Search

Objective: To investigate the accuracy of Vesical Imaging-Reporting and Data System (VI-RADS) in detection of muscle-invasive bladder cancer (MIBC) we performed a systematic review and meta-analysis of the available literature. Materials and Methods: Scopus, Web of Science, PubMed, and EMBASE were searched up to 8 March 2021 for the studies evaluating the diagnostic performance of VI-RADS for the detection of MIBC. Inclusion criteria were patients with bladder cancer; index test of VI-RADS based on multiparametric MRI; reference test of histopathological findings from TURBT, re-TURBT, or cystectomy and study design of cohort. Case reports, review articles, and editorials were eliminated, as well as studies with insufficient knowledge to acquire TP, FP, FN, and TN values of VI-RADS. The MIDAS module of STATA was for statistical analysis. The heterogeneity was explored using subgroup analysis and meta-regression analysis. Results: Overall, 22 eligible studies, consisting of 2,576 participants and 5,414 MRI reports, were included in this meta-analysis. The area under curve (AUC) of VI-RADS at cut-point values of 3 and 4 were 0.93 (95%CI: 0.91, 0.95), 0.93 (95%CI: 0.90, 0.95), respectively. Based on Youden's J statistic, the optimal VI-RADS cutoff value for predicting MIBC was determined as 3 which granted a pooled sensitivity of 89% (95%CI: 87%, 91%; I2=48%) and a specificity of 84% (95%CI: 80%, 87%; I2=90%). Based on meta-regression, the sources of inter-study heterogeneity for VI-RADS ≥ 3 were the sample size > 70, study design, single-center vs multi-center, patient population characteristics (i.e., gender, age), reference standard, histology, magnetic strength, T2WI slice thickness, and the number of radiologists reporting the MRI results (P value ≤ 0.01). Conclusion: The VI-RADS demonstrates consistently high diagnostic accuracy to predict MIBC. This scoring system could be applied in standard staging MRI reports of bladder cancer and can be incorporated into future MIBC work up guidelines.

Purpose: We examined if malnutrition, as defined by the Geriatric Nutritional Risk Index (GNRI), is independently associated with 30-day postoperative complications in patients undergoing nephrectomy for the treatment of renal cancer. Materials and methods: Using the American College of Surgeons National Surgical Quality Improvement Program database from 2006-2019, we identified patients ≥65 years old who underwent nephrectomy for renal cancer. The following formula for GNRI was used to define preoperative nutritional status: 1.489 x serum albumin (g/L) + 41.7 x (current body weight [kg]/ ideal body weight [kg]). Based on the GNRI, patients were classified as having no (> 98), moderate (92-98), or severe malnutrition (< 92). After adjusting for potential confounders, multivariable logistic regression analyses were performed to assess the association between GNRI and 30-day postoperative complications. Odds ratios (OR) with 95% confidence intervals (CI) were reported. Results: A total of 7,683 patients were identified, of which 1,241 (16.2%) and 872 (11.3%) had moderate and severe malnutrition, respectively. Compared to normal nutrition, moderate and severe malnutrition were significantly associated with a greater odds of superficial surgical site infection, progressive renal insufficiency, readmission, extended length of stay, and non-home discharge. Severe malnutrition was also associated with urinary tract infection (OR 2.10, 95% CI 1.31-3.35) and septic shock (OR 2.93, 95% CI 1.21-7.07). Conclusion: Malnutrition, as defined by a GNRI ≤ 98, is an independent predictor of 30-day complications following nephrectomy. The GNRI could be used to counsel elderly patients with renal cancer prior to nephrectomy.

