Tag: Prostate cancer

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Changing the LATITUDE of Treatment for High-Risk Hormone-Naïve Prostate Cancer: STAMPEDE-ing Towards Androgen Biosynthesis Inhibition

June 13, 2017/by Zachary Klaasen

Earlier this month at the annual American Society of Clinical Oncology (ASCO) meeting in Chicago, IL, Dr. Karim Fizazi and Dr. Nicholas James (@Prof_Nick_James) presented results from the LATITUDE and STAMPEDE trials, respectively. These randomized controlled trials (RCTs) assessed the utility of adding abiraterone acetate (AA) + prednisone to conventional androgen deprivation therapy (ADT) among men with high-risk, hormone-naïve prostate cancer. Since Dr. Charles Huggins’ 1941 Nobel prize winning finding that ADT is highly effective in controlling metastatic prostate cancer, nearly 70 years passed before CHAARTED and STAMPEDE demonstrated in 2015 that the addition of docetaxel to ADT prolongs survival in men with high volume metastatic prostate cancer. The de novo metastatic prostate cancer global incidence is striking: 3% in the US and rising, 6% across Europe, 4-10% in Latin America, and nearly 60% in Asia-Pacific. Historically, ADT has been standard of care, however most men with metastases progress to metastatic castration-resistant prostate cancer (mCRPC) driven by the reactivation of androgen receptor (AR) signaling. The rationale for adding AA + prednisone to ADT for metastatic hormone-naïve prostate cancer patients is threefold: (i) the mechanism of resistance to ADT may develop early, (ii) ADT alone does not inhibit androgen synthesis by the adrenal glands or prostate cancer cells, and (iii) AA + prednisone improves overall survival (OS) in mCRPC patients and reduces tumor burden in high-risk, localized prostate cancer.

LATITUDE

LATITUDE was conducted at 235 sites in 34 countries in Europe, Asia-Pacific, Latin America, and Canada. The objectives of the study were to evaluate the addition of AA + prednisone to ADT on clinical benefit in men with newly diagnosed, high-risk, metastatic hormone-naïve prostate cancer. Patients were stratified by the presence of visceral disease (yes/no) and ECOG performance status (0, 1 vs 2) and then randomized 1:1 to either ADT + AA (1000 mg daily) + prednisone (5 mg) (n=597) or ADT + placebo (n=602). The co-primary endpoints were OS and radiographic progression-free survival (rPFS). Secondary endpoints included time to: (i) pain progression, (ii) PSA progression, (iii) next symptomatic skeletal event, (iv) chemotherapy, and (v) subsequent prostate cancer therapy. The study was powered to detect an HR of 0.67 and 0.81 in favor of AA for rPFS and OS, respectively.
Over a median follow-up of 30.4 months, patients treated with ADT + AA + prednisone had a 38% risk reduction of death (HR 0.62, 95%CI 0.51-0.76) compared to ADT + placebo.

Median OS was not yet reached in the ADT + AA + prednisone arm compared to 34.7 months in the ADT + placebo arm. OS rates at 3 years for the ADT + AA + prednisone arm was 66%, compared to 49% in the ADT + placebo arm. This OS benefit was consistently favorable across all subgroups including ECOG 0 and 1-2, visceral metastases, Gleason ≥8 disease, and bone lesions >10.

There was also 53% risk of reduction of radiographic progression or death for patients treated with ADT + AA + prednisone (median 33.0 months; HR 0.47, 95%CI 0.39-0.55) compared to ADT + placebo (14.8 months).

Secondary endpoints showed statistically significant improvement for ADT + AA + prednisone, including time to PSA progression (HR 0.30, 95%CI 0.26-0.35), time to pain progression (HR 0.70, 95%CI 0.58-0.83), time to next symptomatic skeletal event (HR 0.70, 95%CI 0.54-0.92), time to chemotherapy (HR 0.44, 95%CI 0.35-0.56), and time to subsequent prostate cancer therapy (HR 0.42, 95%CI 0.35-0.50).

Secondary to the results presented at ASCO, the study was discontinued after the first interim analysis. Adverse events were comparable in the two groups. Hypertension only rarely required treatment discontinuation, and only two patients discontinued treatment due to hypokalemia (no hypokalemia-related deaths). Two patients in each arm died of cerebrovascular events, and 10 patients treated with ADT + AA + prednisone compared to 6 patients treated with ADT + placebo died of cardiac disorders.

STAMPEDE

STAMPEDE is a large multi-stage, multi-arm, RCT being conducted in the United Kingdom to assess the utility of novel therapeutic agents in conjunction with ADT. Currently being tested are AA, enzalutamide, zoledronic acid, docetaxol, celecoxib and radiotherapy (RT). The AA arm of the study was presented at ASCO as a late-breaking abstract. Inclusion criteria included men with locally advanced or metastatic prostate cancer, including newly diagnosed with N1 or M1 disease, or any two of the following: stage T3/4, PSA ≥ 40 ng/mL, or Gleason score 8-10. Patients undergoing prior radical prostatectomy or RT were eligible if they had more than one of the following: PSA ≥ 4 ng/mL and PSADT < 6 months, PSA ≥ 20 ng/mL, N1, or M1 disease. Patients were then randomized 1:1 to standard of care (SOC; ADT for ≥2 years, n=957) vs SOC + AA (1000 mg) + prednisone 5 mg daily (n=960). Treatment with RT was mandated in patients with N0M0 disease, while strongly encouraged for N1M0 patients. Primary outcomes were OS and failure-free survival (FFS), where failure was defined as PSA failure, local failure, lymph node failure, distant metastases or prostate cancer death. Secondary outcome included toxicity and skeletal-related events (SREs). The study was powered to detect a 25% improvement in OS for the treatment group (requiring 267 control arm mortalities).
Both groups were balanced and patients were predominantly metastatic (52% M1, 20% N+M0, 28% N0M0), median was PSA 53 ng/mL, and 99% were treated with LHRH analogues. Over a median follow-up of 40 months, there were 262 control arm deaths, of which 82% were prostate cancer-related; there were 184 deaths in the SOC + AA + prednisone arm. There was a 37% relative improvement in overall survival (HR 0.63, 95%CI 0.52-0.76) favoring SOC + AA + prednisone.

A Forrest plot split on stratification factors demonstrated no evidence of heterogeneity based on any of the factors, including M0/M1 status (p=0.37). Second, SOC+AA + prednisone demonstrated a 71% improvement in FFS (HR 0.29, 95%CI 0.25-0.34), with an early split in the KM curves.

