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Association Between Baseline Prostate MRI PI-RADS Classification and Risk of Gleason Upgrade During Active Surveillance: A Systematic Review and Meta-Analysis - Beyond the Abstract

Active surveillance (AS) has become a cornerstone of contemporary prostate cancer management, offering men with favorable risk-disease a strategy that preserves quality of life while limiting the risk of worsening oncologic outcomes.1 However, one of the persistent challenges in AS is identifying which patients are most likely to experience clinically meaningful progression in order to tailor monitoring intensity without drifting toward overtreatment.2 This challenge is especially relevant given the growing use of adjunctive predictive tools, such as tissue-based genetic testing.3
In our systematic review and meta-analysis, we sought to clarify the question: Does the baseline prostate MRI PI-RADS score meaningfully predict the risk of Gleason Grade Group (GGG) upgrading during AS? Although MRI is now a standard part of prostate cancer diagnosis, the prognostic role of the PI-RADS scoring system in the AS setting has remained less clearly defined.

Across 11 studies and 6,309 patients, we found a consistent and clinically significant association between higher PI-RADS scores and subsequent biopsy upgrading. Across the studies, patients with baseline PI-RADS 4-5 were more than twice as likely to upgrade compared to patients with baseline PI-RADS 1-3. Moreover, the risk rose stepwise across PI-RADS categories, with PI-RADS 5 lesions carrying nearly a fourfold increased risk of upgrading relative to PI-RADS 1-2.

These findings reinforce what many clinicians have observed anecdotally: MRI PI-RADS provide prognostic information that can meaningfully inform AS management. The consistency of effect sizes across heterogeneous cohorts, biopsy techniques, and MRI protocols underscores the robustness of this signal. These results support the growing efforts to adopt risk-adapted surveillance intensity, as patients with PI-RADS 4-5 lesions may benefit from earlier or more frequent subsequent biopsies.4 Limitations of our study include the retrospective nature of many of the included studies, variability in MRI quality, radiologist expertise, and AS protocols. Prospective validation is needed to refine how PI RADS should be operationalized in surveillance algorithms.

Written by: Shayan Smani,1 Nishan Sohoni,1 Marcin Miszczyk,2,3 Tamás Fazekas,2 Pawel Rajwa,4,5 Alyssa A. Grimshaw,1 Vinaik M. Sundaresan,1 Soum D. Lokeshwar,1 Jeffrey Weinreb,1 Preston C. Sprenkle,1 Matthew R. Cooperberg,6 Tyler M. Seibert,7 Shahrokh F. Shariat,2 William J. Catalona,8 Michael S. Leapman,9,10

  1. Yale School of Medicine, New Haven, CT, USA.
  2. Medical University of Vienna, Vienna, Austria.
  3. WSB University, Dąbrowa Górnicza, Poland.
  4. Semmelweis University, Budapest, Hungary.
  5. University College London, London, UK.
  6. University of California, San Francisco School of Medicine, San Francisco, CA, USA.
  7. University of California, San Diego, School of Medicine, La Jolla, CA, USA.
  8. Northwestern Feinberg School of Medicine, Chicago, IL, USA.
  9. Yale School of Medicine, New Haven, CT, USA.
  10. Department of Urology, Yale University School of Medicine, New Haven, CT, USA. 
References:

  1. Cooperberg MR, Carroll PR, Klotz L. Active surveillance for prostate cancer: progress and promise. Journal of Clinical Oncology 2011;29(27):3669–3676.
  2. Litwin MS, Tan H-J. The Diagnosis and Treatment of Prostate Cancer: A Review. JAMA 2017;317(24):2532–2542. DOI: 10.1001/jama.2017.7248.
  3. Jairath NK, Dal Pra A, Vince Jr R, et al. A systematic review of the evidence for the decipher genomic classifier in prostate cancer. European urology 2021;79(3):374–383.
  4. Soeterik TFW, van Melick HHE, Dijksman LM, Biesma DH, Witjes JA, van Basten JA. Follow-up in Active Surveillance for Prostate Cancer: Strict Protocol Adherence Remains Important for PRIAS-ineligible Patients. Eur Urol Oncol 2019;2(5):483–489. (In eng). DOI: 10.1016/j.euo.2019.01.010.
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