To evaluate the diagnostic agreement between readers in VI-RADS interpretation to detect muscle-invasive bladder cancer (MIBC) preoperatively, we conducted a systematic review and meta-analysis of the available data. Scopus, PubMed, Web of Science, and Embase databases were systematically searched up to November 13, 2021. Case reports, review articles, editorials, and studies with insufficient data were eliminated. The Quality Appraisal of the Diagnostic Reliability Checklist was used to assess the risk of bias. The degree of agreement was determined by Cohen's kappa coefficient (κ) for comparison of data. The heterogeneity of these studies was explored using subgroup analysis and meta-regression analysis. The level of confidence was set at 0.05. All analyses were conducted in STATA 16.0. Overall, 19 eligible studies, consisting of 2439 participants, were included in this meta-analysis. The inter-reader agreement for VI-RADS in MIBC detection ranged from κ of 0.45 to 0.96 among included studies. The pooled inter-reader reliability was calculated as 0.76 [95% CI 0.73-0.80; I

This study seeks to identify patient socioeconomic factors that may be associated with no-shows to our academic urology clinics. This was a retrospective analysis of patient attendance to appointments scheduled at the main urology clinics of our academic center between April 2018 and April 2019. Attendance to scheduled appointments was computed and analyzed with respect to patients’ demographics and socioeconomic status, along with clinic site, type of provider scheduled with, and reason for visit. Chi-square test and simple and multiple logistic regression were performed in order to determine the relationship between patient no-show rates and the variables for appointment characteristics. The cohort of patients at highest risk for no-show was associated with those who were uninsured (OR = 30.00, 95% CI: 23.73-–7.92; p

Background: Primary adenoid cystic carcinoma (ACC) is the second most common primary tracheal neoplasms but the data for optimal treatment plan is limited. This study is an update of our institutional experience treating primary ACC of the trachea with neutron radiotherapy.

We reviewed and analyzed the most effective methods to reduce infectious complications (IC) after transrectal prostate biopsy (TRPB). We included only prospective randomized-controlled trials in the analysis. The analysis neither demonstrated any superiority of fluoroquinolones over other antibiotic classes nor of targeted antibiotics over empiric regimens in men undergoing TRPB. However, longer course antibiotics (3 days or more) compared to single dose or day regimens, combination of fluoroquinolones with aminoglycosides compared to fluoroquinolones alone and povidone-iodine rectal cleansing compared to control significantly reduced IC following TRPB. A combination of addition of aminoglycosides to oral antibiotics for 3 days along with povidone-iodine rectal cleansing may be an optimum strategy to minimize the risk of IC after TRPB.

The role of multiparametric MRI (mp-MRI) for postproton radiation evaluation is unclear. In this pilot study, we characterize the mp-MRI features using the Prostate Imaging-Reporting and Data System (PI-RADS) for recurrent prostate cancer (PCa) following proton radiation therapy.After obtaining IRB approval, we identified 163 consecutive cases who underwent MRI-fusion prostate biopsy at our institution from November 2017 to May 2020. This study evaluated patients with prostate cancer (PCa) with biochemical recurrence following proton radiation. Patients were excluded if they had grossly metastatic disease, metal fragments, implanted devices, or with surgically removed prostates. The mpMRI studies were reviewed in depth and scored by 2 fellowship-trained radiologists. Following MRI-fusion biopsy of lesions of interest (LOI), slides were read by fellowship-trained pathologists.We found 14 patients with 16 lesions who met the study inclusion criteria. The median age was 69 years (range 57-79) and median time to biochemical recurrence was 7.3 years (range 3-13). On post-treatment imaging, decreases in prostate size and diffusely decreased T2 signal intensity were observed, making the use of apparent diffusion coefficient (ADC) and early enhancement at dynamic contrast enhanced (DCE) imaging often necessary for diagnosis of disease recurrence. We identified a total of 16 lesions with PIRADS scores of 3 or higher. Of these lesions, there were 5 PIRADS 3 lesions (4/5 (80%) without prostate cancer), 7 PIRADS 4-5 lesions (6 (86%) had high risk Pca), and 4 lesions with unassigned PIRADS scores (100% had high risk cancers). Among the MRI variables, diffusion weighted imaging (DWI) heterogeneity had the strongest association with recurrence of PCa (P0.001).Results of our pilot study showed that the PIRADS scoring system in the postproton radiation therapy setting has some correlations with prostate cancer recurrence; However, the clinical value of these findings are unclear. While definitive PIRADS categorization of lesions demonstrated expected frequency of cancer consistent with the scoring system, all unassigned lesions also harbored malignancy suggesting a cautious approach to PIRADS scoring system in postproton radiation setting. The findings from this study may be validated using a larger cohort.

