Abstract
BackgroundSeveral active surveillance (AS) criteria have been established to screen insignificant prostate cancer (insigPCa, defined as organ confined, low grade and small volume tumors confirmed by postoperative pathology). However, their comparative diagnostic performance varies. The aim of this study was to compare the diagnostic accuracy of contemporary AS criteria and validate the absolute diagnostic odds ratio (DOR) of optimal AS criteria.MethodsFirst, we searched Pubmed and performed a Bayesian network meta-analysis (NMA) to compare the diagnostic accuracy of contemporary AS criteria and obtained a relative ranking. Then, we searched Pubmed again to perform another meta-analysis to validate the absolute DOR of the top-ranked AS criteria derived from the NMA with two endpoints: insigPCa and favorable disease (defined as organ confined, low grade tumors). Subgroup and meta-regression analyses were conducted to identify any potential heterogeneity in the results. Publication bias was evaluated.ResultsSeven eligible retrospective studies with 3,336 participants were identified for the NMA. The diagnostic accuracy of AS criteria ranked from best to worst, was as follows: Epstein Criteria (EC), Yonsei criteria, Prostate Cancer Research International: Active Surveillance (PRIAS), University of Miami (UM), University of California-San Francisco (UCSF), Memorial Sloan-Kettering Cancer Center (MSKCC), and University of Toronto (UT). I2 = 50.5%, and sensitivity analysis with different insigPCa definitions supported the robustness of the results. In the subsequent meta-analysis of DOR of EC, insigPCa and favorable disease were identified as endpoints in ten and twenty-two studies, respectively. The pooled DOR for insigPCa and favorable disease were 0.44 (95%CI, 0.31–0.58) and 0.66 (95%CI, 0.61–0.71), respectively. According to a subgroup analysis, the DOR for favorable disease was significantly higher in US institutions than that in other regions. No significant heterogeneity or evidence of publication bias was identified.ConclusionsAmong the seven AS criteria evaluated in this study, EC was optimal for positively identifying insigPCa patients. The pooled diagnostic accuracy of EC was 0.44 for insigPCa and 0.66 when a more liberal endpoint, favorable disease, was used.Systematic Review Registration[https://www.crd.york.ac.uk/prospero/], PROSPERO [CRD42020157048].
Highlights
An estimated 1.28 million new cases of prostate cancer (PCa) occurred in 2018 worldwide [1], and PCa remains the second most commonly diagnosed cancer in men [2]
Each study was only included in the analysis if it met the following criteria: [1] the study was retrospective in design; [2] the participants fulfilled the requirements of any active surveillance (AS) criteria and were treated with radical prostatectomy (RP) without neoadjuvant androgen deprivation treatment; [3] a head-to-head comparison of the diagnostic accuracies of two or more AS criteria was presented; and [4] postsurgical pathology (RP specimen) results were available, especially for cases of pathologically insignificant PCa or favorable disease
Seven criteria were identified in this study: Epstein criteria (EC) [5], Prostate Cancer Research International: Active Surveillance (PRIAS) [34], Memorial Sloan-Kettering Cancer Center (MSKCC) [35], University of California, San Francisco (UCSF) [36], University of Miami (UM) [37], University of Toronto (UT) [38], and Yonsei criteria [31]; for details of these included critera see Supplementary Table 1
Summary
An estimated 1.28 million new cases of prostate cancer (PCa) occurred in 2018 worldwide [1], and PCa remains the second most commonly diagnosed cancer in men [2]. With the intention of avoiding overtreatment and preserving quality of life, active surveillance (AS) was originally suggested in 1994 [5], Epstein et al first introduced the definition of clinically insignificant prostate cancer (insigPCa), which is defined as organconfined, no Gleason pattern 4/5 and small volume PCa, and the Epstein criteria (EC) was established to predict these insigPCa. Since AS has been offered as an alternative to immediate curative intervention in men with favorable-risk PCa. Most patients are monitored on surveillance with PSA and digital rectal examination (DRE) at least biannually, and received surveillance prostate biopsies at a 1–2-year interval. Several active surveillance (AS) criteria have been established to screen insignificant prostate cancer (insigPCa, defined as organ confined, low grade and small volume tumors confirmed by postoperative pathology). The aim of this study was to compare the diagnostic accuracy of contemporary AS criteria and validate the absolute diagnostic odds ratio (DOR) of optimal AS criteria
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