Favorable-risk Prostate Cancer Research Articles

Temporal trend in risk of prostate cancer death in men with favourable-risk prostate cancer.

Changes in work-up and histopathological assessment have caused stage and grade migration in men with prostate cancer (PCa). The aim of this study was to assess temporal trends in risk of PCa death for men with favourable-risk PCa managed with primary radical prostatectomy or observation. Men aged 75 or younger with Charlson Comorbidity index 0-1 diagnosed with favourable-risk PCa (T1-T2, prostate specific antigen [PSA] <20 ng/mL and Gleason score 6 or 7[3+4]) in the period 2000-2016 who were treated with primary radical prostatectomy or managed with observation in PCBaSe 4.0. Treatment groups were compared following propensity score matching, and risk of PCa death was estimated by use of Cox regression analyses. A total of 9,666 men were selected for each treatment strategy. The 7-year cumulative incidence of PCa death decreased in all risk and treatment groups. For example, the incidence in men diagnosed with low-risk PCa and managed with observation was 1.2% in 2000-2005, which decreased to 0.4% in 2011-2016. Corresponding incidences for men with intermediate-risk PCa managed with observation were 2.0% and 0.7%. The relative risk of PCa death was lower in men with low-risk PCa managed with radical prostatectomy compared to observation: in 2000-2005 hazard ratio (HR) 0.20 (95% confidence interval [CI] 0.10-0.38) and in 2011-2016 HR 0.35 (95% CI 0.05-2.26). Corresponding risks for men with intermediate-risk PCa were HR 0.28 (95% CI 0.16-0.47) and HR 0.21 (95% CI 0.04-1.18). The absolute risk reduction of radical prostatectomy compared to observation for men with low-risk PCa was 1% in 2000-2005 and 0.4% in 2011-2016, and for men with intermediate-risk PCa 1.1% in 2000-2005 and 0.7% in 2011-2016. Men diagnosed in 2011-2016 with low-risk and favourable intermediate-risk PCa have a similar relative benefit but smaller absolute benefit of curative treatment compared to men diagnosed in 2000-2005.

Impact of Family History and Germline Genetic Risk Single Nucleotide Polymorphisms on Long-Term Outcomes of Favorable-Risk Prostate Cancer.

Family history and germline genetic risk single nucleotide polymorphisms (SNPs) have been separately shown to stratify lifetime risk of prostate cancer. Here, we evaluate the combined prognostic value of family history of prostate and other related cancers and germline risk SNPs among patients with favorable-risk prostate cancer. A total of 1367 participants from the prospective Health Professionals Follow-up Study diagnosed with low- or favorable intermediate-risk prostate cancer from 1986 to 2017 underwent genome-wide SNP genotyping. Multivariable Cox regression was used to estimate the association between family history, specific germline risk variants, and a 269 SNP polygenic risk score with prostate cancer‒specific death. Family history of prostate, breast, and/or pancreatic cancer was observed in 489 (36%) participants. With median follow-up from diagnosis of 14.9 years, participants with favorable-risk prostate cancer with a positive family history had a significantly higher risk of prostate cancer‒specific death (HR 1.95, 95% CI 1.15-3.32, P = .014) compared to those without any family history. The rs2735839 (19q13) risk allele was associated with prostate cancer‒specific death (HR 1.81 per risk allele, 95% CI 1.04-3.17, P = .037), whereas the polygenic risk score was not. Combined family history and rs2735839 risk allele were each associated with an additive risk of prostate cancer‒specific death (HR 1.78 per risk factor, 95% CI 1.25-2.53, P = .001). Family history of prostate, breast, or pancreatic cancer and/or a 19q13 germline risk allele are associated with an elevated risk of prostate cancer‒specific death among favorable-risk patients. These findings have implications for how family history and germline genetic risk SNPs should be factored into clinical decision-making around favorable-risk prostate cancer.

Delaying Surgery in Favorable-Risk Prostate Cancer Patients: An NCDB Analysis of Oncologic Outcomes