The Geriatric Nutritional Risk Index (GNRI) is a simple screening tool to predict nutrition-related risk of morbidity and mortality in older patients. We assessed whether preoperative GNRI was associated with 30-day complications after radical cystectomy (RC).Using the American College of Surgeons National Surgical Quality Improvement Program database, we identified patients 65 years or older who underwent RC for the treatment of bladder cancer between 2007 and 2019. Patients were dichotomized into at-risk (GNRI ≤98) or no-risk (GNRI98) groups. Using propensity score matching, the 2 groups were compared for baseline differences and 30-day outcomes. We evaluated GNRI as an independent predictor of postoperative complications using multivariable logistic regression analysis.We identified 2,926 patients eligible for analysis. After propensity score matching, patients in the at-risk GNRI group had higher rates of any complication (p=0.017), blood transfusion (p=0.002), extended length of stay (p=0.004) and nonhome discharge (p0.001). Multivariable logistic regression analysis revealed that a decreasing GNRI is an independent prognostic factor for mortality (OR 1.05, 95% CI 1.01-1.08, p=0.009), blood transfusion (OR 1.03, 95% CI 1.02-1.04, p0.001), pneumonia (OR 1.04, 95% CI 1.01-1.07, p=0.013), extended length of stay (OR 1.03, 95% CI 1.02-1.05, p0.001) and nonhome discharge (OR 1.04, 95% CI 1.03-1.06, p0.001).We demonstrate that nutritional status evaluated by GNRI predicts 30-day complications after RC.

Studies directly comparing the different combination therapies offered to men with metastatic castration sensitive prostate cancer (mCSPC), are not available yet. This study was designed using the network meta-analysis (NMA) framework to provide a comparison of the different available options for the treatment of men with mCSPC.A systematic search was performed and the prospective randomized controlled trials reporting the overall survival (OS) or failure-free survival (FFS) were selected for review. A total of 14 studies were included in the NMA.The addition of abiraterone, apalutamide, docetaxel, and docetaxel with zoledronic acid to the androgen deprivation therapy (ADT) demonstrated a significant improvement in the OS. In indirect comparison, abiraterone had a higher impact on the OS as compared to docetaxel (hazard ratio [HR]: 1.21, 95% confidence interval [CI]: 1.0-1.46) and docetaxel with zoledronic acid (HR: 1.31, 95% CI: 1.05-1.63) but not apalutamide. Furthermore, apalutamide was not different than docetaxel or docetaxel with zoledronic acid. There was a significant improvement in the FFS with the combination of abiraterone, apalutamide, docetaxel (HR: 0.61, 95% CI: 0.46-0.81), docetaxel with zoledronic acid (HR: 0.62, 95% CI: 0.43-0.9), and enzalutamide (HR: 0.39, 95% CI: 0.25-0.61) as compared to the ADT alone. Similar to the indirect comparison of OS, abiraterone outperformed docetaxel (HR: 1.66, 95% CI: 1.12-2.47), docetaxel with zoledronic acid (HR: 1.69, 95% CI: 1.06-2.68), and enzalutamide (HR: 1.06, 95% CI: 0.63-1.80), but not apalutamide in terms of impact on the FFS.Overall, abiraterone demonstrated better OS and FFS outcomes as compared to all the other combination strategies in this NMA.