SOC + AA + prednisone also significantly decreased SREs among the entire cohort (HR 0.46, 95%CI 0.37-0.58), as well as specifically in the M1 cohort (HR 0.45, 95%CI 0.37-0.58). This resulted in a 55% reduction in SREs in the M1 subset analysis.

When looking at treatment progression, 89% of the SOC arm went on to next line of therapy, whereas 79% of the SOC + AA + prednisone arm received additional therapy, most commonly docetaxel. As expected, the rate of Grade 3-5 adverse events was higher in the SOC + AA prednisone arm (47% vs. 33%), and were primarily cardiovascular (HTN, MI, cardiac dysrhythmias) or hepatic (transaminitis) in nature.

REACTION, INTERPRETATION & FUTURE DIRECTIONS

As has become the norm during academic conferences, there was significant buzz on Twitter over the course of the two days these results were presented:

This also included the New England Journal of Medicine immediately tweeting after the presentations that LATITUDE and STAMPEDE were published instantaneously:

Furthermore, immediately following Dr. Fizazi’s presentation of LATITUDE, Dr. Eric Small from @UCSF presented a discussion of LATITUDE. A number of important points were raised. First, although this was a well-designed, placebo controlled, randomized phase III study, early unblinding (although appropriate) resulting in an HR of 0.62 for OS is based on only 50% of the targeted total deaths. Making conclusions based on interim analyses must be made with caution. However, with every endpoint reaching statistical significance and conditional probability modeling, if the study had remained blinded, the probability of reaching the same conclusions is high. Second, since twice as many patients in the ADT + placebo arm received life-prolonging therapy than compared to the ADT + AA + placebo arm, the benefit of AA is not explained by more secondary life-prolonging therapy, strengthening the cause for AA + ADT.

Perhaps the most interesting and pertinent clinical comparison is assessing outcomes of the LATITUDE and CHAARTED (high-volume disease) treatment arms (AA vs docetaxel). With similar median OS outcomes between the ADT control arms of the two trials (suggesting similar populations), the HRs for OS based on treatment are nearly identical:

Similarly, the rPFS outcomes were comparable between the two trials:

With nearly identical OS and rPFS outcomes for men receiving ADT + AA or ADT + docetaxel, the question becomes whether the impact of adding AA to ADT is volume or risk dependent. Results from the STAMPEDE trial would suggest remarkably similar outcomes support the use of AA + ADT in patients with less burden of disease. Arguably the most important slide of the meeting was captured and tweeting by Dr. Agarwal (@neerajaiims):

Dr. Small eloquently summarized future directions into two groups. Unanswered questions regarding efficacy include: (i) Can a genomic classifier be used to select patients more likely to benefit from AA or docetaxel? (ii) Can AA be added in even earlier settings (with radiation? Increasing PSAs?) (iii) Should AA and docetaxel be combined or used sequentially? Additionally, there are also unanswered questions regarding AA resistance, including (i) Will the mechanisms of resistance to AA be the same when used in the non-mCRPC setting? (ii) Will androgen receptor amplification still be observed? (iii) Will there be an increased risk of treatment-associated small cell/neuroendocrine prostate cancer? (iv) Does adding chemotherapy or AA to ADT result in more aggressive disease at the time of resistance? (v) What is the optimal therapy for a patient who progresses on ADT + AA, compared to a patient who progresses on ADT + docetaxel? Given the avoidance of potential chemotherapy related side effects (ie. neutropenic complications) for an oral, long-term treatment, AA + ADT should be considered standard of care for untreated, high-risk metastatic prostate cancer.

But what is the long-term economic landscape like when practice changing trials such as LATITUE and STAMPEDE suddenly thrust an expensive medication such as AA + prednisone directly to the forefront of hormone-naïve disease? Following these presentations, urologic oncologist, Twitter veteran, and Forbes correspondent Dr. Ben Davies (@daviesbj) wrote a provocative piece highlighting the potential ‘financial toxicity’ (particularly in the United States) that may result downstream of these trials:

A conservative estimate is a wholesale cost of $115,000 per year per patient for AA + prednisone, resulting in a crude estimate of a $2.8 billion annual expenditure for the drug in the United States alone if used in the hormone-naïve setting, according to Dr. Davies. As Dr. Davies also points outs, although the patent for AA expired in 2016 and there are currently 13 applications to make generic AA, the patent for prednisone lasts until 2027, with $30 billion riding on the lawsuit. Dr. David Penson (@urogeek) succinctly summarized via Twitter:

Strictly academically speaking, LATITUDE and STAMPEDE, in addition to the docetaxel benefits of CHAARTED, have provided clinicians with exciting Level 1 evidence for improving patient care in the high-risk/metastatic setting. The investigators and more importantly the thousands of patients and families are to be thanked and congratulated for their perseverance, hard-work, and willingness to participate in these practice-changing clinical trials. It is our job as clinicians to continue advocating the best treatment for our patients, whether this be through economic barriers in the United States, or access to appropriate care on a global scale.

Zach Klaassen, MD

Urologic Oncology Fellow

University of Toronto/Princess Margaret Cancer Centre

Toronto, Ontario, Canada

@zklaassen_md

What’s the Diagnosis?

May 24, 2017/by admin Z.9

This patient is undergoing radiotherapy for recurrent prostate cancer. Images from Fodor et al, BJUI 2017.

No such quiz/survey/poll

The 5th BJUI Social Media Awards

May 17, 2017/1 Comment/by Declan Murphy

It’s hard to believe that we have been doing the BJUI Social Media Awards for five years now! I recall vividly our inaugural BJUI Social Media Awards in 2013, as the burgeoning social media community in urology gathered in the back of an Irish Bar in San Diego to celebrate all things social. At that time, many of us had only got to know each other through Twitter, and it was certainly fun going around the room putting faces with twitter handles for the first time. That spirit continues today as the “uro-twitterati” continues to grow, and the BJUI Awards, (or the “Cult” Awards as our Editor-in-Chief likes to call them), remains a fun annual focus for the social-active urology community to meet up in person.

As you may know, we alternate the Awards between the annual congresses of the American Urological Association (AUA) and of the European Association of Urology (EAU). Last year, we descended on Munich, Germany to join the 13,000 or so other delegates attending the EAU Annual Meeting and to enjoy all the wonderful Bavarian hospitality on offer. This year, we set sail for the #AUA17 Annual Congress in Boston, MA, along with over 16,000 delegates from 100 different countries. What a great few days in beautiful Boston and a most welcome return for the AUA to this historic city. Hopefully it will have a regular spot on the calendar, especially with the welcome dumping of Anaheim and Orlando as venues for the Annual Meeting.