IntroductionConcern for overtreatment in very low-, low-, and favorable intermediate-risk prostate cancer has promoted a more conservative approach through active surveillance (AS) with comparable survival outcomes. We analyzed the National Cancer Database (NCDB) to determine if delaying radical prostatectomy greater than 6 months is associated with an increase in the rate of adverse pathology or secondary treatment (adjuvant or salvage) at radical prostatectomy. MethodsUtilizing the NCDB from 2004 to 2019, 40 to 75-year-old men with very low-, low-, and favorable-intermediate-risk prostate cancer, as defined by the National Comprehensive Cancer Network, were identified for this study. These individuals received radical prostatectomy either before or after 6 months following diagnosis. Clinical, demographic, and pathologic characteristics were obtained. Adverse pathologic outcomes were defined as pT3-4N0-1 and/or positive surgical margins. Multiple logistic regression models were used to predict delays in treatment, adverse pathologic outcomes, and receipt of secondary therapy. Survival analysis was performed using the Cox Proportional Hazards Model and the Kaplan-Meier Method. ResultsOf the 195,397 patients who met inclusion criteria, only 13,393 patients received surgery 6 months after diagnosis. The median time of delay was 7.5 months compared to 2.3 months in the immediate treatment group. Overall, delaying surgery had no statistically significant impact on adverse pathologic outcomes, regardless of risk category. However, when accounting for the interaction between race and delayed treatment, non-Hispanic black patients who received a delay in treatment were more likely to experience adverse features (OR 1.12, 95%CI 1.00-1.26, P = .041). Conversely, patients who had delayed surgery were less likely to receive additional therapy (either adjuvant or salvage) (OR 0.60, 95%CI 0.52-0.68, P < .001). Survival analysis showed that both groups fared well, with a 5-year survival of 97% for both groups. The treatment group was not predictive of survival. ConclusionOverall, delaying surgery more than 6 months following diagnosis did not have a significant impact on adverse pathologic features or overall survival. However, when specifically looking at non-Hispanic black patients with a treatment delay, these patients were at increased risk for adverse features, suggesting that the negative impact of treatment delay depends on the patient's race. As race is a social construct, this finding likely points to the complex socioeconomic factors that contribute to overall health outcomes rather than any inherent disease characteristics. Lastly, delayed treatment patients were actually less likely to require secondary therapy, regardless of race, possibly reflecting high clinician acumen in selecting patients appropriate for treatment delay. The results suggest that patients who ultimately “fail” AS and require subsequent surgery have overall comparable survival outcomes. However, pathologic outcomes are dependent on the patient's underlying race, with non-Hispanic black patients experiencing an increased risk of adverse outcomes if treatment is delayed.

Updated 5-year results for short course abiraterone acetate and LHRH agonist for unfavorable intermediate and favorable high-risk prostate cancer.

Combined androgen deprivation therapy (ADT) and radiotherapy (RT) improves outcomes for intermediate and high-risk prostate cancer. Treatment intensification with abiraterone acetate/prednisone (AAP) provides additional benefit for high-risk disease. We previously reported 3-year outcomes of a single-arm prospective multicenter trial (AbiRT trial) of 33 patients with unfavorable intermediate risk (UIR) and favorable high risk (FHR) prostate cancer undergoing short course, combination therapy with ADT, AAP, and RT. Here we report the final analysis demonstrating a high rate of testosterone recovery (97%) and excellent biochemical progression-free survival (97%) at 5 years. These data support comparative prospective studies of shorter, more potent ADT courses in favorable high-risk prostate cancer.

The impact of genomic biomarkers on a clinical risk prediction model for upgrading/upstaging among men with favorable-risk prostate cancer.

The challenge of distinguishing indolent from aggressive prostate cancer (PCa) complicates decision-making for men considering active surveillance (AS). Genomic classifiers (GCs) may improve risk stratification by predicting end points such as upgrading or upstaging (UG/US). The aim of this study was to assess the impact of GCs on UG/US risk prediction in a clinicopathologic model. Participants had favorable-risk PCa (cT1-2, prostate-specific antigen [PSA] ≤15ng/mL, and Gleason grade group 1 [GG1]/low-volume GG2). A prediction model was developed for 864 men at the University of California, San Francisco, with standard clinical variables (cohort 1), and the model was validated for 2267 participants from the Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE) registry (cohort 2). Logistic regression was used to compute the area under the receiver operating characteristic curve (AUC) to develop a prediction model for UG/US at prostatectomy. A GC (Oncotype Dx Genomic Prostate Score [GPS] or Prolaris) was then assessed to improve risk prediction. The prediction model included biopsy GG1 versus GG2 (odds ratio [OR], 5.83; 95% confidence interval [CI], 3.73-9.10); PSA (OR, 1.10; 95% CI, 1.01-1.20; per 1ng/mL), percent positive cores (OR, 1.01; 95% CI, 1.01-1.02; per 1%), prostate volume (OR, 0.98; 95% CI, 0.97-0.99; per mL), and age (OR, 1.05; 95% CI, 1.02-1.07; per year), with AUC 0.70 (cohort 1) and AUC 0.69 (cohort 2). GPS was associated with UG/US (OR, 1.03; 95% CI, 1.01-1.06; p<.01) and AUC 0.72, which indicates a comparable performance to the prediction model. GCs did not substantially improve a clinical prediction model for UG/US, a short-term and imperfect surrogate for clinically relevant disease outcomes.

Oncological Outcomes in Men With Favorable Intermediate Risk Prostate Cancer Enrolled in Active Surveillance.

To evaluate the long-term oncological outcomes in men with intermediate risk prostate cancer (PCa) enrolled in active surveillance (AS). From April 2015 to December 2022, 30 men with Gleason score 3+4/ISUP Grade Group2 (GG2), greatest percentage of cancer (GPC) ≤50%, Gleason pattern 4 ≤10%, ≤3 positive biopsy cores were enrolled in AS. All patients underwent confirmatory transperineal saturation biopsy (SPBx: 20 cores) 12 months from diagnosis plus multiparametric magnetic resonance (mpMRI) evaluation. At the last follow-up, 68Ga prostate-specific membrane antigen (PSMA) positron-emission tomography (PET)/computed tomography (CT) was added: lesions with PIRADS score ≥3 and/or standardized uptake value (SUVmax) >5 were submitted to four targeted cores. Three out of 30 (10%) men with GG2 PCa were reclassified at confirmatory biopsy. At the last follow-up (median 5.2 years), only 2 of 27 (7.4%) men were reclassified and 23/30 (76.6%) continued AS. Men with favorable GG2 PCa enrolled in AS have good long-term oncological results. The use of selective criteria (i.e., SPBx, mpMRI, PSMA PET/CT) reduces the risk of reclassification.