Low-grade prostate cancer has low mortality rates at 10 years; however, it is unclear if the response is sustained for up to 25 years of follow-up.Using Surveillance, Epidemiology, and End Results database, the overall and cancer-specific mortality rates were compared among men ≤ 55 years of age diagnosed with low-grade prostate cancer that either had radical prostatectomy, radiotherapy, or no known treatment.Of the 62,772 men diagnosed with low-grade prostate cancer between 1975 and 2016, about 60%, 20% and 20% of men underwent radical prostatectomy, radiotherapy, and no known treatment, respectively. At a median follow-up of 10 years, almost 2% and 7% of men died of prostate cancer and other causes, respectively. The overall mortality was significantly better in radical prostatectomy group compared to no known treatment group (HR 1.99, CI 1.84-2.15, P value 0.001), but not between the radiotherapy and no known treatment groups. Moreover, the overall and cancer-specific mortality rates in the radiotherapy group were almost two and three times compared to the radical prostatectomy group, respectively (HR 2.15, CI 2.01-2.29, P value 0.001 for overall mortality and HR 2.87, CI 2.5-3.29, P value 0.001 for cancer-specific mortality).The study confirms low mortality rates in men diagnosed with low-grade prostate cancer for over 25 years' follow-up. While radical prostatectomy improves survival significantly compared to no known treatment, radiotherapy is associated with an increase in overall and cancer-specific mortality, which may be related to long-term toxicities.

PURPOSE/OBJECTIVE(S) To report 10-year outcomes for patients treated with proton therapy for localized prostate cancer. MATERIALS/METHODS The 10-year outcomes from a prospective outcome tracking protocol were assessed and reported for 1272 men with localized prostate cancer. Risk groups were classified per NCCN guidelines. Median proton therapy dose was 78 GyRBE (72 to 82 GyRBE) delivered at 1.8 to 2 GyRBE per fraction. Androgen deprivation therapy (ADT) was received by 193 men for a median 6 months (range 1 to 36 months). Biochemical control was defined using the Phoenix definition. Common Terminology Criteria for Adverse Events, version 5.0, was used for toxicity scoring. The International Prostate Symptom Score (IPSS) and Expanded Prostate Index Composite (EPIC) was used for patient-reported outcomes. Freedom from biochemical failure (FFBF) and toxicity rates were calculated using the Kaplan Meier method. EPIC domain score changes considered clinically significant were 5 (bowel), 6 (urinary irritative /obstructive), 7 (urinary incontinence), and 11 (sexual). RESULTS The median follow-up time was 10.2 years. The 10-year FFBF rates for patients with very low-risk, low-risk, favorable intermediate-risk, unfavorable intermediate-risk, high-risk, and very high-risk prostate cancer were 97%, 96%, 88%, 82%, 68%, 49%, respectively. Median PSA nadir was 0.2 ng/mL. On multivariate analysis, risk category, PSA, and the presence of perineural invasion predicted 10-year biochemical control. The 7- and 10-year grade 3+ gastrointestinal and urologic toxicity rates were 1.0% and 1.3% and 4.1% and 6.2%, respectively. On multivariate analysis (MVA), the use of prescription blood thinners significantly increased the 10-year risk for grade 3+ gastrointestinal toxicity. The use of prescription blood thinners, the presence of diabetes mellitus, a prostate volume 40+ grams, the use of pretreatment alpha blockers, an IPSS score of 15+, and the use of ADT were associated with late grade 3+ genitourinary (GU) toxicity on MVA. The dose-volume histogram parameter V70 (GyRBE) of bladder volume (< 33 cc vs. 33+ cc) also predicted for late grade 3+ GU toxicity on MVA. A clinically significant decline in EPIC sexual summary scores occurred at 10 years (67 to 41). No other clinically significant change was seen in EPIC summary scores. CONCLUSION These long-term results show that proton therapy can provide favorable biochemical control outcomes for patients with localized prostate cancer. Additional strategies are needed to improve disease control for patients with very high-risk disease. Late grade 3+ GI toxicity rates are low and, as noted with other radiation modalities, the rate of late grade 3+ GU toxicity increases with time even after 5 years. There was an expected decline in overall sexual function as the patient cohort aged following proton therapy. These long-term results establish benchmarks for future comparative trials.

