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AUA 2019

AUA 2019: Natural History of Prostate Cancer On Active Surveillance: Stratification By MRI Using the PRECISE Recommendations in a UK Cohort over 11 Years

Chicago, IL (UroToday.com) The PRECISE recommendations for MRI in men on active surveillance include repeated measurement of each lesion and attribution of a PRECISE radiological progression score for the likelihood of clinically significant change over time.1 A 1-5 Likert scale is used where 1 shows regression of a previously visible lesion, 3 denotes stability and 5 is definitive radiological stage progression. At the prostate cancer active surveillance session at AUA 2019, Dr. Giganti and colleagues presented results of their comparison of the PRECISE score with clinical progression in men who are managed using an MRI-led active surveillance protocol.

Men on active surveillance for low or intermediate risk prostate cancer who had had two or more MRI scans between April 2006 and September 2017 were included. The NICE recommendations for active surveillance in the UK is as follows:
AUA2019 natural history 1
A total of 535 scans from 150 men were re-reported by a dedicated radiologist to give a PI-RADS v2 score for each scan, measurement of all lesions and a PRECISE score for the likelihood of radiological progression. Clinical progression was defined by histological progression to >= Gleason Grade Group 3 and/or initiation of active treatment. Tumor growth rate between serial scans was calculated – patients typically received an MRI every 6 months while on active surveillance.

Freedom from clinical progression at 12, 24 and 60 months for PRECISE 1-2 was 100% at all time points; for PRECISE 3 it was 98.4%, 96.7%, 96.7% and for PRECISE 4-5 it was 98.5%, 92.4%, 67.1%. There was a significant difference between PRECISE 1-2 vs 4-5 and PRECISE 3 vs 4-5 (p < 0.001). Fifty-six men (37%) had a visible lesion on all scans, and their tumor growth rate (%) by planimetry was higher with higher PRECISE scores (p < 0.05). The authors acknowledge several limitations of the study, including the fact that serial biopsies were not routinely performed and that the biopsy approach at baseline varied (standard vs targeted).The Kaplan-Meier curves show the rate of clinical progression stratified by PRECISE score (1-2 vs 3 vs 4-5) in the overall population (n=150):
AUA2019 natural history 2

Dr. Giganti concluded with several key take home messages:
  • The PRECISE scoring system has the attributes to become a principal predictor of prostate cancer progression
  • Radiological stability (PRECISE 1-3) in men on active surveillance is associated with a high rate of freedom from clinical progression.
  • The widespread use of PRECISE recommendations might have two main clinical consequences:
o   Identification of men on active surveillance who progress (PRECISE 4-5) in a timely manner, promoting rebiopsy/treatment
o   Avoidance of repeat biopsy for men with PRECISE 1-3, reducing the burden of surveillance for the individual and the healthcare system


Presented by: Francesco Giganti, UCL Centre for Medical Imaging, University College London, London, UK

Co-Authors: Armando Stabile, Vasilis Stavrinides, Adam Retter, Clement Orczyk, London, United Kingdom, Valeria Panebianco, Rome, Italy, Alex Freeman, Charles Jameson, Shonit Punwani, Clare Allen, Alex Kirkham, Mark Emberton, Caroline M Moore, London, United Kingdom

Written by: Zachary Klaassen, MD, MSc – Assistant Professor of Urology, Georgia Cancer Center, Augusta University - Medical College of Georgia, Twitter: @zklaassen_md at the American Urological Association's 2019 Annual Meeting (AUA 2019), May 3 – 6, 2019 in Chicago, Illinois

References:
  1. Moore CM, Giganti F, Albertsen P, et al. Reporting Magnetic Resonance Imaging in Men on Active Surveillance for Prostate Cancer: The PRECISE Recommendations-A Report of a European School of Oncology Task Force. Eur Urol 2017 Apr;7(4):648-655.