Awards

On therefore to the Awards. These took place on Saturday 13^th May 2017 in the City Bar of the Westin Waterfront Boston. Over 80 of the most prominent uro-twitterati from all over the world turned up to enjoy the hospitality of the BJUI and to hear who would be recognised in the 2017 BJUI Social Media Awards. We actually had to shut the doors when we reached capacity so apologies to those who couldn’t get in! Individuals and organisations were recognised across 12 categories including the top gong, The BJUI Social Media Award 2017, awarded to an individual, organization, innovation or initiative who has made an outstanding contribution to social media in urology in the preceding year. The 2013 Award was won by the outstanding Urology Match portal, followed in 2014 by Dr Stacy Loeb for her outstanding individual contributions, and in 2015 by the #UroJC twitter-based journal club. Last year’s award went to the #ilooklikeaurologist social media campaign which we continue to promote.

This year our Awards Committee consisted of members of the BJUI Editorial Board – Declan Murphy, Prokar Dasgupta, Matt Bultitude, Stacy Loeb, John Davis, as well as BJUI Managing Editor Scott Millar whose team in London (Max and Clare) drive the content across our social platforms. The Committee reviewed a huge range of materials and activity before reaching their final conclusions.

The full list of winners is as follows:

Most Read Blog@BJUI – “The optimal treatment of patients with localized prostate cancer: the debate rages on”. Dr Chris Wallis, Toronto, Canada

Most Commented Blog@BJUI – “It’s not about the machine, stupid”. Dr Declan Murphy, Melbourne, Australia

Most Social Paper – “Novel use of Twitter to disseminate and evaluate adherence to clinical guidelines by the European Association of Urology”. Accepted by Stacy Loeb on behalf of herself and her colleagues.

Best BJUI Tube Video – “Combined mpMRI Fusion and Systematic Biopsies Predict the Final Tumour Grading after Radical Prostatectomy”. Dr Angela Borkowetz, Dresden, Germany

Best Urology Conference for Social Media – #USANZ17 – The Annual Scientific Meeting of the Urological Association of Australia & New Zealand (USANZ) 2017. Accepted by Dr Peter Heathcote, Brisbane, Australia. President of USANZ.

Best Urology App – The EAU Guidelines App. Accepted by Dr Maria Ribal, Barcelona, Spain, on behalf of the EAU.

Innovation Award – BJUI Urology Ontology Hashtags keywords. Accepted by Dr Matthew Bultitude, London, UK, on behalf of the BJUI.

#UroJC Award – Dr Brian Stork, Michigan, USA. Accepted by Dr Henry Woo of Brian’s behalf.

Most Social Trainee – Dr Chris Wallis, Toronto, Canada

Best Urology Journal for Social Media –Journal of Urology/Urology Practice. Accepted by Dr Angie Smith, Chapel Hill, USA, on behalf of the AUA Publications Committee.

Best Urology Organisation – Canadian Urological Association. Accepted by Dr Mike Leveridge, Vice-President of Communications for CUA.

The BJUI Social Media Award 2017 – The Urology Green List, accepted by Dr Henry Woo, Sydney, Australia.

All the Award winners (except Dr Brian Stork who had to get home to work), were present to collect their awards themselves. A wonderful spread of socially-active urology folk from all over the world, pictured here with BJUI Editor-in-Chief, Prokar Dasgupta.

A special thanks to our outstanding BJUI team at BJUI in London, Scott Millar, Max Cobb and Clare Dunne, who manage our social media and website activity as well as the day-to-day running of our busy journal.

See you all in Copenhagen for #EUA18 where we will present the 6th BJUI Social Media Awards ceremony!

Declan Murphy

Peter MacCallum Cancer Centre, Melbourne, Australia

Associate Editor, BJUI

@declangmurphy

The USPSTF Changes Course: a “C” rating for PSA screening in ages 55-69. I did not see this coming.

April 11, 2017/5 Comments/by John Davis

It should surprise no one that I never agreed with the 2012 United States Preventive Services Task Force to give PSA a “D” rating that has led to decreases in U.S. rates of PSA testing, biopsies, and diagnosis of low- through high-risk cancer. I take care of men with prostate cancer in a multidisciplinary clinic at a dedicated cancer hospital. I perform robotic surgeries and manage over a 1,000 men on active surveillance. If you search the BJUI blogs, you can find the often viewed (>80K) “Melbourne Consensus Statement on Prostate Cancer Testing” that included 15 authors who produced 5 consensus statements on the topic. There are 62 comments—comment #5 is a fairly famous one that equates the panel to “a group of 10 pig-farmers telling us we should eat more bacon.” So yes, I think I count as a pig farmer here. My maternal grandfather and great uncle farmed pigs in Western Tennessee, so it does run in the family.

Figure 1: It was either this or robotics

That said, it always seemed odd, that as a large country and major healthcare market, we rolled out PSA screening in the 1990s with wild enthusiasm and without data on benefit, only to then try and roll it back in when faced with two conflicting level 1 evidence studies. Meanwhile, the American Urological Association guidelines recommended PSA screening (with the “shared decision making caveat”)—mostly mirroring the European study—for men ages 55-69 (also consensus statement 1 from the Melbourne consensus). However, a recent fact struck me during a conference talk—Urologists in the U.S. are estimated to order <10% of all PSA tests, and a vast majority are from primary care physicians. So in essence it doesn’t matter as much what we think of one guideline versus another, it’s what the primary care specialties think that matters. As the USPSTF is targeted at primary care, their D rating did have an effect—fewer PSA tests, biopsies, and diagnosis of all grades of cancer (not just Gleason 6). We have heard stories over the years that specialty exams in primary care were starting to feature PSA screening questions, and the “don’t screen” answer was the one you got credit for. But I was also never convinced that most primary care physicians were comfortable with abandoning screening either. They must have seen what we saw—real cancers presenting later stage.

Some memorable quotes along these years of debate:

“There is no evidence prostate carcinogenesis has declined.” Joel Nelson, J Urol 2015

“I believe the USPSTF recommendations have created confusion at the patient and primary physician level, and that this confusion did not likely result in more informed, shared decision making, but instead avoidance of the issue.” Samir Taneja, J Urol.