Precise determination and assessment of bladder cancer (BC) extent of muscle invasion involvement guides proper risk stratification and personalized therapy selection. In this context, segmentation of both bladder walls and cancer are of pivotal importance, as it provides invaluable information to stage the primary tumor. Hence, multiregion segmentation on patients presenting with symptoms of bladder tumors using deep learning heralds a new level of staging accuracy and prediction of the biologic behavior of the tumor. Nevertheless, despite the success of these models in other medical problems, progress in multiregion bladder segmentation, particularly in MRI and CT modalities, is still at a nascent stage, with just a handful of works tackling a multiregion scenario. Furthermore, most existing approaches systematically follow prior literature in other clinical problems, without casting a doubt on the validity of these methods on bladder segmentation, which may present different challenges. Inspired by this, we provide an in-depth look at bladder cancer segmentation using deep learning models. The critical determinants for accurate differentiation of muscle invasive disease, current status of deep learning based bladder segmentation, lessons and limitations of prior work are highlighted.

Objective: This study was designed to provide an indirect comparison of the urinary and sexual domain outcomes and complications after newer minimally invasive surgical therapy (MIST) of Aquablatio...

Introduction Randomized clinical trials have shown combination therapy to be superior in progression-free survival (PFS) rates when compared with sunitinib alone. However, there have been no direct comparisons among the combination strategies making it unclear as to which may be the preferred option. We performed a network meta-analysis of the combination therapy (immune checkpoint inhibitor plus axitinib or bevacizumab) used in metastatic renal cell carcinoma (mRCC) and provided a rank order preference based on PFS, and adverse events (AEs). Materials and methods A systematic search on the treatment of mRCC using combination therapy till July 2019 was done. Studies reporting on combination therapies with immune checkpoint inhibitor plus axitinib or bevacizumab for mRCC were selected. Frequentist method was used for rank order generation. Results A total of 3 studies consisting of 2672 patients were selected. All combination therapies demonstrated improved PFS when compared with sunitinib alone. The rank order for PFS showed combination of pembrolizumab plus axitinib had the highest probability of favorability followed by avelumab plus axitinib and atezolizumab plus bevacizumab (surface under the cumulative ranking 0.9, 0.7, and 0.4, respectively). For AEs, pembrolizumab plus axitinib had the least AEs ≥grade 3, followed by avelumab plus axitinib and atezolizumab plus bevacizumab (surface under the cumulative ranking 0, 0.5, 1.0). Conclusions This network meta-analysis demonstrates that combination of pembrolizumab plus axitinib may be the preferred option based on efficacy and side effect profile compared with avelumab plus axitinib or atezolizumab plus bevacizumab. However, all the 3 combination strategies were superior to sunitinib alone in improving PFS in patients with mRCC.

INTRODUCTION AND OBJECTIVE:Recently, the Phase-III trials with second generation androgen receptor antagonists (Apalutamide, Enzalutamide and Darolutamide) have shown similar efficacy, leaving clin...

INTRODUCTION AND OBJECTIVE:Spinal cord injury (SCI) is one of the most devastating injuries not only to the patient but also to the family and society. Genitourinary (GU) complications are among th...

INTRODUCTION AND OBJECTIVE:The natural history of prostate cancer (PC) in men of > 70 years of age is not well defined. Although the current recommendation for PC screening is limited to 70 years o...

INTRODUCTION AND OBJECTIVE:Patient no-show to scheduled outpatient ambulatory clinic appointments adversely impacts healthcare costs and the quality of patient care. In this study, we seek to ident...

INTRODUCTION AND OBJECTIVE:The combination of immune checkpoint inhibitors and antiangiogenics have emerged as a new treatment modality for metastatic renal cell carcinoma (mRCC). Recent randomized...