Long-Term Outcomes Associated with Different High-Dose-Rate Brachytherapy Dose Regimens for Favorable and Unfavorable Intermediate Risk Prostate Cancer.

To present long-term efficacy outcomes of prostate high-dose-rate (HDR) brachytherapy monotherapy using 38 Gy in 4 fractions, 24 Gy in 2 fractions, and 27 Gy in 2 fractions for men with favorable and unfavorable intermediate risk prostate cancer. Patients treated with HDR brachytherapy monotherapy for NCCN favorable (FIR) or unfavorable (UIR) intermediate risk prostate cancer from 1999-2020 were identified in a prospectively maintained, single institution database. Patients with less than two years of follow-up and those treated with single fraction HDR brachytherapy were excluded. Biochemical failure was determined using Phoenix criteria. 10-year biochemical control (BC), local control (LC), and distant metastasis (DM) rates were estimated using the Kaplan-Meier method. Two hundred sixty-seven patients were included. One hundred eighty-nine had FIR and 78 had UIR prostate cancer, with median follow-up of 9.6 years and 7.2 years, respectively. Of the 189 patients with FIR prostate cancer, 59 (31.2%) received 38 Gy in 4 fractions, 26 (13.7%) received 24 Gy in 2 fractions, and 104 (55.0%) received 27 Gy in 2 fractions. Of the 78 patients with UIR prostate cancer, 20 (25.6%) received 38 Gy in 4 fractions, 11 (14.1%) received 24 Gy in 2 fractions, and 47 (60.2%) received 27 Gy in 2 fractions. Date ranges of treatment for the respective fractionation schedules were 1999-2010, 2007-2016, and 2009-2020. Upfront androgen deprivation therapy (ADT) was given to 12 (6.3%) patients with FIR and 10 (12.8%) patients with UIR. 10-year rates of BC for FIR and UIR patients were 90.1% and 78.8% (p = 0.004), respectively. 10-year rates of LC were 92.4% and 85.0% (p = 0.06), respectively. 10-year rates of DM were 1.9% and 4.7% (p = 0.12), respectively. For FIR patients, 10-year BC rates were 96.2% for patients receiving 38 Gy in 4 fractions vs. 86.3% (p = 0.07) for those treated with the 2-fraction regimens, while 10-year LC rates were 97.9% and 89.0% (p = 0.049), respectively. Within the UIR subset, the 10-year BC rates for patients receiving 38 Gy in 4 fractions and patients receiving treatment in 2 fractions were 95.0% and 70.6% (p = 0.038). 10-year LC rates were 100% and 77.8% (p = 0.045), respectively. 10-year BC rates by treatment schedule are shown in the table below. HDR brachytherapy monotherapy results in excellent long-term local control for intermediate risk prostate cancer. Improvements in biochemical and local disease control for patients treated with 38 Gy in 4 fractions warrants consideration of prospective study of optimal treatment dosing regimens.

A Phase I/II Dose-Escalation Study Evaluating the Safety of 21 Gy, 23 Gy, and 25 Gy for High Dose Rate (HDR) Prostate Brachytherapy: An Interim Toxicity Report.

Single-fraction high dose rate (HDR) prostate brachytherapy has shown improved actuarial biochemical control rates from 66% to 82% with dose escalation from 19 to 20.5 Gy, respectively, but is still inferior to the reported low dose rate brachytherapy control rates of over 90%. We aimed to identify whether dose escalation to 21, 23, and 25 Gy can be safely accomplished. Patients with previously untreated, pathologically confirmed, low-risk (cT1-T2a, Gleason ≤6, PSA <10 ng/mL) or favorable intermediate risk (Gleason 3+4, percentage of positive biopsy cores <50%, ≤1 NCCN intermediate risk factor) prostate adenocarcinoma were enrolled from a single institution. PSA and toxicity assessment were performed at baseline and at routine 6-month follow-ups. From May 9, 2018 to May 12, 2022, 18 patients were enrolled. None had received prior androgen deprivation therapy, 44% had low risk disease, and 61% were ECOG 0 at baseline. Median age was 68 years (total range: 43-79), and 83% were Caucasian. Eight patients received 21 Gy, nine patients received 23 Gy, and one patient received 25 Gy, with the 25 Gy cohort still accruing. The mean prostate size and range, determined by pre-operative prostate volume study on trans-rectal ultrasound, were as follows: 21Gy cohort (mean: 41.2cc; range: 21.9-63.1cc), 23Gy Cohort (mean: 41.2cc, range 28.3-71.7cc), 25Gy cohort (65.3cc). A median of 17 catheters (range: 16-20) were implanted. At a median follow-up of 35.7 months (range: IQR 4.4 - 50.2), only one grade 3 toxicity was reported, which was an ulcerative colitis (UC) flare noted in a patient whose UC was poorly controlled, requiring multiple courses of prednisone in the 6 months prior to his brachytherapy. Regarding toxicities attributable to therapy, fourteen and four patients experienced a grade 1 and 2 genitourinary toxicity respectively; four and four patients experienced a grade 1 and 2 reproductive system toxicity respectively; one patient experienced a grade 1 GI toxicity. Two patients needed foley catheters upon discharge, with neither requiring the foley long term. There were two treatment failures in the 21Gy cohort at 1.39 and 1.67 years from date of HDR brachytherapy; date of failure was defined by the first PSA 2.0ng/mL over nadir. Of these patients, one underwent focal salvage HDR, whilst the other underwent radical prostatectomy with only 1% of the volume involved by prostate cancer. Of note, there was seminal vesicle involvement on restaging prostate biopsy for the patient that underwent radical prostatectomy, however, this was not appreciated on the final prostatectomy specimen. Both patients have no evidence of disease currently. HDR brachytherapy appears well tolerated in patients with low to favorable intermediate risk prostate cancer at 21 and 23 Gy, with more accrual needed at 25Gy. Long-term follow-up needed to assess efficacy.