Amen. So now it’s 2017 and the USPSTF has looked at the data again. They’ve had their “analysis” methods on the web for a while so we know something was planned. I can’t find authorship credits anywhere—we always complained that no prostate cancer experts were involved in the past, and now wondering who is driving this ship. The take home messages are:

Offer PSA screening to ages 55-69 with shared decision making. The narrative is not “do screening.” It’s a full paragraph with the often told caveats of individualized decisions, potential harms and benefits. It’s limited to the reduction in mortality way of thinking, i.e. no thought to preventing metastatic progression, palliative care, etc.
Don’t screen in men ages 70 and older. From an evidence standpoint—hard to argue and the AUA guidelines are similar. The Melbourne Consensus is at least polite enough to point out that not all men over age 70 are going to drop dead any minute, and maybe some of them should be screened if very healthy (level of evidence = CS for common sense).
We recognized that men with a family history of prostate cancer or African American race are higher risk, but we don’t have evidence to support a different screening policy. Again—hard to argue with the evidence and the AUA says the same.

So really that’s it—3 main concepts. This is likely to be a significant impact in the U.S., depending upon whether or not primary care physicians change practice (and their exam questions are the same with a different correct answer).

Probably what is on your mind now is “why the change.” It does not appear to be one thing—not even recent publications revealing a more significant pattern of PSA contamination in the PLCO trial. The checklist seems to include: 1) PCLO “issues”, 2) more data from ERSPC and its subsets, 3) more data on treatment benefit, and 4) increased use of active surveillance in low-risk disease. So the balance tipped in favor of a “C” although they state the benefits and harms are still close. Fair enough.

As I re-read the 2013 Melbourne Consensus and compare to the 2017 USPSTF statement, there is a lot of overlap now. So congrats to the Melbourne group for getting it right in the first place. I, myself, did not see this coming—just another example of why I don’t invest in individual stocks or otherwise pretend to know the future.

I apologize as I re-read this, as I realize we Americans think the world revolves around us. Many of you certainly live in countries that are against routine screening and manage to get by. By all means, please sound off on what you think this means for the international picture of men’s health.

Figure 2: Scenic Melbourne at dusk

John W. Davis is BJUI Associate Editor for oncology. @jdhdavis

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EAU 2017 Congress Days 1&2

April 5, 2017/4 Comments/by Rajesh Nair

≠WeAreNotAfraid. Perhaps the standout memory of EAU – London 2017. The 32nd Annual EAU Congress in London was marked with a message of defiance from colleagues and delegates from London, Great Britain, Europe and Worldwide. These were messages of solidarity, which rang through in person and on social media after an attack at Westminster. It was quite simple. London, Europe and the World will continue regardless of these tragic events and our urological fraternity beautifully demonstrated this as days following, a record-breaking attendance of 12000 delegates from over 123 countries descended to the Excel Centre in London, UK.

EAU-2017 had surpassed many a milestone. A record breaking 5000 abstracts were submitted for poster and video presentations from over 81 countries. 1200 presentations were displayed across 300 poster and video sessions. This year showcased an expansion of the number of plenary sessions from 4 to 7 allowing for a greater choice for all delegates. The quality, breadth and expertise behind the EBUS educational courses must be commended. Finally, as always, live surgery, which has year on year, proved to be popular was broadcast from Guy’s Hospital, London. They showcased the crème de la crème of surgical talent from live procedures with over 30 surgeons involved in operating, moderating, acting as patient advocates and in organisation. I, as I am sure all delegates extend our gratitude to the patients involved during the live surgical broadcast.

The camaraderie was clear to see. One could not take more than ten steps without running into a colleague or friend. It was a perfect opportunity to catch up, network and build relationships. Perhaps it was Prof. Sir Bruce Keogh (NHS England’s Medical Director and Commissioner of the Commission for Health Improvement (CHI)) who described it best in his opening address: ‘meetings like this are vitally important since it is at these occasions that knowledge and professional links are developed, and at these events ideas take seed and take hold: the important ideas that will later lead to significant work and progress in medicine.”

In addition, the opening ceremony showcased some the serious talent in urology. Awards for Prof. Paul Abrams, Prof. Per-Anders Abrahamsson, Prof. Christian Gratzke, Dr. Riccardo Autorino and Mr. Richard Turner-Warwick demonstrated their commitment, hard work and dedication to the specialty.

Day 1 began with multiple subspecialty meetings and meetings between affiliated sections. These themed discussions were stimulating and really addressed the trials and tribulations as well as successes in the delivery of urology worldwide. Day 1 also showcased a fantastic session organised by the prostate cancer prevention group. They examined the role of active surveillance in low risk prostate cancer with specific reference to data from ProtecT, ESRPC and the PLCO trials. Prof. Hamdy gave a comprehensive overview of the ProtecT study and reminded the audience that the risk of death from prostate cancer remains low (1% over ten years), and that surgery and radiotherapy although reduce cancer progression can result in bothersome side effects. The increasing role of urine based biomarkers; microRNA, imaging and genetic testing were all discussed when redefining the cohort of patients suitable for active surveillance.

The night ended with drinks at the Healtap, a bar outside Guy’s hospital, London. This was a throwback to the past for many. Old friends and colleagues, past fellows and current urologists all gathered to reminisce about past UK experiences. Following this, a late night serious session of serious recording and video production ensued with Declan Murphy and Alastair Lamb. For those open surgical protagonists who wonder ‘what have the robots ever done for us?’ I encourage you to watch:

The opening plenary session of Day 2: ‘Sleepless nights: Would you do the same again?’ chaired by Mr. Tim O’Brien critically re-evaluates some of the management decisions for kidney cancer from a medico-legal perspective. This session was fascinating and almost akin to a TV drama. A medico-legal lawyer (Mr. Leigh) vociferously cross-examining key members of faculty and an audience watching them sweat over what would have been initially perceived an acceptable clinical decision. A key message: allow your patients to take on decisions and not shoulder the entire burden yourself and the phrase; ‘your skills are for your patient, your notes are for yourselves’ continues to resonate.

Another EAU annual conference goes by with yet more casualties from a verbal punch up. The second session showcased a debate on robotic salvage prostatectomy between Declan Murphy and Axel Heidenreich. Perhaps the blood spilt from this joust reminded the audience that despite the rising bank of evidence favouring salvage prostatectomy, there will always remains debate when a salvage procedure is associated with increased morbidity and risk for the patient.