Introduction: Studies using apalutamide, enzalutamide, or darolutamide have shown improved metastasis free survival (MFS) rates, leaving clinicians with a dilemma of choosing one over the other, for nonmetastatic castration recurrent prostate cancer (nmCRPC). We performed a network meta-analysis to provide an indirect comparison of oncologic outcomes and adverse events (AEs) of these medications. Material and Methods: We searched PubMed, MEDLINE, and SCOPUS databases, for studies reporting apalutamide, enzalutamide, or darolutamide until January 25, 2020. Results were input into an EndNote library, and data were extracted into a predefined template. Progression free survival (PFS) was defined as radiologic progression or death. Network meta-analysis was done using R and meta-analysis was performed with RevMan v. 5. Surface under the cumulative ranking (SUCRA) value was used to provide rank probabilities. Results: We found 3 studies reporting results for apalutamide, enzalutamide, and darolutamide. MFS was significantly lower in patients receiving darolutamide compared to both apalutamide (hazard ratio [HR]: 0.73, 95% confidence interval [CI]: 0.55–0.97) and enzalutamide (HR: 0.71, 95% CI: 0.54–0.93). MFS was similar for enzalutamide and apalutamide (HR: 0.97, 95% CI: 0.73–1.28). In PFS, apalutamide showed a slightly higher rate compared to darolutamide (HR: 0.76, 95% CI: 0.59–0.99). There was no difference in overall survival (OS) between any of the medications. There was no statistically significant difference in AEs profile of the 3 medications. However, darolutamide had the highest SUCRA value and probability of being the most preferred medication based on AEs profile. Conclusion: Enzalutamide and apalutamide had similar and higher MFS rate in indirect comparison with darolutamide. In cases where AEs are concerning, darolutamide might be the preferred agent.

Background Recent guidelines recommend active management of prostate cancer (CaP), especially high-risk disease, in elderly men. However, descriptive data from a large cohort with extended follow up on the risk of death from CaP in men diagnosed over 70 years of age and its relationship to Gleason score (GS) and serum prostate specific antigen (PSA) level is lacking. Using the Surveillance, Epidemiology, and End Results database, we evaluated the influence of GS and serum PSA levels on the risks of mortality from PC (PCM) and mortality from other causes in localized (LPC) and metastatic (MPC) disease in elderly population. Methods Men diagnosed with PC over 70 years of age between 2004 and 2016 were divided into LPC and MPC groups, categorized by age: 70–74, 75–79, 80–84, 85–89, and ≥90 years and stratified by GS 7, and serum PSA level 50 ng/mL. Competing risk estimates for PCM and mortality from other causes were generated for both groups. Results Of the 85,649 men, 85.5 % were LPC at diagnosis. Overall, at a median follow up of 4 years, 15% of the men had died including a third from PC. While 30% in men with GS >7 in LPC group, which accounted for almost half of total deaths for age 70–84 years. The GS >7 was also significantly associated with PCM in men with MPC. Furthermore, PCM directly correlated with serum PSA levels, with mortality rates reaching up to 50% and 70% for PSA >50 ng/dl for LPC and MPC, respectively. Conclusions There is a substantial risk of dying in men diagnosed with LPC over 70 years of age with GS >7 or a serum PSA >20 ng/mL. Furthermore, the risk for death for MPC directly correlated with GS with PCM increasing from 10%–30% for GS ≤7 to >50% for GS >7. The data, in conjunction with other clinical parameters such as comorbidities could be used to counsel elderly men on management options of PC for both localized and metastatic PC.