Long-Term Follow-Up Analysis of NRG Oncology RTOG 0415: A Randomized Phase III Non-Inferiority Study Comparing Two Fractionation Schedules in Patients with Favorable-Risk Prostate Cancer

To assess whether the efficacy of a hypofractionated (H) schedule is no worse than a conventional (C) schedule in men with low-risk prostate cancer. Accrual began April 2006 and ended in December 2009. 1115 men with favorable-risk prostate cancer were randomly assigned 1:1 to a conventional (C) schedule (73.8 Gy in 41 fractions over 8.2 weeks) or to a hypofractionated (H) schedule (70 Gy in 28 fractions over 5.6 weeks). The trial was designed to establish with 90% power and alpha = 0.05 that (H) results in 5-year disease-free survival (DFS) that is not lower than (C) by more than 7% (hazard ratio (HR) < 1.52). Protocol specified secondary endpoints evaluated for noninferiority include: biochemical recurrence (BR), local progression, disease-specific survival, and overall survival. One thousand ninety-two protocol eligible men were analyzed: 542 to C and 550 to H. Median follow-up is 12.75 years. Baseline characteristics were not different according to treatment arm. The estimated 12-year DFS is 56.1% (95% CI 51.5, 60.5) in the C arm and 61.8% (57.2, 66.0) in the H arm. The DFS hazard ratio (H/C) is 0.85 (0.71-1.03), confirming non-inferiority (p<0.001). Twelve-year cumulative incidence of biochemical recurrence (BR) was 17.0% (CI 13.8, 20.5) in the C-RT and 9.9% (CI 7.5, 12.6) in the H-RT arm; (HR = 0.56, (0.40-0.78) suggesting improved efficacy with H. Additional pre-specified secondary endpoints were non-inferior Late Grade ≥ 3 GI toxicity is 3.2% (C) vs. 4.4% (H), Relative risk (RR) for H vs. C 1.39 (CI 0.75, 2.55) Late Grade ≥ 3 GU toxicity is 3.4% (C) vs. 4.2% (H), RR = 1.26 (CI 0.69, 2.30). In men with favorable-risk prostate cancer, long-term disease-free survival is non-inferior with 70 Gy in 28 fractions compared to 73.8 Gy in 41 fractions. The risk of BR is reduced with moderate hypofractionation. No differences in late Grade ≥3 GI/GU toxicity were observed between the arms. (ClinicalTrials.gov identifier: NCT00331773).

PP04 Presentation Time: 11:27 AM: Mature Toxicity and Effectiveness Outcomes Associated with Three Treatment Schedules of High-Dose-Rate Brachytherapy Monotherapy for Favorable-Risk Prostate Cancer

PP04 Presentation Time: 11:27 AM: Mature Toxicity and Effectiveness Outcomes Associated with Three Treatment Schedules of High-Dose-Rate Brachytherapy Monotherapy for Favorable-Risk Prostate Cancer

Gallium-68 Prostate-specific Membrane Antigen Positron Emission Tomography/Computed Tomography in Active Surveillance for Prostate Cancer Trial (PASPoRT)

