Abstracts from the New England Section of the AUA 2020: A Virtual Experience

© The Canadian Journal of Urology TM : International Supplement, August 2020 P20 Evaluating the AUA Guidelines: cT2b-c Grade Group 1 Prostate Cancer Esther L. Finney, MD , KristianD. Stensland, MD, MPH, David Canes, MD,Andrea Sorcini, MD, Alireza Moinzadeh, MD, Harras B. Zaid, MD Lahey Hospital and Medical Center, Burlington, MA, USA Introduction: The AUA and NCCN guidelines broadly stratify prostate cancers into low, intermediate (including favorable and unfavorable), and high risk groups to guide management. Included within the unfavorable intermediate risk category are patients with clinical T2b-c, grade group 1 (GG1) cancer with elevated PSA between 10-20. The AUA guidelines state that these patients “may not represent unfavorable risk disease”, though little data exists to guide management here. Therefore, we aimed to assess whether the disease severity and outcomes of this subgroup more closely align with favorable or unfavorable intermediate risk prostate cancer. Materials &Methods: The National Cancer Database was queried for all non-metastatic prostate cancer cases from 2010-2015. Patients were stratified into low, favorable intermediate, unfavorable intermediate, and high-risk groups by clinical T stage, GG, and PSA, according to the current AUA guidelines. Patients with GG1 clinical T2b-c disease were further separated into two distinct groups based on PSA (< 10 vs. 10-20). We compared 5-year overall survival (OS) using the Kaplan-Meier method and log-rank test for all patients, and stratified by treatment received (surgery or radiation). We then assessed associations with OS using a multivariable Cox proportional hazards model. Results: A total of 482,378 cases were included, of which 31% were low, 25% favorable intermediate, 18% unfavorable intermediate, and 24% high risk. Men with cT2b-c, GG1, PSA < 10 comprised 1.67% (8065); cT2b-c, GG2, PSA 10-20 comprised 0.2% (1005). Patients with GG1, cT2b-c, PSA10-20 disease had similar OSl at 5 years to the unfavorable intermediate-risk group regardless of treatment modality (surgery: 93.4% vs. 92.8%; radiation: 79.4% vs. 81.9%, both p > 0.05). In the multivariable model, the cT2b-c, GG1, PSA10-20 risk factor had a similar effect on survival as the unfavorable intermediate group factor (HR 1.12, 95%CI 0.91-1.37, p = 0.29). In contrast, patients with cT2b-c, GG1, PSA< 10 had 5 year OS rates of 93%, comparable to men in the low-risk category (92.6%, p = 0.14) and significantly better than that of men in the intermediate favorable risk category (90%, p < 0.001). Survival was similar when stratified by treatment and onmultivariable modeling. Conclusions: Men with cT2b-c, GG1, PSA10-20 disease have OS rates similar to those of men with unfavorable intermediate-risk disease regardless of treatment modality chosen. For men with PSA< 10 in this same strata, outcomes were similar to low risk disease and significantly better than the intermediate favorable risk group. Predicting Cancer Detection Rates from Multiparametric Prostate MRI: Refining the PI-RADS Categorization System Francisco Ramos, BS 1 , Aaron Fleishman, MPH 2 , Ruslan Korets, MD 2 , Michael Johnson, MD 2 , Aria Olumi, MD 2 , Leo Tsai, MD, PhD 2 , Boris Gershman, MD 2 1 Harvard Medical School, Boston, MA, USA; 2 Beth Israel Deaconess Medical Center, Boston, MA, USA Introduction: The PI-RADS categorization represents the standardized method for assessing risk of prostate cancer in men undergoing multiparametric prostate MRI. However, there exists a substantial discrepancy in widely accepted cancer detection rates for each PI-RADS category as reported in seminal prospective studies (e.g., PROMIS, PRECISION) and cancer-detection rates (CDRs) observed in real-world clinical practice. We hypothesized that CDRs vary according to patient and MRI features beyond what is captured in the PI-RADS categorization. Herein, we examine the associations of clinical and radiographic features with CDRs and develop a predictive model to improve patient counseling and clinical management. Materials &Methods: We identified men aged 18-89 with a diagnosis of elevated PSAor Gleason 6 prostate cancer on active surveillance and ≥ 1 PI-RADS 3-5 lesion on prostate MRI who underwent MRI-U/S fusion prostate biopsy in the office or in-boreMRI-targeted biopsy in Interventional Radiology. Only targeted biopsy cores were considered for MRI- U/Sfusionbiopsy.Theassociationsofclinicalandradiographicfeatureswith theper-lesion cancer-detection rate (CDR; Gleason 6-10) and clinically-significant cancer detection rate (csCDR; Gleason 7-10) were examined using multivariable logistic regression following a univariable screen at the p < 0.10 level. Patients with Gleason 6 prostate cancer on active surveillance were excluded from CDR analyses. Results: Targeted biopsy was performed for 216 lesions in 169 patients, including MRI-U/S fusion biopsy in 130 lesions and in-bore MRI-targeted biopsy in 86 lesions. Median pre-biopsy PSA was 7.2 ng/mL (IQR 5.2-10.2). Thirty percent of lesions were in biopsy-naïve patients, while 29% were in patients on active surveillance for Gleason 6 prostate cancer. PI-RADS category was 3 in 17.1%, 4 in 51.9%, and 5 in 31.0% of lesions. Lesions were located in the anterior/transition zone in 58.8% of cases, and median lesion diameter was 13 mm (IQR 9-17 mm). Overall, the CDR was 48% and the csCDR was 26%. In multivariable regression models predicting CDR, number of prior biopsies (OR 0.18, 95%CI 0.06-0.47 for 1; OR 0.16, 95%CI 0.05-0.47 for 2+ versus none), PSAdensity (OR 1.75, 95% CI 1.15-2.88) and PI-RADS category (OR 5.39, 95%CI 1.43-29.1 for 4; OR 15.1, 95% CI 3.54-88.8for5versus3)were independentlyassociatedwithCDR(Table1).Inmultivariable models predicting csCDR, abnormal DRE (OR 2.75, 95%CI 1.22-6.19), solitary lesion on MRI (OR 2.42, 95%CI 1.13-5.48 versus 2+), PSA density (OR 1.04, 95%CI 1.00-1.09), and PI-RADS category (OR 3.30, 95%CI 1.03-13.7 for 4; OR 3.44, 95% CI 1.03-14.4 for 5 versus 3) were independently associated with csCDR (Table 1). The bootstrap-adjusted c-index was 0.80 for the CDR model and 0.71 for the csCDR model. Conclusions: In this study, several clinical and radiographic features were independently associated with risk of malignancy in men undergoing MRI-targeted biopsy for elevated PSA. Such models can be operationalized to provide personalized risk-stratification beyond the PI-RADS categorization. P19 Poster Session II 38