Role of Surveillance Biopsy with No Cancer as a Prognostic Marker for Reclassification: Results from the Canary Prostate Active Surveillance Study

Development and validation of a model for predicting the risk of prostate cancer

BACKGROUND

Abnormal hematologic parameters before patients undergoing prostate biopsy play a pivotal role in guiding the surgical management of prostate cancer (PCa) incidence. This study aims to establish the first nomogram for predicting PCa risk for better surgical management.

METHODS

We retrospectively reviewed and analyzed the data including basic information, preoperative hematologic parameters, and imaging examination of 540 consecutive patients who underwent transrectal ultrasound (TRUS)-guided prostate biopsy for elevated prostate-specific antigen (PSA) in our medical center between 2017 and 2021. Logistic regression analysis was used to determine the risk factors for PCa occurrence, and the nomogram was constructed to predict PCa occurrence. Finally, the data including 121 consecutive patients in 2022 were prospectively collected to further verify the results.

RESULTS

In retrospective analyses, univariate and multivariate logistic analyses identified that three variables including age, diabetes, and De Ritis ratio (aspartate transaminase/alanine transaminase, AST/ALT) were determined to be significantly associated with PCa occurrence. A nomogram was constructed based on these variables for predicting the risk of PCa, and a satisfied predictive accuracy of the model was determined with a C-index of 0.765, supported by a prospective validation group with a C-index of 0.736. The Decision curve analysis showed promising clinical application. In addition, our results also showed that the De Ritis ratio was significantly correlated with the clinical stage of PCa patients, including T, N, and M stages, but insignificantly related to the Gleason score.

CONCLUSIONS

The increased De Ritis ratio was significantly associated with the risk and clinical stage of PCa and this nomogram with good discrimination could effectively improve individualized surgical management for patient underdoing prostate biopsy.

Is Active Surveillance Too Active?

PURPOSE OF REVIEW

Many prostate cancer active surveillance protocols mandate serial monitoring at defined intervals, including but certainly not limited to serum PSA (often every 6 months), clinic visits, prostate multiparametric MRI, and repeat prostate biopsies. The purpose of this article is to evaluate whether current protocols result in excessive testing of patients on active surveillance.

RECENT FINDINGS

Multiple studies have been published in the past several years evaluating the utility of multiparametric MRI, serum biomarkers, and serial prostate biopsy for men on active surveillance. While MRI and serum biomarkers have promise with risk stratification, no studies have demonstrated that periodic prostate biopsy can be safely omitted in active surveillance. Active surveillance for prostate cancer is too active for some men with seemingly low-risk cancer. The use of multiple prostate MRIs or additional biomarkers do not always add to the prediction of higher-grade disease on surveillance biopsy.

Impact of a negative confirmatory biopsy on risk of disease progression among men on active surveillance for prostate cancer

OBJECTIVE

Most prostate cancer active surveillance (AS) protocols suggest a confirmatory biopsy within 12 to 18 months of diagnosis to mitigate the risk of unsampled high-grade disease. We investigate whether the results of confirmatory biopsy impact AS outcomes and could be used to tailor surveillance intensity.

METHODS

We retrospectively reviewed our institutional database of prostate cancer patients managed by AS from 1997 to 2019 who underwent confirmatory biopsy and ≥3 biopsies overall. Biopsy progression was defined as either an increase in grade group or an increase in the proportion of positive biopsy cores to >34% and was compared between patients with a negative vs positive confirmatory biopsy using the Kaplan-Meier method and Cox proportional hazards regression.

RESULTS

We identified 452 patients meeting inclusion criteria for this analysis, of whom 169 (37%) had a negative confirmatory biopsy. With a median follow-up of 6.8 years, 37% of patients progressed to treatment, most commonly due to biopsy progression. A negative confirmatory biopsy was significantly associated with biopsy progression-free survival in multivariable analysis (HR 0.54, 95% CI 0.34-0.88, P = 0.013), adjusting for known clinical and pathologic factors, including use of mpMRI prior to confirmatory biopsy. Negative confirmatory biopsy was also associated with an increased risk of adverse pathologic features at prostatectomy but not with biochemical recurrence among men who ultimately underwent definitive treatment.

CONCLUSIONS

A negative confirmatory biopsy is associated with a lower risk of biopsy progression. While the increased risk of adverse pathology at time of definitive treatment sounds a small cautionary note regarding decreasing surveillance intensity, the majority of such patients have a favorable outcome on AS.