BACKGROUND Patients with prostate cancer and their providers face uncertainty as they consider adjuvant radiotherapy (ART) or salvage radiotherapy (SRT) after undergoing radical prostatectomy. The authors prospectively evaluated the impact of the Decipher test, which predicts metastasis risk after radical prostatectomy, on decision making for ART and SRT. METHODS A total of 150 patients who were considering ART and 115 who were considering SRT were enrolled. Providers submitted a management recommendation before processing the Decipher test and again at the time of receipt of the test results. Patients completed validated surveys on prostate cancer (PCa)-specific decisional effectiveness and PCa-related anxiety. RESULTS Before the Decipher test, observation was recommended for 89% of patients considering ART and 58% of patients considering SRT. After Decipher testing, 18% (95% confidence interval [95% CI], 12%-25%) of treatment recommendations changed in the ART arm, including 31% among high-risk patients; and 32% (95% CI, 24%-42%) of management recommendations changed in the salvage arm, including 56% among high-risk patients. Decisional Conflict Scale (DCS) scores were better after viewing Decipher test results (ART arm: median DCS before Decipher, 25 and after Decipher, 19 [P

Placement of fiducial markers for prostate radiotherapy (RT) is associated with a 2% to 3% risk of bacterial urinary tract infection (UTI) that may progress to sepsis necessitating hospitalization. These bacterial UTIs are primarily due to flouroquinolone (FQ) resistant Escherichia coli (E. coli). The incidence of this complication has increased in recent years. The purpose of this study is to determine whether rectal culture and sensitivity (CS) to identify FQ resistant E. coli obtained before placement of fiducial markers for prostate RT reduces the likelihood of this complication.In total, 412 patients treated with RT at the University of Florida Proton Therapy Institute between 2015 and 2017 were included in the study. Rectal CS were obtained at the time of initial consultation which preceded placement of fiducial markers for planning and realignment for prostate RT. Patients in whom resistant E. coli were identified had their prophylactic antibiotic regimen modified accordingly. Whether bacterial UTI requiring hospitalization following fiducial placement occurred was prospectively recorded in the medical record on the first day of RT.One of 412 patients (0.2%) developed bacterial sepsis requiring hospitalization after fiducial placement.Rectal CS to identify FQ resistant E. coli before placement of fiducial markers for prostate RT likely reduces the risk of bacterial UTI necessitating hospitalization.

BACKGROUND Patients with prostate cancer and their providers face uncertainty as they consider adjuvant radiotherapy (ART) or salvage radiotherapy (SRT) after undergoing radical prostatectomy. The authors prospectively evaluated the impact of the Decipher test, which predicts metastasis risk after radical prostatectomy, on decision making for ART and SRT. METHODS A total of 150 patients who were considering ART and 115 who were considering SRT were enrolled. Providers submitted a management recommendation before processing the Decipher test and again at the time of receipt of the test results. Patients completed validated surveys on prostate cancer (PCa)‐specific decisional effectiveness and PCa‐related anxiety. RESULTS Before the Decipher test, observation was recommended for 89% of patients considering ART and 58% of patients considering SRT. After Decipher testing, 18% (95% confidence interval [95% CI], 12%‐25%) of treatment recommendations changed in the ART arm, including 31% among high‐risk patients; and 32% (95% CI, 24%‐42%) of management recommendations changed in the salvage arm, including 56% among high‐risk patients. Decisional Conflict Scale (DCS) scores were better after viewing Decipher test results (ART arm: median DCS before Decipher, 25 and after Decipher, 19 [P, Use of the Decipher test appears to result in a change in treatment decision making in a substantial percentage of men with prostate cancer who are considering adjuvant or salvage radiotherapy after radical prostatectomy. Decisional effectiveness improves for both patients and providers with use of the Decipher test.