BackgroundThe use of clinical parameters, including prebiopsy magnetic resonance imaging (MRI), to decide between active surveillance (AS) and active therapy for prostate cancer (PCa) leads to imperfect selection. Additional prostate-specific membrane antigen (PSMA) positron emission tomography/computed tomography (PET/CT) imaging may improve risk stratification. ObjectiveTo study risk stratification and patient selection for AS with the addition of PSMA PET/CT to standard practice. Design, setting, and participantsA single-centre prospective cohort study (NL69880.100.19) enrolled patients recently diagnosed with PCa who started AS. At diagnosis, all participants had undergone prebiopsy MRI and targeted biopsy for visualised lesions. Patients underwent an additional [68Ga]-PSMA PET/CT and targeted biopsy of all PSMA lesions with a maximum standardised uptake value (SUVmax) of ≥4 not covered by previous biopsies. Outcome measurements and statistical analysisThe primary outcome was the number needed to scan (NNS) to detect one patient with upgrading. The study was powered to detect an NNS of 10. Regarding secondary outcomes, univariate logistic regressions analyses were performed on all patients and on the patients who received additional PSMA targeted biopsies on the likelihood of upgrading. Results and limitationsA total of 141 patients were included. Additional PSMA targeted biopsies were performed in 45 (32%) patients. In 13 (9%) patients, upgrading was detected: nine grade group (GG) 2, two GG 3, one GG 4, and one GG 5. The NNS was 11 (95% confidence interval 6–18). Of all participants, PSMA PET/CT and targeted biopsies yielded upgrading most frequently in patients with negative MRI (Prostate Imaging Reporting and Data System [PI-RADS] 1–2). Of patients who received additional PSMA targeted biopsies, upgrading was most frequently found in those with higher prostate-specific antigen density and negative MRI. Limitations included the lack of comparison with standard repeat biopsy, no central review of MRI, and possibility of biopsy sampling error. ConclusionsPSMA PET/CT can further improve PCa risk stratification and selection for AS patients diagnosed after MRI and targeted biopsies. Patient summaryProstate-specific membrane antigen positron emission tomography/computed tomography and additional targeted prostate biopsies can identify more aggressive prostate cancer cases previously missed in patients recently started with expectant management for favourable-risk prostate cancer.

Recommendations for patients with prostate cancer who wish to undergo a kidney transplant

Over the past half a century, kidney transplants have increased significantly and more patients that are elderly are receiving kidney transplants. As a result, the eligibility of patients with prostate cancer who wish to receive a kidney transplant has become a significant issue facing the transplant community. Many questions have arisen because prostate cancer is an extremely variable disease that many times do not harm the patients but at other times, can cause the death of the patient.If a patient has prostate cancer, should he be allowed to receive a kidney transplant? Should he receive the transplant after treatment for prostate cancer or without such treatment? How should the transplant community determine his eligibility? Most agree that those with high-risk prostate cancer should be treated first and have a waiting period prior to kidney transplant. Almost all low-risk prostate cancer patients are candidates for active surveillance. More and more urologists are doing active surveillance for favorable intermediate risk prostate cancer patients. We believe that all patients who are reasonable candidates for active surveillance based on the National Comprehensive Cancer Network (NCCN) guidelines for prostate cancer are reasonable candidates for kidney transplant without treatment for prostate cancer. We recommend using a combination of shared-decision making that involves prostate cancer risk-stratification as well as adjunctive tests such as imaging with multiparametric MRI (mpMRI) and genomic testing such as Decipher, Oncotype DX or Polaris, in order to inform whether or not patients with prostate cancer can receive a kidney transplant without treatment for prostate cancer.

PO-1499 Extracranial stereotactic radiotherapy in low and favourable intermediate risk prostate cancer

PO-1499 Extracranial stereotactic radiotherapy in low and favourable intermediate risk prostate cancer

Expanding the role of PSMA PET in active surveillance

IntroductionAccurate grading at the time of diagnosis is fundamental to risk stratification and treatment decision making, particularly for men being considered for Active Surveillance (AS). With the introduction of prostate-specific membrane antigen (PSMA) positron emission tomography (PET) there has been considerable improvement in sensitivity and specificity for the detection and staging of clinically significant prostate cancer. Our study aims to determine the role of PSMA PET/CT in men with newly diagnosed low or favourable intermediate risk prostate cancer to better select men for AS.MethodThis is a retrospective single centre study performed from January 2019 and October 2022. This study includes men identified from electronic medical record system who had undergone a PSMA PET/CT following newly diagnosed low or favourable-intermediate risk prostate cancer. Primary outcome was to assess the change in management for men being considered for AS following PSMA PET/CT results on the basis of PSMA PET characteristics.ResultsIn total, there were 11 of 30 men (36.67%) who were assigned management by AS and 19 of 30 men (63.33%) who had definitive treatment. 15 of the 19 men that needed treatment had concerning features on PSMA PET/CT results. Of the 15 men with concerning features on PSMA PET, 9 (60%) men were found to have adverse pathological features on final prostatectomy features.ConclusionThis retrospective study suggests that PSMA PET/CT has potential to influence the management of men with newly diagnosed prostate cancer that would otherwise be appropriate for active surveillance.

A modeling study to estimate prostate cancer-specific mortality on active surveillance for men with favorable intermediate-risk prostate cancer: Results from the SEARCH cohort.

