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Article of the week: Likert vs PI‐RADS v2: a comparison of two radiological scoring systems for detection of clinically significant PCa

Every week, the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an editorial written by a prominent member of the urological community and a video prepared by the authors; we invite you to use the comment tools at the bottom of each post to join the conversation. 

If you only have time to read one article this week, we recommend this one. 

Likert vs PI‐RADS v2: a comparison of two radiological scoring systems for detection of clinically significant prostate cancer

Christopher C. Khoo*, David Eldred-Evans*, Max Peters, Mariana Bertoncelli Tanaka*, Mohamed Noureldin*, Saiful Miah*, Taimur Shah*, Martin J. Connor*, Deepika Reddy*, Martin Clark§, Amish Lakhani§, Andrea Rockall§, Feargus Hosking-Jervis*, Emma Cullen*, Manit Arya*, David Hrouda, Hasan Qazi, Mathias Winkler*, Henry Tam§ and Hashim U. Ahmed*

*Imperial Prostate, Division of Surgery, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Imperial Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK, Department of Radiotherapy, University Medical Centre, Utrecht, The Netherlands, §Department of Radiology, Charing Cross Hospital, Imperial College Healthcare NHS Trust and Department of Urology, St. George’s Hospital, St. George’s Healthcare NHS Trust, London, UK

Abstract

Objective

To compare the clinical validity and utility of Likert assessment and the Prostate Imaging Reporting and Data System (PI‐RADS) v2 in the detection of clinically significant and insignificant prostate cancer.

Patients and Methods

A total of 489 pre‐biopsy multiparametric magnetic resonance imaging (mpMRI) scans in consecutive patients were subject to prospective paired reporting using both Likert and PI‐RADS v2 by expert uro‐radiologists. Patients were offered biopsy for any Likert or PI‐RADS score ≥4 or a score of 3 with PSA density ≥0.12 ng/mL/mL. Utility was evaluated in terms of proportion biopsied, and proportion of clinically significant and insignificant cancer detected (both overall and on a ‘per score’ basis). In those patients biopsied, the overall accuracy of each system was assessed by calculating total and partial area under the receiver‐operating characteristic (ROC) curves. The primary threshold of significance was Gleason ≥3 + 4. Secondary thresholds of Gleason ≥4 + 3, Ahmed/UCL1 (Gleason ≥4 + 3 or maximum cancer core length [CCL] ≥6 or total CCL≥6) and Ahmed/UCL2 (Gleason ≥3 + 4 or maximum CCL ≥4 or total CCL ≥6) were also used.

Table 1: Comparison of Likert and Prostate Imaging Reporting and Data System scoring.

Results

The median (interquartile range [IQR]) age was 66 (60–72) years and the median (IQR) prostate‐specific antigen level was 7 (5–10) ng/mL. A similar proportion of men met the biopsy threshold and underwent biopsy in both groups (83.8% [Likert] vs 84.8% [PI‐RADS v2]; P = 0.704). The Likert system predicted more clinically significant cancers than PI‐RADS across all disease thresholds. Rates of insignificant cancers were comparable in each group. ROC analysis of biopsied patients showed that, although both scoring systems performed well as predictors of significant cancer, Likert scoring was superior to PI‐RADS v2, exhibiting higher total and partial areas under the ROC curve.

Conclusions

Both scoring systems demonstrated good diagnostic performance, with similar rates of decision to biopsy. Overall, Likert was superior by all definitions of clinically significant prostate cancer. It has the advantages of being flexible, intuitive and allowing inclusion of clinical data. However, its use should only be considered once radiologists have developed sufficient experience in reporting prostate mpMRI.

Editorial: Does prostate MRI reporting system affect performance of MRI in men with a clinical suspicion of PCa?

Magnetic Resonance Imaging (MRI) of prostate continues to transform the way prostate cancer is being diagnosed and risk stratified. Multiple prospective single (e.g. the Biparametric MRI for Detection of Prostate Cancer [BIDOC] [1] and Improved Prostate Cancer Diagnosis ‐ Combination of Magnetic Resonance Imaging and Biomarkers [IMPROD] [2]) and multi‐institution trials (e.g. PROstate MRI Imaging Study [PROMIS] [3], PRostate Evaluation for Clinically Important Disease: Sampling Using Image‐guidance Or Not? [PRECISION] [4], multi‐institutional IMPROD (Multi‐IMPROD) [5], Assessment of Prostate MRI Before Prostate Biopsies [MRI‐FIRST] [6]) have demonstrated the potential of prostate MRI to limit the number of unnecessary biopsies in men with suspected prostate cancer.