The ‘twitosphere’ was heavily active. The beauty of this as always is that if you were to miss sessions, lectures or abstracts, the ability to follow them on twitter in real time adds another dimension to conference attendance.

The most re-tweeted slide was presented by Dr. Ashish Kamat, a simple yes incredibly powerful slide demonstrating the equivalence in disease specific survival between high grade T1 urothelial carcinoma of the bladder and advanced prostate cancer reminded us all of the need to be vigilant and aggressive with high grade non muscle invasive disease of the bladder.

Day 2 brought out some of the best in abstracts, EBUS courses and updates in clinical trials. The latest developments in urological research include: the PROstate MRI Imaging Study (PROMIS) trial results reviewed by Hashim Ahmed and futher evidence and discussion from the Prostate Testing for Cancer and Treatment (ProtecT) trial by Freddie Hamdy. Prof. Jim Catto gave an eloquent talk examining the role of the enhanced recovery programme in radical cystectomy.

What a fantastic start to the meeting! As you shall see, the remainder of the meeting did not disappoint. Dr. Hendrick Borgmann will reveal all in the update of day 3 and 4.

Mr. Rajesh Nair

Fellow in Robotics and Uro-Oncology

The Royal Melbourne Hospital & Peter MacCallum Hospital, Melbourne, Australia

Twitter: @nairajesh

TRoMbone is launched!

April 3, 2017/3 Comments/by Prasanna Sooriakumaran

TRoMbone is launched! The UK feasibility randomised trial Testing radical prostatectomy in men with prostate cancer and oligoMetastases to the bone has opened at Oxford University Hospitals (PI Freddie Hamdy), University College London Hospitals (PI John Kelly) and Royal Surrey County Hospital (PI Chris Eden). Men <75 with newly-diagnosed prostate cancer and 1-3 skeletal lesions on any standard-of-care imaging (CT, bone scan, MRI, or PET) who are fit for surgery and deemed to be technically operable are eligible. Emerging but lower-quality data suggests a role for treatment of the primary tumour in men with oligo-metastatic prostate cancer and this UK study will investigate this question with level 1 evidence.

Participants will be randomly allocated to standard-of-care treatment (hormones +/- chemotherapy) versus standard-of-care treatment plus surgery to remove the prostate and draining lymph nodes (radical prostatectomy plus extended pelvic lymphadenectomy). A qualitative recruitment investigation to optimise accrual will be conducted by the University of Bristol (Caroline Wilson) and biologic samples will be collected, processed and stored in a repository at the Institute of Cancer Research (Gerhardt Attard).

We will assess technical feasibility, safety and complications of surgery in oligo-metastatic prostate cancer, and examine ways to improve recruitment in this pilot study. TRoMbone is managed by the Surgical Intervention Trials Unit at the University of Oxford and funded by the Prostate Cancer Foundation and The Urology Foundation.

We need to recruit 50 men over a 12-month period, and are seeking referrals from other centres to increase accrual. Centres that demonstrate ability to refer eligible patients will be able to take part in the main trial if we can demonstrate feasibility in this phase and get funding for the larger study.

So please look out for these patients and send them to me at UCLH, Freddie in Oxford, or Chris in Guildford. One of the three of us will do the surgery if they get randomised to it, but of course you’re welcome to come with the patients. If you have any queries please contact me, the study CI (P. Sooriakumaran (PS); [email protected]) or the study co-ordinator (Neelam Hassanali; [email protected]). You can start them on androgen deprivation and ‘stop the clock’ before you refer them to us. The extra burden of participating in this study is minimal. They will require one visit for consent, and one follow-up visit at 3 months after randomisation. The surgical group will also have two other visits for their surgery and catheter removal. The rest of the follow-up can be done back at your referring centre or with us, whatever you and the patient prefer. If it’s your standard policy to give them chemotherapy or metastasis-directed therapy with SBRT then you can still do that as part of the study.

With your help we can demonstrate that this study is feasible in the UK and we can lead the way in the surgical management of oligo-metastatic prostate cancer.

P. Sooriakumaran [social type=”facebook” opacity=”dark’ label=’PLACE_LINK_HERE[/social]

BMedSci(Hons) BMBS(Hons) PhD PGCMedLaw ADCClinInv FRCS(Urol) FEBU USLME

Consultant Urological Surgeon, UCL Hospitals NHS Foundation Trust & Honorary Clinical Senior Researcher, University of Oxford

Article of the Week: 3-Tesla mpMRI and TRUS-Bx in PCa patients on AS

March 29, 2017/by admin Z.9

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 accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and 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, it should be this one.

Value of 3-Tesla multiparametric magnetic resonance imaging and targeted biopsy for improved risk stratification in patients considered for active surveillance

Rodrigo R. Pessoa*, Publio C. Viana†, Romulo L. Mattedi‡, Giuliano B. Guglielmetti*, Mauricio D. Cordeiro*, Rafael F. Coelho*, William C. Nahas* and Miguel Srougi*

Departments of *Urology, †Diagnostic and Interventional Radiology, and ‡Department of Pathology, Instituto do Cancer, Universidade de Sao Paulo Faculdade de Medicina Hospital das Clinicas, Sao Paulo, SP, Brazil

Read the full article

Abstract

Objective

To evaluate the role of multiparametric magnetic resonance imaging (mpMRI) of the prostate and transrectal ultrasonography guided biopsy (TRUS-Bx) with visual estimation in early risk stratification of patients with prostate cancer on active surveillance (AS).

Patients and Methods

Patients with low-risk, low-grade, localised prostate cancer were prospectively enrolled and submitted to a 3-T 16-channel cardiac surface coil mpMRI of the prostate and confirmatory biopsy (CBx), which included a standard biopsy (SBx) and visual estimation-guided TRUS-Bx. Cancer-suspicious regions were defined using Prostate Imaging Reporting and Data System (PI-RADS) scores. Reclassification occurred if CBx confirmed the presence of a Gleason score ≥7, greater than three positive fragments, or ≥50% involvement of any core. The performance of mpMRI for the prediction of CBx results was assessed. Univariate and multivariate logistic regressions were performed to study relationships between age, prostate-specific antigen (PSA) level, PSA density (PSAD), number of positive cores in the initial biopsy, and mpMRI grade on CBx reclassification. Our report is consistent with the Standards of Reporting for MRI-targeted Biopsy Studies (START) guidelines.

