3/13/2016

Prostate Cancer: MR’s Role in Screening and Active Surveillance Toronto, Canada Masoom Haider, MD, FRCP(C) Professor of Radiology, University of Toronto Clinician Scientist, Ontario Institute of Cancer Research Senior Scientist, Sunnybrook Research Institute Chief, Dept of Medical Imaging Sunnybrook Health Sciences Centre [email protected]

Acknowledgment – Dr L. Klotz

Disclosure(s) • Masoom Haider – I have no financial relationships with commercial interests to disclose

2

March 13, 2016

1

3/13/2016

Acknowledgements L. Klotz L Milot L Sugar M DaRosa

3

J Trachtenberg T vanderKwast N Fleshner A Loblaw D Vesprini

March 13, 2016

Prostate Cancer Detection and Surveillance

Significant Cancer

TRUS Bx

PSA

15-20% men10 years

HGPIN/Normal

Insignificant Cancer

4

2

3/13/2016

PSA Screening

PSA

• Overdiagnosis • Overtreatment 27:1 @ 13 years • US Preventative Services Task Force 2012 – Recommendation against PSA screening

Schröder, F. H. et al (2014). Screening and prostate cancer mortality: results of the European Randomised Study of Screening for Prostate Cancer (ERSPC) at 13 years of follow-up. Lancet, 384(9959), 2027–35. 5

March 13, 2016

TRUS Bx

6

March 13, 2016

3

3/13/2016

Active Surveillance • Actively monitoring the disease with the expectation to intervene with the intent to cure only if essential • Based on the belief that if appropriate triggers for intervention are identified the patient will still have a favorable outcome • Part of current guidelines – an accepted form of treatment for low risk prostate cancer

7

Entrance Criteria for AS Institution

8

Gleason

PSA

Stage

Cores positive

European Randomised study

≤3+3

PSA ≤10; PSAD≤0.2 ng/ml

≤T2

≤2 cores

Johns Hopkins

≤3+3

PSA ≤10; PSAD≤0.15 ng/ml

≤T1

MSKCC

≤3+3

PSA ≤10;

≤T2

Royal Marsden, UK

≤3+4

PSA ≤15;

≤T2a

Toronto

≤3+3 or ≤3+4*

UCSF

≤3+3

PSA ≤10

≤T2

≤33% cores; ≤50% of a core

University of Miami

≤3+3

PSA ≤10

≤T2

≤2 cores; ≤20% of a core

PSA ≤10 or PSA ≤15*

≤2 cores; ≤50% of a core ≤3 cores; ≤50% of a core ≤50% of a core

≤T2b

March 13, 2016

4

3/13/2016

Surveillance Approach Re-biopsy

PSA

Trigger

Toronto (Canada)

6-12m q3-4 yrs

q3mo x 2yr q6mo

PSADT6 or >2 pos cores

Hopkins (USA)

Annual

≤q6mo

Selection criteria breached Perineural invasion*

9

Long term outcome Sunnybrook

Johns Hopkins

Eligibility

All Gleason 6, PSA = 3/5 Path

SEN

SPEC

PPV

NPV

UCL2

94 (88–99)

23 (17–29)

34 (28–40)

89 (79–98)

UCL1

98 (93–100)

22 (16–27)

21 (15–27)

98 (93–100)

Gleason 4+3

100 (100–100)

19 (14–24)

6 (3–10)

100 (100–100)

Gleason 3+4

93 (85–100)

21 (15–27)

24 (18–30)

92 (83–100)

CCLmax 6

98 (91–100)

21 (15–27)

19 (13–24)

98 (93–100)

CCLmax 4

94 (87–99)

22 (16–28)

28 (23–34)

91 (82–98)

Any cancer

90 (86–95)

28 (20–37)

60 (53–67)

70 (55–84)

5mm Template Biopsy – Median PSA 5.8 Abd-Alazeez M, et al. Performance of multiparametric MRI in men at risk of prostate cancer before the first biopsy: a paired validating cohort study using template prostate mapping biopsies as the reference standard. Prostate cancer and prostatic diseases. Mar 2014;17(1):40-6. Median PSA 5.3 23

March 13, 2016

For mpMRI >= 4/5 Path

SEN

SPEC

PPV

NPV

UCL2

68 (56–78)

69 (61–76)

48 (38–58)

83 (77–89)

UCL1

81 (68–91)

66 (60–73)

34 (25–44)

94 (90–97)

Gleason 4+3

92 (73–100)

61 (54–67)

11 (5–17)

99 (97–100)

Gleason 3+4

70 (57–81)

65 (58–71)

35 (25–44)

89 (84–994)

CCLmax 6

80 (66–92)

65 (58–72)

30 (21–39)

95 (91–98)

CCLmax 4

71 (58–83)

67 (60–75)

42 (32–51)

88 (82–93)

Any cancer

56 (48–64)

75 (65–83)

73 (64–81)

58 (50–67

5mm Template Biopsy – Median PSA 5.8 Abd-Alazeez M, et al. Performance of multiparametric MRI in men at risk of prostate cancer before the first biopsy: a paired validating cohort study using template prostate mapping biopsies as the reference standard. Prostate cancer and prostatic diseases. Mar 2014;17(1):40-6. 24

Median PSA 5.3

March 13, 2016

12

3/13/2016

Workflow PiRads >=4 50

5

1/2/3

50 Risk Calc

MRI

4/5

TRUSBx/MRI

7

MRIBx

43 100

2

Decrease in low risk cancer detection rate of 87%/89% Biopsy cores required down 84%/88% Increase in intermediate & high risk cancer detection rate by 18%/13%

Therapy

25

Cost and Quality of Life

Total costs of the MRI strategy are almost equal to the standard of care Reduction in overdiagnosis and overtreatment results in improvement in quality of life

26

March 13, 2016

13

3/13/2016

Prostate Cancer Screening

Significant Cancer

TRUS Bx

MRI PSA

15-20% men10 years

HGPIN/Normal

Insignificant Cancer

27

Pilot Study in Screening (2016) n=47 PSA < 4.0 ng/mL MRI Score 3 or less

GS 6

GS >=7 or more

1 (33.3%)

2 (66.7%)

4 or more

2 (33.3%)

4 (66.6%)

PSA ≥ 4.0 ng/mL 3 or less

3 (100%)

0

4 or more

0

6 (100%)

A Pilot Study to Evaluate the Role of Magnetic Resonance Imaging for Prostate Cancer Screening in the General Population. Nam RK, Wallis CJ, Stojcic-Bendavid J, Milot L, Sherman C, Sugar L, Haider MA J Urol. 2016 Feb 12 epub 28

March 13, 2016

14

3/13/2016

ADC 672

29

Screening

• No North American Guideline Recommends MRI Pre-Biopsy • It does not matter - MRI pre-biopsy will gain adoption wherever it can be funded

30

March 13, 2016

15