Limited data exist to help surgeons decide between active surveillance (AS) versus treatment for men with favorable intermediate risk (FIR) prostate cancer. To estimate the theoretical excess risk of prostate cancer-specific mortality (PCSM) with AS versus radical prostatectomy (RP), we determined the risk of PCSM in FIR men undergoing RP and modeled the PCSM risk for AS using a range of increased PSCM scenarios ranging from 1.25x to 2x higher relative to RP. We retrospectively reviewed data from men undergoing RP from 1988 to 2017 at 8 Veterans Affairs hospitals within the SEARCH cohort. Men with FIR PC were identified using the NCCN risk criteria. Risk of PCSM at 5, 10, and 15 years after RP was estimated. Using these estimates, PCSM was then modeled for AS using a range of increased risk of PCSM relative to RP ranging from 1.25x to 2x higher. For the 920 FIR men identified, 5-, 10-, and 15-year survival estimates for PCSM after RP were 99.9%, 99.0%, and 97.8%, respectively. If the risk of PCSM on AS were 1.25-2x greater than RP, there would be 0.54%-2.17% excess risk of PCSM at 15 years. The risk of death for FIR after RP is very low. Assuming even modestly increased PCSM with AS versus RP, the excess risk of death for AS in FIR is low even up to 15 years. These data support the consideration of AS as a relatively safe alternative to RP in FIR men, though prospective randomized trials are needed to validate these findings.

PD32-12 VISUAL AND NUMERIC RISK INFORMATION REDUCES VARIATION IN SURGEON RISK PERCEPTION: RESULTS FROM A RANDOMIZED, CLINICAL VIGNETTE EXPERIMENT

You have accessJournal of UrologyCME1 Apr 2023PD32-12 VISUAL AND NUMERIC RISK INFORMATION REDUCES VARIATION IN SURGEON RISK PERCEPTION: RESULTS FROM A RANDOMIZED, CLINICAL VIGNETTE EXPERIMENT Hung-Jui Tan, David Gotz, Hillary Heiling, Allison Deal, Kara Giannone, Debra Usinger, Sue Blalock, Antonia Bennett, Matthew Nielsen, Daniel Reuland, Alex Sox-Harris, Allison Lazard, Greg Sacks, and Ethan Basch Hung-Jui TanHung-Jui Tan More articles by this author , David GotzDavid Gotz More articles by this author , Hillary HeilingHillary Heiling More articles by this author , Allison DealAllison Deal More articles by this author , Kara GiannoneKara Giannone More articles by this author , Debra UsingerDebra Usinger More articles by this author , Sue BlalockSue Blalock More articles by this author , Antonia BennettAntonia Bennett More articles by this author , Matthew NielsenMatthew Nielsen More articles by this author , Daniel ReulandDaniel Reuland More articles by this author , Alex Sox-HarrisAlex Sox-Harris More articles by this author , Allison LazardAllison Lazard More articles by this author , Greg SacksGreg Sacks More articles by this author , and Ethan BaschEthan Basch More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003325.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Differences in risk perception is a major driver of variation in surgery. Risk prediction tools aim to attenuate these differences, but only a minority of urologists use them. Because data visualization can improve engagement and information processing, we designed a visual risk display and tested its impact on surgeon risk perception. METHODS: Taking a user-centered design approach, the research team engaged a panel of urologists to identify key risk domains and design a visual risk display. From May–June 2022, we administered SUO/AUA members 6 clinical vignettes (A: favorable intermediate risk prostate cancer, B: high risk prostate cancer, C: small renal mass, D: advanced kidney cancer, E: BCG unresponsive, noninvasive bladder cancer, F: muscle-invasive bladder cancer), randomizing them to vignettes plus visual risk display, vignettes plus numeric risk information, and vignettes alone (control). Respondents estimated the risk for other-cause mortality, cancer mortality with/without surgery, serious complications, and adverse functional outcome from 0–100%. Variation was compared using Levene’s test of homogeneity in variance. RESULTS: In total, 333 urologists completed all 6 vignettes with 104 in the visual arm, 111 in the numeric arm, and 118 in the control arm. Most respondents obtained fellowship-training (71.2%) and practice in an academic setting (60.1%). Respondents had 11.7 (SD 10.6) years of experience and performed 11.2 (SD 9.7) major cases per month. As illustrated in the Figure 1, both visual and numeric risk information reduced variation in perceived risk of other-cause mortality (i.e., life expectancy) compared to control (p<0.05). Visual and numeric risk information yielded similar reductions in variation for the other risk domains. However, compared to numeric risk information only, the visual risk display only reduced variation in perceived risk for adverse functional outcomes for cases D, E, and F (p<0.05). CONCLUSIONS: Providing urologists with risk information—whether visual or numeric—reduces variation in perceived risk, particularly for life expectancy and functional outcomes. Additional research is needed to assess whether visual methods further enhance usability and risk communication in the clinical setting. Source of Funding: American Cancer Society © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e911 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Hung-Jui Tan More articles by this author David Gotz More articles by this author Hillary Heiling More articles by this author Allison Deal More articles by this author Kara Giannone More articles by this author Debra Usinger More articles by this author Sue Blalock More articles by this author Antonia Bennett More articles by this author Matthew Nielsen More articles by this author Daniel Reuland More articles by this author Alex Sox-Harris More articles by this author Allison Lazard More articles by this author Greg Sacks More articles by this author Ethan Basch More articles by this author Expand All Advertisement PDF downloadLoading ...