In this issue of the BJUI, Khoo et al. [7] retrospectively analysed reports from a multicentre prostate cancer pathway registry, Rapid Assessment and Prostate Imaging for Diagnosis (RAPID). Men with a clinical suspicion of prostate cancer were enrolled based on various clinical criteria such as: age, performance status, and PSA level. All men had a pre‐biopsy MRI, including dynamic contrast‐enhanced MRI, reported using a 5‐point Likert scale and Prostate Imaging Reporting and Data System version 2.0 (PI‐RADSv2.0) systems by one of four uro‐radiologists (5–9 years of experience of prostate multi‐parametric MRI). Subsequently, all Likert and PI‐RADSv2.0 scores were reviewed by a dedicated reader in a multidisciplinary team setting. Likert scores were reported with knowledge of clinical variables such as: PSA, patient age, and past medical history. Men with Likert or PI‐RADSv2.0 score ≥4 or a score of 3 with a PSA density ≥0.12 ng/mL/mL underwent transperineal targeted prostate biopsies. Additionally, some men below these thresholds deemed to be at particularly high risk of prostate cancer (usually based on presence of other risk factors such as family history, high PSA kinetics or ethnic risk) were also offered biopsy on a case‐by‐case basis. At least three targeted cores were taken from each MRI‐suspicious lesion and no systematic biopsy cores were included in this analysis.

In total, 489 men were included in the analyses, with 377 and 408 men meeting the Likert and PI‐RADSv2.0 biopsy thresholds, respectively, of whom 316 (83.8%) and 346 (84.8%) proceeded to biopsy (P = 0.704), respectively. The Likert system predicted more clinically significant prostate cancer than PI‐RADSv2.0, e.g., 58.2% (184/316) vs 53.2% (184/346) of prostate cancer (P = 0.190) with Gleason score ≥3+4. Detection rates of clinically insignificant prostate cancer were comparable. The authors concluded that the Likert system was superior to PI‐RADSv2.0.

The authors should be congratulated on their effort to improve prostate MRI as a risk‐stratification and biopsy targeting tool. However, caution should be applied when translating these results to other centres. In order to access inter‐centre variability and to allow independent external validation, research groups should provide access to their imaging and patient level data. The authors do not provide such access and do not present inter‐reader variability of Likert vs PI‐RADv2.0 for all enrolled men. Similar to other trials evaluating prostate MRI in men with a clinical suspicion of prostate cancer, true prostate cancer and significant prostate cancer prevalence in this cohort is unknown, as men did not undergo saturation biopsy or prostatectomy with whole‐mount prostatectomy sections.

Overall, this retrospective analysis by Khoo et al. [7], comparing Likert scores reported using clinical variables vs PIRADSv2.0, provides further evidence that good quality prostate MRI can be used as a risk‐stratification and biopsy targeting tool in men with a clinical suspicion of prostate cancer. Each centre needs to develop its own quality control process and continually review its own performance measures of prostate MRI and MRI‐targeted biopsy. Furthermore, in order to access inter‐centre variability in performance of prostate MRI and MRI‐targeted biopsy, free public access to imaging and patient level data should be provided.

