Can the new model be useful in reducing overtreatment of prostate cancer?

Low-risk prostate cancer active monitoring has finally broken through "academic practice" and become the mainstream of clinical practice
in the United States.

Written by | Vague away the little bees

Source | "Medical Community" public account

"For the first time, active surveillance rates for low-risk prostate cancer patients in the U.
S.
reached nearly 60 percent
.
"

At this year's annual meeting of the American Urological Surgery Association (AUA), Matthew Cooperberg, co-director of the Prostate Program at the University of California, San Francisco, announced the data and said it was a significant improvement
over the previous one.

Some prostate cancers are characterized
by slow growth.
It is clinically believed that for elderly patients with low risk of progression, active monitoring and observation of disease progression can be taken according to the specific situation, rather than rushing surgery or radiotherapy
.
This avoids surgical risks, reduces overtreatment, and improves quality of
life.

American professional medical website Medscape described it as a "dawning moment
.
" Active monitoring of low-risk prostate cancer has finally broken through "academic practice" and become the mainstream of clinical practice
in the United States.

What is "MUSIC Mode"?

The results of research in many medical centers internationally show that active prostate cancer surveillance is practical and reliable in terms of safety and efficacy
.

The AUA committee called for an increase in active surveillance for low-risk prostate cancer to 80 percent in
the future.

"In the MUSIC model, it will reach 90%
in 2021.
" Kevin Ginsburg, a urological oncologist at Wayne State University in Detroit, one of the leaders of the MUSIC model, points out that the proportion is almost the same as
Sweden.
The latter has one of the highest rates of active surveillance for low-risk prostate cancer in the
world.

MUSIC's full name is "Michigan Urology Improvement Collaborative Organization.
"
It is an innovative collaborative organization for quality improvement led by physicians, founded in 2012
.
Members include 46 Uropathic Practice Organizations
in Michigan.

Through a series of studies and data, the organization has developed a "MUSIC diagnosis and treatment model" suitable for active monitoring of prostate cancer patients, and proposed guidelines such as imaging standards
.

According to China's "Guidelines for the Diagnosis and Treatment of Prostate Cancer (2022 Edition)", digital rectal examination (at least once a year), prostate-specific antigen detection (at least once every six months), multi-parameter MRI and repeated puncture (at least once every 3-5 years) should be carried out during active monitoring
.

In the United States, in addition to the above, active prostate cancer monitoring will also use a variety of imaging methods, including but not limited to bone scans, CT scans and PET/CT
.

The "MUSIC diagnosis and treatment mode" shows that only 20.
7% of patients need bone scanning, the positive rate is about 17.
0%, and the missed detection rate of metastatic prostate cancer is only 0.
8%, and the negative rate is 38%.

22.
6% of patients require a CT scan, with a positive rate of about 14%, and the missed rate of metastatic prostate cancer is only 0.
4%, and the negative rate is about 44%.

The organization proposes that there are limitations to routine imaging and that special imaging tests can be introduced if necessary, but the specific methods need to be based on the actual situation of the patient
.

The clinical impact of the MUSIC diagnosis and treatment model

The MUSIC collaboration has completed several studies and hopes to gain insight into how proactive monitoring can effectively improve diagnostic quality and care efficiency and reduce overtreatment
of prostate cancer in the clinic.

In one of the studies, 2514 high-risk prostate cancer patients
who received active monitoring were selected in the MUSIC database.
Of these, 1211 (48%) underwent confirmatory checks
.

The main contents of the examination include: (1) repeat the prostate biopsy; (2) Genomic examination; (3) Prostate MRI or biopsy
.
According to the accuracy of the confirmatory check results, the group of reliable results and the group of unreliable results can be distinguished
.

The results showed that for the three groups of patients who did not receive examination, the group with reliable results and the group with unreliable results, the probability of no change in biopsy diagnosis results within 12 months was 68%, 83%, and 90% (P<0.
001), respectively, and the probability of not needing treatment within 24 months was 55%, 81%, and 79% (P<0.
0001),
respectively.