Results

In all, 105 patients were available for analysis in the study. From this cohort, 42 (40%) had PI-RADS 1, 2, or 3 lesions and 63 (60%) had only grade 4 or 5 lesions. Overall, 87 patients underwent visual estimation TRUS-Bx. Reclassification among patients with PI-RADS 1, 2, 3, 4, and 5 was 0%, 23.1%, 9.1%, 74.5%, and 100%, respectively. Overall, mpMRI sensitivity, specificity, positive predictive value, and negative predictive value for disease reclassification were 92.5%, 76%, 81%, and 90.5%, respectively. In the multivariate analysis, only PSAD and mpMRI remained significant for reclassification (P < 0.05). In the cross-tabulation, SBx would have missed 15 significant cases detected by targeted biopsy, but SBx did detect five cases of significant cancer not detected by targeted biopsy alone.

Conclusion

Multiparametric magnetic resonance imaging is a significant tool for predicting cancer severity reclassification on CBx among AS candidates. The reclassification rate on CBx is particularly high in the group of patients who have PI-RADS grades 4 or 5 lesions. Despite the usefulness of visual-guided biopsy, it still remains highly recommended to retrieve standard fragments during CBx in order to avoid missing significant tumours.

March 2017 #urojc summary: Pelvic Lymph Node Dissection with Radical Prostatectomy – Is there enough evidence for and against?

March 13, 2017/by admin Z.9

The twitter-based international urology journal club @iurojc #urojc is back with a splash after a brief hiatus. For the March 2017 #urojc, a lively discussion takes the theme of pelvic node dissection (PLND) on radical prostatectomy (RP) reviewing a timely article by Nicola Fossati et al. The paper was made available open access courtesy of European Urology @EUplatinum.

Benefits and Harms of Different Extents of LND During Radical Prostatectomy for #ProstateCancer: A https://t.co/PxRbbUyQOM

— European Urology (@EUplatinum) February 13, 2017

A systematic review of the literature was performed including all comparative studies of both randomized and non randomized studies, with at least one experimental and one control arm. This summarised 66 studies including more than 250.000 patients with particular focus on different extents of pelvic lymphadenectomy as proposed by the European Association of Urology. Outcome measures studied included oncological features of biochemical recurrence, development of metastases, cancer-specific survival, and overall survival. Adverse events were covered under secondary outcomes, both intra- and postoperatively observed. Finally, quality of PLND was addressed in terms of total number of nodes and total number of positive nodes. Risk of bias was assessed for all studies judging on basis of specific confounders.

The journal club ran for 48 hours from Sunday 5th march. The central question addressed is balance of benefits and drawbacks of lymph node dissection. The corresponding author of the manuscript, Steven Joniau from the University Hospitals of Leuven, Belgium highlighted the role of lymph nodes in prostate cancer recurrence.

#urojc Remember: PCa recurrence often first in regional LN. So, why not remove at RP? @iurojc @ChapinMD @LoebStacy @EveraertsW @dr_coops pic.twitter.com/5GRKhjOJfl

— steven joniau (@joniau) March 6, 2017

However despite this idea, the benefit of PLND is heavily scrutinized from the start. Long term data from a single centre suggested limited benefit.

How do we reconcile what appears to be lack of therapeutic benefit & morbidity for ePLND and current guidelines? #urojc

— Urology JC #urojc (@iurojc) March 5, 2017

Depends on how much time you spend on it😀 JH population was "unique". Therapeutic benefit depends on the cohort being studied.

— Badar M. Mian, MD (@BadarMian1) March 5, 2017

If PSA bcf so high with N1 disease, has PLND really made a diff? How is management changed if N1 disease confirmed pathologically? #urojc

— Urology JC #urojc (@iurojc) March 6, 2017

However PLND has since earlier times been employed as a diagnostic tool, where an optimal template (presacral in addition to extended LND) may be optimal for staging and removal of lymph nodes.

Does need for accurate staging trump (NOT about that man 😊) therapeutic benefit for standard PLND versus ePLND?#urojc pic.twitter.com/6N3bjAoRS2

— Urology JC #urojc (@iurojc) March 5, 2017

Try to encourage in our MDT as node info is often can often fine tune further management after RP #urojc https://t.co/4fZQ2eEVkv

— Nick Brook (@nickbrookMD) March 5, 2017

#urojc But knowlegde gained by PLND may guide decisions regarding adj treatment (which may influence survival)

— steven joniau (@joniau) March 6, 2017

Prospective study shows 'less-than-eLND' insuficient for staging. eLND 94% accurate staging, but misses 24% pos LN compared to seLND pic.twitter.com/f1Fm26SPcp

— steven joniau (@joniau) March 6, 2017

Despite the current state of evidence, PLND is frequently mentioned in the various guidelines available for prostate cancer. However the exact situations when to employ them is questioned by some participants.

How do we reconcile what appears to be lack of therapeutic benefit & morbidity for ePLND and current guidelines? #urojc

— Urology JC #urojc (@iurojc) March 5, 2017

@iurojc @nickbrookMD #EAUGuidelines mention Briganti, MSKCC or Roach nomograms, NCCN doesn't recommend a particular nomogram #urojc pic.twitter.com/QAdE4PBsHa

— Stacy Loeb, MD (@LoebStacy) March 6, 2017

#urojc @joniau @ChapinMD @LoebStacy @dr_coops Makes sense for high risk tumours, but the EAU 5% guideline for PLND is overkill

— Wouter Everaerts (@EveraertsW) March 6, 2017

The various therapeutic options for lymph node metastases also coloured the discussion.

if we can figure out whether postop RT necessary in all N1, ePLND may help avoid unnecessary treatment in some. #urojc

— Brian F. Chapin (@ChapinMD) March 6, 2017

The discussion further continued to the important issue of morbidity, and the associated question of performing an extended PLND (ePLND).

Are we understating morbidity of ePLND? Do we leave these patient on a knifes edge for future lymphodema? (Eg future RT, infection)#urojc

— Urology JC #urojc (@iurojc) March 6, 2017

@joniau lymphoedema is major concern for QoL, especially after eLND+ adj RT,
Needs multiD management #urojc

— Wouter Everaerts (@EveraertsW) March 6, 2017

the baby shouldn't be in the bath. PLND so clearly needs to be tested in a prospective trial. As for ePLND…

— Tim O'Brien (@tsoburol) March 6, 2017

What's your justification for doing an ePLND? Is it because of guideline recommendations?#urojc

— Urology JC #urojc (@iurojc) March 5, 2017

#urojc ePLND = mmmPLND, more morbidity,minutes,money. less BCR, doubt it.