112 Background: Prostate cancer (PC) patients and providers have tremendous uncertainty as they decide on intervention with adjuvant or salvage radiation therapy (ART, SRT) after radical prostatectomy (RP). We prospectively evaluated the impact of Decipher test, a genomic classifier which predicts metastasis post-RP, on providers’ decision-making for ART and SRT. Methods: 150 men considering ART and 115 men considering SRT from 19 sites across the US were enrolled. Participating providers submitted a management recommendation prior to processing the Decipher test and again after receiving test results. We then followed patients for 12 months to assess actual treatment received and patient reported decisional conflict scale (DCS) and a validated survey on PC-related anxiety. Results: Pre-Decipher, observation was recommended for 89% of adjuvant men and 58% of salvage men. Post-Decipher, 17% of treatment recommendations changed in the adjuvant arm and 30% of recommendations changed in the salvage arm. Among adjuvant men, 78% maintained their recommended management 12 months after Decipher; 76% of salvage men maintained their recommended treatment after Decipher. Among 21 adjuvant men who intensified their treatment (observation to ART or ART to ART plus androgen deprivation therapy), 5 (24%) experienced biochemical recurrence with detectable PSA. In adjuvant men, PC-specific anxiety decreased differently among Decipher risk categories (p-value = 0.045), most notably among Decipher high risk men (9.07 [7.87, 10.26] pre-Decipher, 5.61 [5.35,5.88] 12 months post-Decipher). In salvage men, PC-specific anxiety decreased differently among those whose treatment were concordant (10.28 [8.1,12.47] pre-Decipher, 7.18 [6.82,7.54] 12 months post-Decipher) and those whose treatment were intensified (p-value = 0.01), and decreased differently among low-risk and high-risk Decipher patients (p = 0.04). Conclusions: Use of the Decipher test changed treatment decisions that was consistent with the eventual treatment received in three-fourths of adjuvant and salvage men after RP. Several men that pursued ART experienced PSA progression. PC-specific anxiety decreased in both adjuvant and salvage men. Clinical trial information: NCT02080689.

139 Background: Academic centers report the magnetic resonance imaging (MRI)/ transrectal ultrasound (TRUS) fusion biopsy increases detection of high−risk and high Gleason score (GS) prostate cancer (CaP) as compared to standard 12−core biopsy among men for suspected CaP. This prospective trial evaluated the utility and benefits of performing MRI/TRUS fusion biopsy in a community cancer center. Methods: Men suspected of CaP underwent prostate multi−parametric magnetic resonance imaging (mpMRI) using a 1.5 tesla GE 450W GEMS magnet with a 32 channel phased anterior array coil to identify suspicious regions for prostate cancer. Regions were graded with Prostate Imaging Reporting and Data System (PI−RADS V2.0) by a single radiologist (5 years of experience). Men underwent concurrent MRI/TRUS fusion targeted and 12−core standard biopsies using an image guided fusion system. This prospective trial evaluated 79 men for number of positive biopsies by GS, biopsy technique and cohort (biopsy naïve, prior negative biopsy and CaP under surveillance). McNemar test was used for statistical analysis. Results: Study group included 79 men (mean age 66 years) with mean PSA 8.25 ng/mL. Cancer detection rate (CDR) and GS for the entire cohort by biopsy technique were determined. Overall, target biopsy (TB) diagnosed more GS ≥ 7 versus the 12−core standard biopsy (SB) (26 vs 18) and less GS6 (13 vs 21) (p = 0.057). Exact agreement was demonstrated in 66% of cases between TB and SB for GS ≥ 7, GS6 and no cancer. SB found cancers in 11 men missed by the TB, but 73% of these cancers were low grade GS6. TB of higher PI−RADS category lesions found more and higher grade cancers: 73% PI−RAD 5, GS ≥ 7; 80% PI−RAD 4, GS > 6; and 73% PI−RAD 3 were benign. In the biopsy naïve group (32 men), TB detected more GS ≥ 7 than SB (19 vs 13) (p = 0.11). Conclusions: Utilizing a mpMRI with a 1.5 tesla magnet and no endorectal coil, these encouraging preliminary results suggest MRI/TRUS fusion biopsy can be validated in the community for CaP detection. Results support a new paradigm in CaP detection utilizing pre−biopsy mpMRI and targeting higher PI−RADS lesions possibly eliminating SB.