Risk of progression following a negative biopsy in prostate cancer active surveillance

BACKGROUND

Currently, follow-up protocols are applied equally to men on active surveillance (AS) for prostate cancer (PCa) regardless of findings at their initial follow-up biopsy. To determine whether less intensive follow-up is suitable following negative biopsy findings, we assessed the risk of converting to active treatment, any subsequent upgrading, volume progression (>33% positive cores), and serious upgrading (grade group >2) for negative compared with positive findings on initial follow-up biopsy.

METHODS

13,161 men from 24 centres participating in the Global Action Plan Active Surveillance Prostate Cancer [GAP3] consortium database, with baseline grade group ≤2, PSA ≤ 20 ng/mL, cT-stage 1-2, diagnosed after 1995, and ≥1 follow-up biopsy, were included in this study. Risk of converting to treatment was assessed using multivariable mixed-effects survival regression. Odds of volume progression, any upgrading and serious upgrading were assessed using mix-effects binary logistic regression for men with ≥2 surveillance biopsies.

RESULTS

27% of the cohort (n = 3590) had no evidence of PCa at their initial biopsy. Over 50% of subsequent biopsies in this group were also negative. A negative initial biopsy was associated with lower risk of conversion (adjusted hazard ratio: 0.45; 95% confidence interval [CI]: 0.42-0.49), subsequent upgrading (adjusted odds ratio [OR]: 0.52; 95%CI: 0.45-0.62) and serious upgrading (OR: 0.74; 95%CI: 0.59-92). Radiological progression was not assessed due to limited imaging data.

CONCLUSION

Despite heterogeneity in follow-up schedules, findings from this global study indicated reduced risk of converting to treatment, volume progression, any upgrading and serious upgrading among men whose initial biopsy findings were negative compared with positive. Given the low risk of progression and high likelihood of further negative biopsy findings, consideration should be given to decreasing follow-up intensity for this group to reduce unnecessary invasive biopsies.

Association between previous negative biopsies and lower rates of progression during active surveillance for prostate cancer

Purpose

To test any-cause discontinuation and ISUP GG upgrading rates during Active Surveillance (AS) in patients that underwent previous negative biopsies (PNBs) before prostate cancer (PCa) diagnosis vs. biopsy naive patients.

Methods

Retrospective analysis of 961 AS patients (2008–2020). Three definitions of PNBs were used: (1) PNBs status (biopsy naïve vs. PNBs); (2) number of PNBs (0 vs. 1 vs. ≥ 2); (3) histology at last PNB (no vs. negative vs. HGPIN/ASAP). Kaplan–Meier plots and multivariable Cox models tested any-cause and ISUP GG upgrading discontinuation rates.

Results

Overall, 760 (79.1%) vs. 201 (20.9%) patients were biopsy naïve vs. PNBs. Specifically, 760 (79.1%) vs. 138 (14.4%) vs. 63 (6.5%) patients had 0 vs. 1 vs. ≥ 2 PNBs. Last, 760 (79.1%) vs. 134 (13.9%) vs. 67 (7%) patients had no vs. negative PNB vs. HGPIN/ASAP. PNBs were not associated with any-cause discontinuation rates. Conversely, PNBs were associated with lower rates of ISUP GG upgrading: (1) PNBs vs. biopsy naïve (HR:0.6, p = 0.04); (2) 1 vs. 0 PNBs (HR:0.6, p = 0.1) and 2 vs. 0 PNBs, (HR:0.5, p = 0.1); (3) negative PNB vs. biopsy naïve (HR:0.7, p = 0.3) and HGPIN/ASAP vs. biopsy naïve (HR:0.4, p = 0.04). However, last PNB ≤ 18 months (HR:0.4, p = 0.02), but not last PNB > 18 months (HR:0.8, p = 0.5) were associated with lower rates of ISUP GG upgrading.

Conclusion

PNBs status is associated with lower rates of ISUP GG upgrading during AS for PCa. The number of PNBs and time from last PNB to PCa diagnosis (≤ 18 months) appear also to be critical for patient selection.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00345-022-03983-8.

Treatment in the absence of disease reclassification among men on active surveillance for prostate cancer

BACKGROUND

Maintaining men on active surveillance for prostate cancer can be challenging. Although most men who eventually undergo treatment have experienced clinical progression, a smaller subset elects treatment in the absence of disease reclassification. This study sought to understand factors associated with treatment in a large, contemporary, prospective cohort.