by Ivan Jambor and Ugo Falagorio

References

  1. Boesen LNørgaard NLogager V et al. Assessment of the diagnostic accuracy of biparametric magnetic resonance imaging for prostate cancer in biopsy‐naive men: the Biparametric MRI for Detection of Prostate Cancer (BIDOC) study. JAMA Netw Open 201811– 28
  2. Jambor IBoström PJTaimen P et al. Novel biparametric MRI and targeted biopsy improves risk stratification in men with a clinical suspicion of prostate cancer (IMPROD Trial). J Magn Reson Imaging 2017461089– 95
  3. Ahmed HUEl‐Shater Bosaily ABrown LC et al. Diagnostic accuracy of multi‐parametric MRI and TRUS Biopsy in prostate cancer (PROMIS): a paired validating confirmatory  study. Lancet 2017389815– 22
  4. Kasivisvanathan VRannikko ASBorghi M et al. MRI‐targeted or standard biopsy for prostate‐cancer diagnosis. N Engl J Med 20183781767– 77
  5. Jambor IVerho JEttala O et al. Validation of IMPROD biparametric MRI in men with clinically suspected prostate cancer: A prospective multi‐institutional trial. PLoS Med 201916: e1002813.
  6. Rouvière OPuech PRenard‐Penna R et al. Use of prostate systematic and targeted biopsy on the basis of multiparametric MRI in biopsy‐naive patients (MRI‐FIRST): a prospective, multicentre, paired diagnostic study. Lancet Oncol 201920100– 9
  7. Khoo CCEldred‐Evans DPeters M et al. Likert vs PI‐RADS v2: a comparison of two radiological scoring systems for detection of clinically significant prostate cancer. BJU Int 2019; 125:49-55.

 

Video: Likert vs PI-RADS v2

Likert vs PI‐RADS v2: a comparison of two radiological scoring systems for detection of clinically significant prostate cancer

Read the full article

Abstract

Objective

To compare the clinical validity and utility of Likert assessment and the Prostate Imaging Reporting and Data System (PI‐RADS) v2 in the detection of clinically significant and insignificant prostate cancer.

Patients and Methods

A total of 489 pre‐biopsy multiparametric magnetic resonance imaging (mpMRI) scans in consecutive patients were subject to prospective paired reporting using both Likert and PI‐RADS v2 by expert uro‐radiologists. Patients were offered biopsy for any Likert or PI‐RADS score ≥4 or a score of 3 with PSA density ≥0.12 ng/mL/mL. Utility was evaluated in terms of proportion biopsied, and proportion of clinically significant and insignificant cancer detected (both overall and on a ‘per score’ basis). In those patients biopsied, the overall accuracy of each system was assessed by calculating total and partial area under the receiver‐operating characteristic (ROC) curves. The primary threshold of significance was Gleason ≥3 + 4. Secondary thresholds of Gleason ≥4 + 3, Ahmed/UCL1 (Gleason ≥4 + 3 or maximum cancer core length [CCL] ≥6 or total CCL≥6) and Ahmed/UCL2 (Gleason ≥3 + 4 or maximum CCL ≥4 or total CCL ≥6) were also used.

Results

The median (interquartile range [IQR]) age was 66 (60–72) years and the median (IQR) prostate‐specific antigen level was 7 (5–10) ng/mL. A similar proportion of men met the biopsy threshold and underwent biopsy in both groups (83.8% [Likert] vs 84.8% [PI‐RADS v2]; P = 0.704). The Likert system predicted more clinically significant cancers than PI‐RADS across all disease thresholds. Rates of insignificant cancers were comparable in each group. ROC analysis of biopsied patients showed that, although both scoring systems performed well as predictors of significant cancer, Likert scoring was superior to PI‐RADS v2, exhibiting higher total and partial areas under the ROC curve.

Conclusions

Both scoring systems demonstrated good diagnostic performance, with similar rates of decision to biopsy. Overall, Likert was superior by all definitions of clinically significant prostate cancer. It has the advantages of being flexible, intuitive and allowing inclusion of clinical data. However, its use should only be considered once radiologists have developed sufficient experience in reporting prostate mpMRI.

 

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Article of the month: Exercise‐induced attenuation of treatment side‐effects in patients with newly diagnosed PCa beginning androgen‐deprivation therapy: a randomised controlled trial

Every month, the Editor-in-Chief selects an Article of the Month from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an editorial written by a prominent member of the urology community, a video prepared by the authors and a visual abstract providing a graphical representation of the article; we invite you to use the comment tools at the bottom of each post to join the conversation. 

If you only have time to read one article this week, we recommend this one.

Exercise‐induced attenuation of treatment side‐effects in patients with newly diagnosed prostate cancer beginning androgen‐deprivation therapy: a randomised controlled trial

Wilphard Ndjavera*, Samuel T. Orange, Alasdair F. O’Doherty, Anthony S. Leicht, Mark Rochester*, Robert Mills* and John M. Saxton†§

*Department of Urology, Norfolk and Norwich University Hospital, Norwich, UK, Department of Sport, Exercise and Rehabilitation, Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK, Sport and Exercise Science, College of Healthcare Sciences, James Cook University, Townsville, QLD, Australia and §Norwich Medical School, Faculty of Medicine and Health Sciences, Norwich Research Park, University of East Anglia, Norwich, UK

Read the full article

Abstract

Objectives

(i) To assess whether exercise training attenuates the adverse effects of treatment in patients with newly diagnosed prostate cancer beginning androgen‐deprivation therapy (ADT), and (ii) to examine whether exercise‐induced improvements are sustained after the withdrawal of supervised exercise.