— Alan Hay (@alanhaymd) March 5, 2017

@iurojc ePLND does nearly double my time for RALRP. Sometimes even longer then the prostatectomy. #urojc

— Brian F. Chapin (@ChapinMD) March 6, 2017

.@DrHWoo I don't follow–Some N+ men essntlly cured by only RP/PLND. I think it's therapeutic.
But I don't believe ePLND= improvemnt #urojc pic.twitter.com/EwSp4Im5VO

— David Y.T. Chen (@dytcmd) March 6, 2017

Try to encourage in our MDT as node info is often can often fine tune further management after RP #urojc https://t.co/4fZQ2eEVkv

— Nick Brook (@nickbrookMD) March 5, 2017

#urojc But knowlegde gained by PLND may guide decisions regarding adj treatment (which may influence survival)

— steven joniau (@joniau) March 6, 2017

Prospective study shows 'less-than-eLND' insuficient for staging. eLND 94% accurate staging, but misses 24% pos LN compared to seLND pic.twitter.com/f1Fm26SPcp

— steven joniau (@joniau) March 6, 2017

How do we reconcile what appears to be lack of therapeutic benefit & morbidity for ePLND and current guidelines? #urojc

— Urology JC #urojc (@iurojc) March 5, 2017

@iurojc NCCN guidelines recommend PLND for nomogram probability >=2% vs 5% threshold in #eauguidelines #urojc pic.twitter.com/7HYVSYUSJv

— Stacy Loeb, MD (@LoebStacy) March 6, 2017

@iurojc @nickbrookMD #EAUGuidelines mention Briganti, MSKCC or Roach nomograms, NCCN doesn't recommend a particular nomogram #urojc pic.twitter.com/QAdE4PBsHa

— Stacy Loeb, MD (@LoebStacy) March 6, 2017

#urojc @joniau @ChapinMD @LoebStacy @dr_coops Makes sense for high risk tumours, but the EAU 5% guideline for PLND is overkill

— Wouter Everaerts (@EveraertsW) March 6, 2017

The

if we can figure out whether postop RT necessary in all N1, ePLND may help avoid unnecessary treatment in some. #urojc

— Brian F. Chapin (@ChapinMD) March 6, 2017

The discussion further continued to the important issue of morbidity, and the associated question of performing an extended PLND (ePLND).

Are we understating morbidity of ePLND? Do we leave these patient on a knifes edge for future lymphodema? (Eg future RT, infection)#urojc

— Urology JC #urojc (@iurojc) March 6, 2017

@joniau lymphoedema is major concern for QoL, especially after eLND+ adj RT,
Needs multiD management #urojc

— Wouter Everaerts (@EveraertsW) March 6, 2017

the baby shouldn't be in the bath. PLND so clearly needs to be tested in a prospective trial. As for ePLND…

— Tim O'Brien (@tsoburol) March 6, 2017

What's your justification for doing an ePLND? Is it because of guideline recommendations?#urojc

— Urology JC #urojc (@iurojc) March 5, 2017

#urojc ePLND = mmmPLND, more morbidity,minutes,money. less BCR, doubt it.

— Alan Hay (@alanhaymd) March 5, 2017

@iurojc ePLND does nearly double my time for RALRP. Sometimes even longer then the prostatectomy. #urojc

— Brian F. Chapin (@ChapinMD) March 6, 2017

.@DrHWoo I don't follow–Some N+ men essntlly cured by only RP/PLND. I think it's therapeutic.
But I don't believe ePLND= improvemnt #urojc pic.twitter.com/EwSp4Im5VO

— David Y.T. Chen (@dytcmd) March 6, 2017

if we can figure out whether postop RT necessary in all N1, ePLND may help avoid unnecessary treatment in some. #urojc

— Brian F. Chapin (@ChapinMD) March 6, 2017

The increasing use of PSMA PET/CT provided other spread pattern data to be considered. And finally temporal changes in PSA testing is observed to affect the need for LND.

How might Ga68 PSMA PET/CT change the dynamic? Early data shows a lot of disease above the diaphragm. #urojc https://t.co/zyX9czHuwH

— Urology JC #urojc (@iurojc) March 6, 2017

Although, with PSMA PET/CT we're finding crazy spread patterns (e.g. Isolated supraclav nodal met) #urojc

— Matt Cooperberg (@dr_coops) March 6, 2017

I dunno… in 2017 I think it's a very rare pt who needs the RP and doesn't need the LND! #urojc @iurojc

— Matt Cooperberg (@dr_coops) March 6, 2017

#urojc @dr_coops @LoebStacy @iurojc the pt who "doesn't need PLND" probably often doesn't need RP either. Especially in PSA era

— David Y.T. Chen (@dytcmd) March 6, 2017

From the poll which ran during the discussion, about half responders would perform extended PLND for staging, while the rest were divided almost equally between therapeutic benefit and adherence to guideline recommendations.

Why do you do ePLND?#urojc

— Urology JC #urojc (@iurojc) March 5, 2017

Probably all participants of the discussion agrees for the need of a proper randomised study addressing role of PLND.

But "therapeutic benefits of PLND during radical prostatectomy remain unproven"@ChapinMD @LoebStacy @EveraertsW @dr_coops #urojc

— Henry Woo (@DrHWoo) March 6, 2017

At the end of a busy 48 hours, the discussion had been joined by top experts in the field of prostate cancer, generated more than 200 tweets and reached more than 700 thousand impressions the world over.

Special thanks to @EUplatinum for allowing open access for this month's paper. Special thanks to author @joniau for participating #urojc

— Urology JC #urojc (@iurojc) March 7, 2017

Yodi Soebadi (@yodisoebadi) is an Indonesian urologist, trained at Universitas Airlangga, currently pursuing doctoral research at KU Leuven in Belgium.

RSM Urology Winter Meeting 2017, Northstar, California

February 17, 2017/6 Comments/by Niyati Lobo

This year’s Annual RSM Urology Section Winter Meeting, hosted by Roger Kirby and Matt Bultitude, was held in Lake Tahoe, California.

A pre-conference trip to sunny Los Angeles provided a warm-up to the meeting for a group of delegates who flew out early to visit Professor Indy Gill at the Keck School of Medicine. We were treated to a diverse range of live open, endourological and robotic surgery; highlights included a salvage RARP with extended lymph node dissection and a robotic simple prostatectomy which was presented as an alternative option for units with a robot but no/limited HoLEP expertise.