METHODS

This study identified 1789 men in the Canary Prostate Cancer Active Surveillance Study cohort enrolled as of 2020 with a median follow-up of 5.6 years. Clinical and demographic data as well as information on patient-reported quality of life and urinary symptoms were used in multivariable Cox proportional hazards regression models to identify factors associated with the time to treatment RESULTS: Within 4 years of their diagnosis, 33% of men (95% confidence interval [CI], 30%-35%) underwent treatment, and 10% (95% CI, 9%-12%) were treated in the absence of reclassification. The most significant factor associated with any treatment was an increasing Gleason grade group (adjusted hazard ratio [aHR], 14.5; 95% CI, 11.7-17.9). Urinary quality-of-life scores were associated with treatment without reclassification (aHR comparing "mostly dissatisfied/terrible" with "pleased/mixed," 2.65; 95% CI, 1.54-4.59). In a subset analysis (n = 692), married men, compared with single men, were more likely to undergo treatment in the absence of reclassification (aHR, 2.63; 95% CI, 1.04-6.66).

CONCLUSIONS

A substantial number of men with prostate cancer undergo treatment in the absence of clinical changes in their cancers, and quality-of-life changes and marital status may be important factors in these decisions.

LAY SUMMARY

This analysis of men on active surveillance for prostate cancer shows that approximately 1 in 10 men will decide to be treated within 4 years of their diagnosis even if their cancer is stable. These choices may be related in part to quality-or-life or spousal concerns.

Reliability of Serial Prostate Magnetic Resonance Imaging to Detect Prostate Cancer Progression During Active Surveillance: A Systematic Review and Meta-analysis

CONTEXT

Although magnetic resonance imaging (MRI) is broadly implemented into active surveillance (AS) protocols, data on the reliability of serial MRI in order to help guide follow-up biopsy are inconclusive.

OBJECTIVE

To assess the diagnostic estimates of serial prostate MRI for prostate cancer (PCa) progression during AS.

EVIDENCE ACQUISITION

We systematically searched PubMed, Scopus, and Web of Science databases to select studies analyzing the association between changes on serial prostate MRI and PCa progression during AS. We included studies that provided data for MRI progression, which allowed us to calculate diagnostic estimates. We compared Prostate Cancer Radiological Estimation of Change in Sequential Evaluation (PRECISE) accuracy with institution-specific definitions.

EVIDENCE SYNTHESIS

We included 15 studies with 2240 patients. Six used PRECISE criteria and nine institution-specific definitions of MRI progression. The pooled PCa progression rate, which included histological progression to Gleason grade ≥2, was 27%. The pooled sensitivity and specificity were 0.59 (95% confidence interval [CI] 0.44-0.73) and 0.75 (95% CI 0.66-0.84) respectively. There was significant heterogeneity between included studies. Depending on PCa progression prevalence, the pooled negative predictive value for serial prostate MRI ranged from 0.81 (95% CI 0.73-0.88) to 0.88 (95% CI 0.83-0.93) and the pooled positive predictive value ranged from 0.37 (95% CI 0.24-0.54) to 0.50 (95% CI 0.36-0.66). There were no significant differences in the pooled sensitivity (p = 0.37) and specificity (p = 0.74) of PRECISE and institution-specific schemes.

CONCLUSIONS

Serial MRI still should not be considered a sole factor for excluding PCa progression during AS, and changes on MRI are not accurate enough to indicate PCa progression. There was a nonsignificant trend toward improved diagnostic estimates of PRECISE recommendations. These findings highlight the need to further define the optimal triggers and timing of biopsy during AS, as well as the need for optimizing the quality, interpretation, and reporting of serial prostate MRI.

PATIENT SUMMARY

Our study suggests that serial prostate magnetic resonance imaging (MRI) alone in patients on active surveillance is not accurate enough to reliably rule out or rule in prostate cancer progression. Other clinical factors and biomarkers along with serial MRI are required to safely tailor the intensity of follow-up biopsies.

Active surveillance for prostate cancer: selection criteria, guidelines, and outcomes

INTRODUCTION

Active surveillance (AS) has been widely adopted for the management of men with low-risk prostate cancer. However, there is still a lack of consensus surrounding the optimal approach for monitoring men in AS protocols. While conservative management aims to reduce the burden of invasive testing without compromising oncological safety, inadequate assessment can result in misclassification and unintended over- or undertreatment, leading to increased patient morbidity, cost, and undue risk. No universally accepted AS protocol exists, although numerous strategies have been developed in an attempt to optimize the management of clinically localized disease. Variability in selection criteria, reclassification, triggers for definitive treatment, and follow-up exists between guidelines and institutions for AS. In this review, we summarize the landscape of AS by providing an overview of the existing AS protocols, guidelines, and their published outcomes.