Patients and Methods

In all, 50 patients with prostate cancer scheduled for ADT were randomised to an exercise group (n = 24) or a control group (n = 26). The exercise group completed 3 months of supervised aerobic and resistance exercise training (twice a week for 60 min), followed by 3 months of self‐directed exercise. Outcomes were assessed at baseline, 3‐ and 6‐months. The primary outcome was difference in fat mass at 3‐months. Secondary outcomes included: fat‐free mass, cardiopulmonary exercise testing variables, QRISK®2 (ClinRisk Ltd, Leeds, UK) score, anthropometry, blood‐borne biomarkers, fatigue, and quality of life (QoL).

Table 2 Outcomes at baseline, 3- and 6-months.

Results

At 3‐months, exercise training prevented adverse changes in peak O2 uptake (1.9 mL/kg/min, P = 0.038), ventilatory threshold (1.7 mL/kg/min, P = 0.013), O2 uptake efficiency slope (0.21, P = 0.005), and fatigue (between‐group difference in Functional Assessment of Chronic Illness Therapy‐Fatigue score of 4.5 points, P = 0.024) compared with controls. After the supervised exercise was withdrawn, the differences in cardiopulmonary fitness and fatigue were not sustained, but the exercise group showed significantly better QoL (Functional Assessment of Cancer Therapy‐Prostate difference of 8.5 points, P = 0.034) and a reduced QRISK2 score (−2.9%, P = 0.041) compared to controls.

Conclusion

A short‐term programme of supervised exercise in patients with prostate cancer beginning ADT results in sustained improvements in QoL and cardiovascular events risk profile.

 

Editorial: The benefits of regular exercise

January is the month when we wish each other happiness and success for the year ahead. It is also the month when many are recovering from the excesses of the festive season. This is the time when gyms and diets become popular again with offers of reduced rates to attract customers. For Londoners the spring marathon is not far away and you often see runners training in different parks despite the cold weather and icy routes.

If you think this year is the one where you are about to start going to the gym, then we recommend you the best shake for post workout to add extra point to your routine.

Is this just a temporary fad? Or is there truly some benefit to be had by exercising regularly?

Over the past few years, we have published several papers showing clear associations between metabolic syndrome and LUTS, and the benefits of preoperative optimisation with diet and exercise prior to major urological surgery. In this issue of the BJUI, we present a small but well‐designed randomised controlled trial on the benefits of exercise in attenuating the treatment side‐effects in patients with newly diagnosed prostate cancer starting on androgen‐deprivation therapy [1]. It is an example of collaborative working between Urologists and experts on Sport, Exercise and Rehabilitation therapy. The authors clearly demonstrate that a short‐term programme of supervised exercise results in improvements in quality of life and cardiovascular risk profile in patients on hormonal therapy. Even after the supervised exercise was withdrawn and followed by self‐directed exercise, the benefits continued as compared to the control group.

As Urologists, we can help our patients in this journey by adopting a more active lifestyle ourselves. Inspired by Fiona Godlee’s article in the BMJ [2], I have started printing it and actually handing it/e‐mailing it to my patients. The paper describes physical activity as ‘The miracle cure’ with very few side‐effects. Any level of activity is better than none and a gentle start usually avoids an unexpected injury.

There is no better time to lead by example this New Year!

by Prokar Dasgupta

References

  1. Ndjevera WOrange STO’Doherty AF et al. Exercise‐induced attenuation of treatment side‐effects in patients with newly diagnosed prostate cancer beginning androgen‐deprivation therapy: a randomised controlled trial. BJU Int 2019: 125; 28-37.
  2. Godlee FThe miracle cureBMJ 2019366l5605.

