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TOPLINE:

In a cohort study of patients with prostate cancer, MRI-led risk-adapted active surveillance demonstrated effectiveness in risk stratification. The approach showed that MRI visibility and the presence of secondary Gleason pattern 4 at baseline were associated with higher rates of progression and treatment initiation.

METHODOLOGY:

• Researchers analysed 1150 patients who started active surveillance between February 2000 and July 2023, including those with a Gleason score (GS) ≤ 3 + 4, prostate-specific antigen (PSA) < 20 ng/mL, and at least two MRI scans.
• Participants underwent PSA testing three to four times in the first year, followed by biannual testing; MRI was performed at baseline and 12 months, with an additional MRI scan performed at 24 months for those with MRI-visible lesions at baseline.
• Patients were stratified into four groups on the basis of baseline risk factors, including GS (3 + 3 vs 3 + 4) and MRI visibility ("non-visible disease" vs "visible disease").
• The primary outcome was event-free survival, with an event defined as the detection of GS ≥ 4 + 3 or the initiation of any prostate cancer treatment.
• The median follow-up duration was 64 months per person overall and 72 months for 732 patients without an event. At baseline, 64% of patients had GS 3 + 3 and 36% had GS 3 + 4; 49% of those with GS 3 + 4 had MRI-visible disease.

TAKEAWAY:

• Event-free survival rates varied significantly on the basis of the risk group, with 5-year rates of 91% for non-visible GS 3 + 3, 71% for MRI-visible GS 3 + 3, 71% for non-visible GS 3 + 4, and 44% for MRI-visible GS 3 + 4 disease.
• Among 487 patients who underwent follow-up biopsies, histological upgrade to GS ≥ 4 + 3 occurred in 67 patients; non-visible GS 3 + 3 cases had 5- and 10-year rates of 1.2% and 6.1%, respectively, for histological progression to GS ≥ 4 + 3, while the rates were 17% and 43% for those with MRI-visible GS 3 + 4 disease at baseline, respectively.
• Progression to nodal or bone metastases was observed in 10 patients, occurring only in those who had declined recommended follow-up MRI and/or biopsies.
• The 10-year rate of commencing treatment was 28% for those with non-visible GS 3 + 3 disease vs 85% for those with MRI-visible GS 3 + 4 disease and 46% for those with non-visible GS 3 + 4 disease vs 54% for those with MRI-visible GS 3 + 3 disease.

IN PRACTICE:

"Results from our cohort suggest that AS [active surveillance] patients can be monitored safely with MRI, and the decision to biopsy was based on MRI findings and PSA changes. Prospective, multicentre, clinical trials are required and currently being designed to further evaluate this approach," the authors wrote.

SOURCE:

This study was led by Cameron Englman, Division of Surgery & Interventional Science, University College London, London, England. It was published online on May 27, 2025, in European Urology.

LIMITATIONS:

Compared with time-based biopsy protocols, the MRI-led risk-adapted approach may underestimate histological progression. Additionally, as a cohort study without a strict protocol, practice evolved alongside contemporary pathology and radiology standards, with MRI quality, reporting standards, and the definition of radiological progression varying over time, particularly improving after the adoption of the PRECISE recommendations in 2016.

DISCLOSURES:

This study did not receive any specific funding. Several authors reported receiving consulting fees and grants and having other ties with various sources.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.