METHODS

A comprehensive electronic search was performed to identify representative studies and guidelines pertaining to AS selection criteria and outcomes.

CONCLUSION

While AS is a safe and increasingly utilized treatment modality for lower-risk forms of PCa, ongoing research is needed to optimize patient selection as well as surveillance protocols along with improved implementation across practices. Further, assessment of companion risk assessment tools, such as mpMRI and tissue-based biomarkers, is also needed and will require rigorous prospective study.

Negative first follow-up prostate biopsy on active surveillance is associated with decreased risk of upgrading, suspicion of progression and converting to active treatment

OBJECTIVE

To determine the risk of disease progression and conversion to active treatment following a negative biopsy while on active surveillance (AS) for prostate cancer (PCa).

PATIENTS AND METHODS

Men on an AS programme at a single tertiary hospital (London, UK) between 2003 and 2018 with confirmed low-intermediate-risk PCa, Gleason Grade Group <3, clinical stage <T3 and a diagnostic prostate-specific antigen (PSA) level of <20 ng/mL. This cohort included men diagnosed by transrectal ultrasonography guided (12-14 cores) or transperineal (median 32 cores) biopsy. Multivariate Cox hazards regression analysis was undertaken to determine (i) risk of upgrading, (ii) clinical or radiological suspicion of disease progression, and (iii) transitioning to active treatment. Suspicion of disease progression was defined as any biopsy upgrading, >30% positive cores, magnetic resonance imaging (MRI) Likert score >3/T3 or PSA level of >20 ng/mL. Conversion to treatment included radical or hormonal treatment.

RESULTS

Among the 460 eligible patients, 23% had negative follow-up biopsy findings. The median follow-up was 62 months, with one to two repeat biopsies and two MRIs per patient during that period. Negative biopsy findings at first repeat biopsy were associated with decreased risk of converting to active treatment (hazard ration [HR] 0.18, 95% confidence interval [CI] 0.09-0.37; P < 0.001), suspicion of disease progression (HR 0.56, 95% CI: 0.34-0.94; P = 0.029), and upgrading (HR 0.48, 95% CI 0.23-0.99; P = 0.047). Data are limited by fewer men with multiple follow-up biopsies.

CONCLUSION

A negative biopsy finding at the first scheduled follow-up biopsy among men on AS for PCa was strongly associated with decreased risk of subsequent upgrading, clinical or radiological suspicion of disease progression, and conversion to active treatment. A less intense surveillance protocol should be considered for this cohort of patients.

Confirmatory multiparametric magnetic resonance imaging at recruitment confers prolonged stay in active surveillance and decreases the rate of upgrading at follow-up

BACKGROUND

To understand the value of multiparametric magnetic resonance imaging (mpMRI) and targeted biopsies at recruitment on active surveillance (AS) outcomes.

MATERIALS AND METHODS

This retrospective single-center study enrolled two cohorts of 206 and 310 patients in AS. The latter group was submitted to mpMRI and targeted biopsies at recruitment. Kaplan-meier curves quantified progression-free survival (PFS) and Bioptic-PFS (B-PFS: no upgrading or >3 positive cores) in the two cohorts. Cox-regression analyses tested independent predictors of PFS and B-PFS. In patients submitted to radical prostatectomy (RP) after AS, significant cancer (csPCa) was defined as: GS ≥ 4 + 3 and/or pT ≥ 3a and/or pN+ . Logistic-regression analyses predicted csPCa at RP.

RESULTS AND LIMITATIONS

Median time follow-up and median time of persistence in AS were 46 (24-70) and 36 (23-58) months, respectively. Patients submitted to mpMRI at AS begin, showed greater PFS at 1- (98% vs. 91%), 3- (80% vs. 57%), and 5-years (70% vs. 35%) follow-up, respectively (all p < 0.01). At Cox-regression analysis only confirmatory mpMRI± targeted biopsy (HR: 0.3; 95% CI 0.2-0.5; p < 0.01) at AS begin was an independent predictor of PFS. Globally, 50 (16%) vs. 128 (62%) and 26 (8.5%) vs. 64 (31%) [all p < 0.01] men in the two groups experienced any-cause and bioptic AS discontinuation, respectively. Patients submitted to confirmatory mpMRI experienced greater 1-(98% vs. 93%), 3-(90% vs. 75%), and 5-years (83% vs. 56%) B-PFS, respectively (all p < 0.01). At Cox-regression analysis, mpMRI±-targeted biopsy at AS begin was associated with B-PFS (HR: 0.3; 95% CI 0.2-0.6; p < 0.01). No differences were recorded in csPCa rates between the two groups (22% vs. 28%; p = 0.47). Limitations of the study are the single-center retrospective nature and the absence of long-term follow-up.