Video: Exercise‐induced attenuation of treatment side‐effects in patients with newly diagnosed PCa beginning androgen‐deprivation therapy

Exercise‐induced attenuation of treatment side‐effects in patients with newly diagnosed prostate cancer beginning androgen‐deprivation therapy: a randomised controlled trial

Read the full article

Abstract

Objectives

(i) To assess whether exercise training attenuates the adverse effects of treatment in patients with newly diagnosed prostate cancer beginning androgen‐deprivation therapy (ADT), and (ii) to examine whether exercise‐induced improvements are sustained after the withdrawal of supervised exercise.

Patients and Methods

In all, 50 patients with prostate cancer scheduled for ADT were randomised to an exercise group (n = 24) or a control group (n = 26). The exercise group completed 3 months of supervised aerobic and resistance exercise training (twice a week for 60 min), followed by 3 months of self‐directed exercise. Outcomes were assessed at baseline, 3‐ and 6‐months. The primary outcome was difference in fat mass at 3‐months. Secondary outcomes included: fat‐free mass, cardiopulmonary exercise testing variables, QRISK®2 (ClinRisk Ltd, Leeds, UK) score, anthropometry, blood‐borne biomarkers, fatigue, and quality of life (QoL).

Results

At 3‐months, exercise training prevented adverse changes in peak O2 uptake (1.9 mL/kg/min, P = 0.038), ventilatory threshold (1.7 mL/kg/min, P = 0.013), O2 uptake efficiency slope (0.21, P = 0.005), and fatigue (between‐group difference in Functional Assessment of Chronic Illness Therapy‐Fatigue score of 4.5 points, P = 0.024) compared with controls. After the supervised exercise was withdrawn, the differences in cardiopulmonary fitness and fatigue were not sustained, but the exercise group showed significantly better QoL (Functional Assessment of Cancer Therapy‐Prostate difference of 8.5 points, P = 0.034) and a reduced QRISK2 score (−2.9%, P = 0.041) compared to controls.

Conclusion

A short‐term programme of supervised exercise in patients with prostate cancer beginning ADT results in sustained improvements in QoL and cardiovascular events risk profile.

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Visual abstract: Exercise‐induced attenuation of treatment side‐effects in patients with newly diagnosed prostate cancer beginning androgen‐deprivation therapy: a randomised controlled trial

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Residents’ podcast: Health‐related quality of life among non‐muscle‐invasive bladder cancer survivors: a population‐based study

Maria Uloko is a Urology Resident at the University of Minnesota Hospital. In this podcast she discusses a recent Article of the week:

Health‐related quality of life among non‐muscle‐invasive bladder cancer survivors: a population‐based study

Read the full article

Abstract

Objective

To examine the effect of non‐muscle‐invasive bladder cancer (NMIBC) diagnosis and treatment on survivors’ quality of life (QoL).

Patients and Methods

Of the 5979 patients with NMIBC diagnosed between 2010 and 2014 in North Carolina, 2000 patients were randomly selected to be invited to enroll in this cross‐sectional study. Data were collected by postal mail survey. The European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire‐Core (QLQ‐C30) and the NMIBC‐specific module were included in the survey to measure QoL. Descriptive statistics, t‐tests, anova, and Pearson’s correlation were used to describe demographics and to assess how QoL varied by sex, cancer stage, time since diagnosis, and treatment.

Results

A total of 398 survivors returned questionnaires (response rate: 23.6%). The mean QoL score for QLQ‐C30 (range 0–100, higher = better QoL in all domains but symptoms) for global health status was 73.6, function domain scores ranged from 83.9 to 86.5, and scores for the top five symptoms (insomnia, fatigue, dyspnoea, pain, and financial difficulties) ranged from 14.1 to 24.3. The lowest NMIBC‐specific QoL domain was sexual issues including sexual function, enjoyment, problems, and intimacy. Women had worse bowel problems, sexual function, and sexual enjoyment than men but better sexual intimacy and fewer concerns about contaminating their partner. Stage Ta had the highest global health status, followed by T1 and Tis. QoL did not vary by time since diagnosis except for sexual function. The cystectomy group (n = 21) had worse QoL in sexual function, discomfort with sexual intimacy, sexual enjoyment, and male sexual problems than the non‐cystectomy group (n = 336).

Conclusion

Survivors of NMIBC face a unique burden associated with their diagnosis and the often‐lifelong surveillance and treatment regimens. The finding has important implications for the design of tailored supportive care interventions to improve QoL for NMIBC survivors.

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