After excluding patients who underwent genetic testing, the risk of diagnostic reclassification was lower in the reliable results group compared with the non-examined group (HR 0.
57, 95% CI 0.
38 to 0.
84, P = 0.
005).

In the unreliable results, patients in the group were at higher risk of diagnostic reclassification (HR 1.
97, 95% CI 1.
22 to 3.
19, P = 0.
006).

The above data suggest that patients in the result reliable group were less likely to change their diagnostic results and had a longer
duration of active monitoring of treatment than patients in the unreliable results group.

This suggests that for patients who are considering active monitoring, confirmatory testing may help with risk stratification management, thereby improving clinical efficiency
.

In another study, the research team selected 813 patients
newly diagnosed with low-risk prostate cancer from the MUSIC database over a 19-month period.
Of these, 410 did not receive active monitoring education and guidance, and 403 gave corresponding educational guidance
.

Of the 410 patients without education, 15 (3.
7%) and 21 (5.
2%), respectively, underwent bone scans and CT scans
.
Of the 403 patients educated, bone scans and CT scans were 5 (1.
3%) and 13 (3.
2%, p, 0.
03 and 0.
17, respectively).

This indicates that the use of non-essential imaging tests has further decreased
with the provision of education and guidance to clinical patients.

It is more difficult to "actively monitor" prostate cancer in our country

It is reported that MUSIC holds 3 meetings every year to discuss topics
related to improving prostate cancer care, kidney cancer care and kidney stone care quality.

The organization recognized the need to dig deeper and understand how anxiety and depression affect the decision-making process
.
These negative emotions can affect active monitoring and make them unsustainable
.

In addition, organizations will discuss how to get more prostate cancer patients to be actively monitored
.

Currently, MUSIC is promoting active monitoring
throughout Michigan.
They are also actively sharing data with clinicians everywhere to improve prostate cancer patient care and reduce costs
.

According to the World Health Organization's 2018 statistics, the incidence of prostate cancer in the world ranks second
among all malignant tumors in men.
The incidence rate in China is much lower than that in Europe and the United States, but in recent years, it has also shown an upward trend, and the growth rate is far faster than that of European and American countries
.

According to the "Chinese Expert Consensus on Prostate Cancer Screening (2021 Edition)", only 1/3 of the newly diagnosed prostate cancer patients in China belong to clinically limited prostate cancer, that is, low-risk patients
.
At the time of initial diagnosis, most patients were already in the middle and advanced stages, resulting in the overall prognosis of prostate cancer patients in China being much worse than that of Western developed countries
.
It also means that Chinese patients can use active monitoring, or less
.

References: 1.
"Report on the Development of Malignant Tumors in China (2021)", Chinese Anti-Cancer Association.
2, William T Lowrance, Rodney H Breau, Roger Chou, et al.
Advanced Prostate Cancer: AUA/ASTRO/SUO Guideline.
Journal of Urology.
2021 Jan; 205(1):14-21.
doi:10.
1097/JU.
0000000000001375.
Epub 2020 Sep 22.
3、A Light at the End of the Tunnel for Low-Risk Prostate Cancer?.
Medical News.
4、Ishai Ross , Paul Womble , Jun Ye , et al.
MUSIC: patterns of care in the radiographic staging of men with newly diagnosed low risk prostate cancer.
Journal of Urology.
2015 Apr; 193(4):1159-62.
doi: 10.
1016/j.
juro.
2014.
10.
102.
Epub 2014 Oct 31.
5、Kevin B Ginsburg, Jesse C Jacobs, Ji Qi, et al.
Impact of Early Confirmatory Tests on Upgrading and Conversion to Treatment in Prostate Cancer Patients on Active Surveillance.
Urology.
2021 Jan; 147:213-222.
doi: 10.
1016/j.
urology.
2020.
07.
067.
Epub 2020 Sep 15.
6, Prostate Cancer Screening China Expert Consensus (2021 Edition).
Chinese Journal of Oncology.
2021 Vol.
31, No.
5

Source: Medical Proofreading: Zang Hengjia Editor: Xu Liyan
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.
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.

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