CONCLUSIONS

Confirmatory mpMRI±-targeted biopsies are associated with higher PFS and B-PFS during AS. However, a non-negligible percentage of patients experience csPCa after switching to active treatment.

Cumulative Cancer Locations is a Novel Metric for Predicting Active Surveillance Outcomes: A Multicenter Study

BACKGROUND

Active surveillance (AS) of prostate cancer (PC) has increased in popularity to address overtreatment.

OBJECTIVE

To determine whether a novel metric, cumulative cancer locations (CCLO), can predict AS outcomes in a group of AS patients with low and very low risk.

DESIGN, SETTING, AND PARTICIPANTS

CCLO is obtained by summing the total number of histological cancer-positive locations in both diagnostic and confirmatory biopsies (Bx). The retrospective study cohort comprised three prospective AS cohorts (Helsinki University Hospital: n=316; European Institute of Oncology: n=204; and University of Münster: n=89).

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

We analyzed whether risk stratification based on CCLO predicts different AS outcomes: protocol-based discontinuation (PBD), Gleason upgrading (GU) during AS, and adverse findings in radical prostatectomy (RP) specimens.

RESULTS

In Kaplan Meier analyses, patients in the CCLO high-risk group experienced significantly shorter event-free survival for all outcomes (PBD, GU, and adverse RP findings; all p<0.002). In multivariable Cox regression analysis, patients in the CCLO high-risk group had a significantly higher risk of experiencing PBD (hazard ratio [HR] 12.15, 95% confidence interval [CI] 6.18-23.9; p<0.001), GU (HR 6.01, 95% CI 2.16-16.8; p=0.002), and adverse RP findings (HR 9.144, 95% CI 2.27-36.9; p=0.006). In receiver operating characteristic analyses, the area under the curve for CCLO outperformed the number of cancer-positive Bxs in confirmatory Bx in predicting PBD (0.734 vs 0.682), GU (0.655 vs 0.576) and adverse RP findings (0.662 vs 0.561) and the added value was supported by decision curve analysis.

CONCLUSIONS

CCLO is distinct from the number of positive Bx cores. Higher CCLO predicts AS outcomes and may aid in selection of patients for AS.

PATIENT SUMMARY

For patients on active surveillance for prostate cancer, the cumulative number of cancer-positive locations in diagnostic and confirmatory biopsies is a predictor of active surveillance outcomes.

Predicting Gleason Group Progression for Men on Prostate Cancer Active Surveillance: Role of a Negative Confirmatory Magnetic Resonance Imaging-Ultrasound Fusion Biopsy

PURPOSE

Active surveillance has gained acceptance as an alternative to definitive therapy in many men with prostate cancer. Confirmatory biopsies to assess the appropriateness of active surveillance are routinely performed and negative biopsies are regarded as a favorable prognostic indicator. We sought to determine the prognostic implications of negative multiparametric magnetic resonance imaging-transrectal ultrasound guided fusion biopsy consisting of extended sextant, systematic biopsy plus multiparametric magnetic resonance imaging guided targeted biopsy of suspicious lesions on magnetic resonance imaging.

MATERIALS AND METHODS

All patients referred with Gleason Grade Group 1 or 2 prostate cancer based on systematic biopsy performed elsewhere underwent confirmatory fusion biopsy. Patients who continued on active surveillance after a positive or a negative fusion biopsy were followed. The baseline characteristics of the biopsy negative and positive cases were compared. Cox regression analysis was used to determine the prognostic significance of a negative fusion biopsy. Kaplan-Meier survival curves were used to estimate Grade Group progression with time.

RESULTS

Of the 542 patients referred with Grade Group 1 (466) or Grade Group 2 (76) cancer 111 (20.5%) had a negative fusion biopsy. A total of 60 vs 122 patients with a negative vs a positive fusion biopsy were followed on active surveillance with a median time to Grade Group progression of 74.3 and 44.6 months, respectively (p <0.01). Negative fusion biopsy was associated with a reduced risk of Grade Group progression (HR 0.41, 95% CI 0.22-0.77, p <0.01).

CONCLUSIONS

A negative confirmatory fusion biopsy confers a favorable prognosis for Grade Group progression. These results can be used when counseling patients about the risk of progression and for planning future followup and biopsies in patients on active surveillance.