PD32-08 THE EFFECT OF VISUAL AND NUMERIC RISK INFORMATION ON SURGEON BEHAVIOR: A RANDOMIZED, CLINICAL VIGNETTE EXPERIMENT

You have accessJournal of UrologyCME1 Apr 2023PD32-08 THE EFFECT OF VISUAL AND NUMERIC RISK INFORMATION ON SURGEON BEHAVIOR: A RANDOMIZED, CLINICAL VIGNETTE EXPERIMENT Hung-Jui Tan, David Gotz, Hillary Heiling, Allison Deal, Kara Giannone, Debra Usinger, Sue Blalock, Antonia Bennett, Matthew Nielsen, Daniel Reuland, Alex Sox-Harris, Allison Lazard, Greg Sacks, and Ethan Basch Hung-Jui TanHung-Jui Tan More articles by this author , David GotzDavid Gotz More articles by this author , Hillary HeilingHillary Heiling More articles by this author , Allison DealAllison Deal More articles by this author , Kara GiannoneKara Giannone More articles by this author , Debra UsingerDebra Usinger More articles by this author , Sue BlalockSue Blalock More articles by this author , Antonia BennettAntonia Bennett More articles by this author , Matthew NielsenMatthew Nielsen More articles by this author , Daniel ReulandDaniel Reuland More articles by this author , Alex Sox-HarrisAlex Sox-Harris More articles by this author , Allison LazardAllison Lazard More articles by this author , Greg SacksGreg Sacks More articles by this author , and Ethan BaschEthan Basch More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003325.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The treatment patients receive depends more on their surgeon than their disease. Risk prediction tools aim to address this quandary by providing quantitative risk information, but their clinical impact remains limited. Because data visualization can improve information processing, we designed a visual risk display and tested its impact on surgical decision-making. METHODS: We engaged a panel of urologists to develop a multidimensional, multifaceted visual risk display through user-centered design. The panel further helped us develop clinical vignettes for favorable intermediate risk prostate cancer (A), high risk prostate cancer (B), small renal mass (C), advanced kidney cancer (D), BCG unresponsive, noninvasive bladder cancer (E), and muscle-invasive bladder cancer (F) where surgical equipoise exist. From May–June 2022, we administered these vignettes to SUO and AUA members via Qualtrics, randomizing them to the visual risk display, numeric risk information, and control. Risk estimates were generated from existing risk prediction tools. For each case, respondents rated how likely they would recommend surgery (5-point Likert: strongly against to strongly for surgery) and selected health services they would obtain prior to surgery. Responses were compared using Fisher’s MC exact test with significance level set at 0.05. RESULTS: In total, 333 urologists participated: 104 in the visual arm, 111 in the numeric arm, and 118 in the control arm. Respondents were mostly fellowship-trained (71.2%) and in academic practices (60.1%). A strong or somewhat for surgery recommendation varied by case (A: 19.2%, B: 65.2%, C: 51.9%, D: 51.3%, E: 52.3%, F: 68.8%) but did not differ statistically across arms (p=0.210–0.967). In contrast, the selection of healthcare services such as preoperative care, cardiac clearance, and pulmonary clearance did differ statistically across arms depending on the case (Figure). CONCLUSIONS: Risk information—whether visual or numeric—did not affect a surgeon’s recommendation for surgery, highlighting the strong intuitive nature of surgical decision-making. However, the selection of health services appears more movable, indicating a role for risk prediction tools in optimizing surgical readiness and clinical outcomes. Source of Funding: American Cancer Society © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e910 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Hung-Jui Tan More articles by this author David Gotz More articles by this author Hillary Heiling More articles by this author Allison Deal More articles by this author Kara Giannone More articles by this author Debra Usinger More articles by this author Sue Blalock More articles by this author Antonia Bennett More articles by this author Matthew Nielsen More articles by this author Daniel Reuland More articles by this author Alex Sox-Harris More articles by this author Allison Lazard More articles by this author Greg Sacks More articles by this author Ethan Basch More articles by this author Expand All Advertisement PDF downloadLoading ...

MP19-19 PRIORITIZED RESEARCH QUESTIONS ON THE USE OF ACTIVE SURVEILLANCE FOR THE MANAGEMENT OF PROSTATE CANCER: RESULTS FROM PCASRI CONFERENCE

MP19-19 PRIORITIZED RESEARCH QUESTIONS ON THE USE OF ACTIVE SURVEILLANCE FOR THE MANAGEMENT OF PROSTATE CANCER: RESULTS FROM PCASRI CONFERENCE