On arrival to Northstar, Dr Stacy Loeb (NYU) officially opened the meeting by reviewing the social media urology highlights from 2016. Next up was Professor Joseph Smith (Nashville) who gave us a fascinating insight into the last 100 years of urology as seen through the Journal of Urology. Much like today, prostate cancer and BPH were areas of significant interest although, in contrast, early papers focused heavily on venereal disease, TB and the development of cystoscopy. Perhaps most interesting was a slightly hair-raising description of the management of IVC bleeding from 1927; the operating surgeon was advised to clamp as much tissue as possible, close and then return to theatre a week later in the hopes the bleeding had ceased!

With the promise of beautifully groomed pistes and stunning views of Lake Tahoe, it was hardly surprising that the meeting was attended by a record number of trainees. One of the highlights of the trainee session was the hilarious balloon debate which saw participants trying to convince the audience of how best to manage BPH in the newly inaugurated President Trump. Although strong arguments were put forward for finasteride, sildenafil, Urolift, PVP and HoLEP, TURP ultimately won the debate. A disclaimer: this was a fictional scenario and, to the best of my knowledge, Donald Trump does not have BPH.

The meeting also provided updates on prostate, renal and bladder cancer. A standout highlight was Professor Nick James’ presentation on STAMPEDE which summarized the trial’s key results and gave us a taste of the upcoming data we can expect to see in the next few years.

We were fortunate to be joined by prominent American faculty including Dr Trinity Bivalacqua (Johns Hopkins) and Dr Matt Cooperberg (UCSF) who provided state-of-the-art lectures on potential therapeutic targets and biomarkers in bladder and prostate cancer which promise to usher in a new era of personalized therapy.

A personal highlight was Tuesday’s session on learning from complications. It was great to hear some very senior and experienced surgeons speaking candidly about their worst complications. As a trainee, it served as a reminder that complications are inevitable in surgery and that it is not their absence which distinguishes a good surgeon but rather the ability to manage them well.

There was also plenty for those interested in benign disease, including topical discussions on how to best provide care to an increasingly ageing population with multiple co-morbidities. This was followed by some lively point-counterpoint sessions on robot-assisted versus open renal transplantation (Ravi Barod and Tim O’Brien), Urolift vs TURP (Tom McNicholas and Matt Bultitude) and HOLEP vs prostate artery embolization for BPH (Ben Challacombe and Rick Popert). Professor Culley Carson (University of North Carolina) concluded the session with a state-of-the art lecture on testosterone replacement.

In addition to the excellent academic programme, delegates enjoyed fantastic skiing with perfect weather and unparalleled views of the Sierra Nevada Mountains. For the more adventurous skiiers, there was also a trip to Squaw Valley, the home of the 1960 Winter Olympics. Another highlight was a Western-themed dinner on the shores of Lake Tahoe which culminated in almost all delegates trying their hand at line dancing to varying degrees of success! I have no doubt that next year’s meeting in Corvara, Italy will be equally successful and would especially encourage trainees to attend what promises to be another excellent week of skiing and urological education.

Miss Niyati Lobo
ST3 Urology Trainee, Brighton and Sussex University Hospitals NHS Trust

@niyatilobo

Article of the Week: Accuracy of prostate biopsies for predicting Gleason score in radical prostatectomy specimens: nationwide trends 2000–2012

January 25, 2017/by admin Z.9

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.

If you only have time to read one article this week, it should be this one.

Accuracy of prostate biopsies for predicting Gleason score in radical prostatectomy specimens: nationwide trends 2000–2012

Daniela Danneman*, Linda Drevin†, Brett Delahunt‡, Hemamali Samaratunga§¶, David Robinson**, Ola Bratt††‡‡, Stacy Loeb§§ Par Stattin¶¶*** and Lars Egevad*†††

*Department of Oncology-Pathology, Karolinska Institute, Stockholm, † Regional Cancer Centre, Uppsala University Hospital, Uppsala, Sweden, ‡Wellington School of Medicine and Health Sciences, University of Otago, Wellington, New Zealand, §Aquesta Pathology, ¶The University of Queensland School of Medicine, Brisbane, Qld, Australia, **Department of Urology, Ryhov County Hospital, Jonkoping, Sweden, ††Department of Urology, Cambridge University Hospitals, Cambridge, UK, ‡‡Department of Translational Medicine, Lund University, Lund, Sweden, §§Department of Urology and Population Health, New York University and Manhattan Veterans Affairs Medical Centre, New York, NY, USA, ¶¶Department of Surgical and Perioperative Sciences, Urology and Andrology, Umea University, Umea, ***Department of Surgical Sciences, Uppsala University, Uppsala, Umea, and †††Department of Pathology, Karolinska University Hospital, Stockholm, Sweden

Read the full article

Abstract

Objectives

To investigate how well the Gleason score in diagnostic needle biopsies predicted the Gleason score in a subsequent radical prostatectomy (RP) specimen before and after the 2005 International Society of Urological Pathology (ISUP) revision of Gleason grading, and if the recently proposed ISUP grades 1–5 (corresponding to Gleason scores 6, 3 + 4, 4 + 3, 8 and 9–10) better predict the RP grade.

Patients and Methods

All prostate cancers diagnosed in Sweden are reported to the National Prostate Cancer Register (NPCR). We analysed the Gleason scores and ISUP grades from the diagnostic biopsies and the RP specimens in 15 598 men in the NPCR who: were diagnosed between 2000 and 2012 with clinical stage T1–2 M0/X prostate cancer on needle biopsy; were aged ≤70 years; had serum PSA concentration of <20 ng/mL; and underwent a RP <6 months after diagnosis as their primary treatment.

Results

Prediction of RP Gleason score increased from 55 to 68% between 2000 and 2012. Most of the increase occurred before 2005 (nine percentage points; P < 0.001); however, when adjusting for Gleason score and year of diagnosis in a multivariable analysis, the prediction of RP Gleason score decreased over time (odds ratio [OR] 0.98; P < 0.002). A change in the ISUP grades would have led to a decreasing agreement between biopsy and RP grades over time, from 68% in 2000 to 57% in 2012, with an OR of 0.95 in multivariable analysis (P < 0.001).

Conclusion

Agreement between biopsy and RP Gleason score improved from 2000 to 2012, with most of the improvement occurring before the 2005 ISUP grading revision. Had ISUP grades been used instead of Gleason score, the agreement between biopsy and RP grade would have decreased, probably because of its separation of Gleason score 7 into ISUP grades 2 and 3 (Gleason score 3 + 4 vs 4 + 3).