with an MRI within 6 months after inclusion (Group B, n = 248) and included with an MRI before inclusion (Group C, n = 250) were analyzed. The PRIAS MRI protocol advises MRI with possible target biopsies three months after inclusion if MRI is not performed before inclusion, and at 1 year after inclusion with repeat systematic biopsies. Before the MRI era, systematic biopsies were advised one year after inclusion. Definite treatment in the PRIAS MRI protocol was advised if biopsies showed Grade Group ≥ 2, and for patients before the MRI era if >2 systematic biopsies cores showed prostate cancer or if systematic biopsies show Grade Group ≥ 2. Cumulative incidence curves were used to estimate rates of active surveillance discontinuation. 

In Group B, MRI showed a PIRADS 3, 4 or 5 lesion in 49 (20%), 72 (29%), and 31 (13%) patients, respectively, and in Group C in 58 (23%), 107 (42%), and 20 (8%) patients, respectively. At 15 months, 26% discontinued active surveillance in Group A (21% due to progression), 28% in Group B (22% due to progression, 11% based solely on target biopsies) and 14% in Group C (7% due to progression, 2% based solely on target biopsies):

AUA2020__Roobol_1.png

The median follow-up in Group A was 45 months (IQR 15-85), 14 months (IQR 7-25) in Group B, and 15 months (IQR 8-30) in Group C. 

Dr. Roobol concluded her presentation with the following take-home messages:

  • The use of MRI before inclusion in active surveillance reduces the rate of discontinuation after a period of 15 months from 26-28% to 14%
  • It is however impressive that the reason of discontinuation is still in 50% of the cases related to progression
  • Considering the current excellent prostate cancer-survival data in patients initially treated with active surveillance, the question raises whether upfront MRI excludes patients potentially suitable for active surveillance and as such actually contributes to overtreatment

 

Presented by: Monique Roobol, Ph.D., MSc, Professor, Erasmus University Medical Center Rotterdam, The Netherlands, 

Co-Authors: Henk Luiting, Sebastiaan Remmers, Egbert Boevé, Fabio Badenchini, Fabiana Zollo, Antti Rannikko

Written by: Zachary Klaassen, MD, MSc – Assistant Professor of Urology, Georgia Cancer Center, Augusta University/Medical College of Georgia, twitter: @zklaassen_md at the 2020 American Urological Association (AUA) Annual Meeting, Virtual Experience #AUA20, June 27- 28, 2020

References:
1. Klotz L, Vesprini D, Sethukavalan P, et al. Long-term follow-up of a large active surveillance cohort of patients with prostate cancer. J Clin Oncol 2015;33(3):272-277.
2. Bokhorst LP, Valdagni R, Rannikko A, et al. A Decade of Active Surveillance in the PRIAS Study: An Update and Evaluation of the Criteria Used to Recommend a Switch to Active Treatment. Eur Urol 2016 12;70(6):954-960.
3. Drost FJH, Rannikko A, Valdagni R, et al. Can Active Surveillance Really Reduce the Harms of Overdiagnosing Prostate Cancer? A Reflection of Real Life Clinical Practice in the PRIAS Study. Trans Androl Urol 2018 Feb;7(1):98-105.
4. Briganti A, Fossati N, Catto JWF, et al. Active surveillance for low-risk prostate cancer: The European Association of Urology Position in 2018. Eur Urol 2018 Sep;74(3):357-368.