Four-year outcomes from a multiparametric magnetic resonance imaging (MRI)-based active surveillance programme: PSA dynamics and serial MRI scans allow omission of protocol biopsies.

Prasad Bollina,Andrew James Cameron,Kevin Michael Gallagher,Alasdair Innes,Gill Davis,Edward Christopher,Julian Keanie,Scott Little,Alan McNeill

doi:10.1111/bju.14513

Abstract

ObjectivesTo report outcomes from a multiparametric (mp) magnetic resonance imaging (MRI)‐based active surveillance programme that did not include performing protocol biopsies after the first confirmatory biopsy.Patients and MethodsAll patients diagnosed with Gleason 3 + 3 prostate cancer because of a raised PSA level who underwent mpMRI after diagnosis were included. Patients were recorded in a prospective clinical database and followed up with PSA monitoring and repeat MRI. In patients who remained on active surveillance after the first MRI (with or without confirmatory biopsy), we investigated PSA dynamics for association with subsequent progression. Comparison between first and second MRI scans was undertaken. Outcomes assessed were: progression to radical therapy at first MRI/confirmatory biopsy and progression to radical therapy in those who remained on active surveillance after first MRI.ResultsA total of 211 patients were included, with a median of 4.2 years of follow‐up. The rate of progression to radical therapy was significantly greater at all stages among patients with visible lesions than in those with initially negative MRI (47/125 (37.6%) vs 11/86 (12.8%); odds ratio 4.1 (95% CI 2.0–8.5), P < 0.001). Only 1/56 patients (1.8%) with negative initial MRI scans who underwent a confirmatory systematic biopsy had upgrading to Gleason 3 + 4 disease. PSA velocity was significantly associated with subsequent progression in patients with negative initial MRI (area under the curve 0.85 [95% CI 0.75–0.94]; P <0.001). Patients with high‐risk visible lesions on first MRI who remained on active surveillance had a high risk of subsequent progression 19/76 (25.0%) vs 9/84 (10.7%) for patients with no visible lesions, despite reassuring targeted and systematic confirmatory biopsies and regardless of PSA dynamics.ConclusionMen with low‐risk Gleason 3 + 3 prostate cancer on active surveillance can forgo protocol biopsies in favour of MRI and PSA monitoring with selective re‐biopsy.

Highlights

It is accepted that active surveillance is the first-line treatment option for men with low-risk prostate cancer [1,2].Most active surveillance programmes involve repeat ‘protocol’ or ‘confirmatory’ prostate biopsy
In patients who remained on active surveillance after the first magnetic resonance imaging (MRI), we investigated PSA dynamics for association with subsequent progression
The rate of progression to radical therapy was significantly greater at all stages among patients with visible lesions than in those with initially negative MRI (47/125 (37.6%) vs 11/86 (12.8%); odds ratio 4.1, P < 0.001)

Summary

Introduction

It is accepted that active surveillance is the first-line treatment option for men with low-risk prostate cancer [1,2]. Most active surveillance programmes involve repeat ‘protocol’ or ‘confirmatory’ prostate biopsy. This is performed 1 year after diagnosis and at varying time points subsequently. The reason for this is that, historically, up to 35% of cases were upgraded [3]. In 2014, the National Institute for Health and Care Excellence (NICE) recommended multiparametric MRI (mpMRI) scanning at the time of diagnosis for men on active surveillance in the UK [4]. There is early evidence that using MRI with or without a PSA adjunct to risk-stratify men for confirmatory biopsy may allow safe omission of confirmatory

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