MP38-15 DISCONTINUATION OF ACTIVE SURVEILLANCE WITHOUT RISK RECLASSIFICATION PRIOR TO TREATMENT

You have accessJournal of UrologyCME1 Apr 2023MP38-15 DISCONTINUATION OF ACTIVE SURVEILLANCE WITHOUT RISK RECLASSIFICATION PRIOR TO TREATMENT Mark Pressprich, Cullen Hudson, Ji Qi, Stephanie Ferrante, Khurshid Ghani, Brian Lane, Richard Sarle, Jason Hafron, Michael Cher, Alice Semerjian, Arvin George, Kevin Ginsburg, and For the Michigan Urological Surgery Improvement Collaborative Mark PressprichMark Pressprich More articles by this author , Cullen HudsonCullen Hudson More articles by this author , Ji QiJi Qi More articles by this author , Stephanie FerranteStephanie Ferrante More articles by this author , Khurshid GhaniKhurshid Ghani More articles by this author , Brian LaneBrian Lane More articles by this author , Richard SarleRichard Sarle More articles by this author , Jason HafronJason Hafron More articles by this author , Michael CherMichael Cher More articles by this author , Alice SemerjianAlice Semerjian More articles by this author , Arvin GeorgeArvin George More articles by this author , Kevin GinsburgKevin Ginsburg More articles by this author , and For the Michigan Urological Surgery Improvement Collaborative More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003276.15AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Guideline organizations support the use of active surveillance (AS) for all men with low risk (LR) and select men with favorable intermediate risk (FIR) prostate cancer (PC). Although encouraging AS as the initial approach for favorable-risk PC is an important first step in reducing overtreatment, this strategy is incomplete as it ignores another source of overtreatment: delayed treatment of men on AS who have not had risk reclassification. We evaluated the proportion of men that transitioned from AS to treatment without risk reclassification. METHODS: We reviewed the Michigan Urological Surgery Improvement Collaborative (MUSIC) registry for men diagnosed with NCCN LRPC and FIRPC that underwent treatment after a period of AS to identify the proportion of men that did not have risk reclassification prior to treatment. Reclassification was defined as meeting any criteria for NCCN FIRPC for men initially diagnosed with LRPC and any criteria for NCCN unfavorable intermediate risk PC for men initially diagnosed with FIRPC. RESULTS: From 2013 to 2021, 2118 men in MUSIC underwent treatment after initial AS, of which 741 (35%) did not have risk reclassification prior to treatment. A higher proportion of men with FIRPC underwent treatment without risk reclassification compared with LRPC (50% vs. 29%, p<0.001). The proportion of men with LRPC undergoing delayed treatment decreasing from 60% in 2013 to 23% in 2021 (Figure 1). Alternatively, the proportion of men with FIRPC treated without risk reclassification has remained stable. CONCLUSIONS: The overall percent of patients leaving AS for treatment without risk reclassification has declined in MUSIC, likely due to an increasing acceptance and comfort with AS for favorable-risk PC. The proportion of men with FIRPC undergoing treatment without risk reclassification has remained relatively stable, which may be explained by the clinical uncertainty regarding a treatment threshold for these men on AS. While there remains uncertainty regarding when patients with FIRPC on AS should be treated, there are QI opportunities to reduce overtreatment in men with LRPC on AS, a group for which the urologic community has coalesced around the use of AS as the preferred approach. Source of Funding: none © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e530 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Mark Pressprich More articles by this author Cullen Hudson More articles by this author Ji Qi More articles by this author Stephanie Ferrante More articles by this author Khurshid Ghani More articles by this author Brian Lane More articles by this author Richard Sarle More articles by this author Jason Hafron More articles by this author Michael Cher More articles by this author Alice Semerjian More articles by this author Arvin George More articles by this author Kevin Ginsburg More articles by this author For the Michigan Urological Surgery Improvement Collaborative More articles by this author Expand All Advertisement PDF downloadLoading ...

Socioeconomic determinants are associated with the utilization and outcomes of active surveillance or watchful waiting in favorable-risk prostate cancer.

Active surveillance/watchful waiting (AS/WW) is feasible and effective for favorable-risk prostate cancer (PCa). Understanding socioeconomic determinants of AS/WW may help determine the target population for social support and improve cancer-related survival. The Surveillance, Epidemiology, and End Results Prostate with Watchful Waiting Database 18 Registries identified 229,428 adult men diagnosed with primary localized PCa (clinical T1-T2c, N0M0) during a median follow-up of 45 months between 2010 and 2016. Socioeconomic determinants included socioeconomic status (SES) tertiles, marital status (unmarried vs married), and residency (urban vs rural). Multivariable logistic regression and Cox models determined the adjusted odds ratios (aOR) for AS/WW utilization, and adjusted hazard ratio (aHR) for cancer-specific survival (CSS) and overall survival (OS). The extent of missing data was evaluated by multiple imputation. Sensitivity analyses were performed in multiple imputation datasets. Unmarried patients were more likely to receive AS/WW in low-risk group (aOR, 1.20 [95%CI, 1.12-1.28]; p < 0.001) and favorable intermediate-risk group (aOR, 1.41 [95%CI, 1.26-1.59]; p < 0.001) than married patients. Urban patients had 0.77-fold lower likelihood of AS/WW than rural patients in low-risk group (95% CI, 0.68-0.87; p < 0.001), but not in favorable intermediate-risk groups. Among patients undertaking AS/WW, a significantly worse OS was observed among unmarried patients comparing to married group (aHR, 1.98 [95% CI, 1.50-2.60]; p < 0.001), and patients with high SES had better CSS than low group (aHR, 0.08 [95%CI, 0.01-0.69]; p=0.02). No significant survival difference was found between urban and rural patients. Unmarried or urban patients had significantly higher rates of AS/WW. The utilization and efficacy of conservative management were affected by socioeconomic factors, which might serve as a barrier of treatment decision-making and targeted a population in need of social support.