Renovating the Commission on Cancer's Quality Measure Portfolio.

IMPORTANCE: Nearly 75% of newly diagnosed cancer patients in the United States will receive care from a hospital that is accredited by the Commission on Cancer (CoC). To support hospitals in their quality assurance efforts, the CoC maintains a portfolio of quality measures to give hospitals compliance data with select best practices for cancer care. As the CoC quality measures have evolved over recent years, many clinicians may lack awareness of the intent and content of the measure portfolio, as well as the mechanism by which new measures originate. OBSERVATIONS: The CoC quality measures are based on data that hospitals submit to the National Cancer Database, allowing the CoC to track compliance with a subset of consensus best practices. Each year, new measures are designed by diverse teams of specialists in the different treatment modalities for the tumor types covered by the portfolio. These proposed measures are then subjected to a range of vetting, refinement, and prioritization steps before being voted into the portfolio by the Quality Assurance and Data Committee of the CoC. Over the past 4 years, the CoC has worked to renovate not only the portfolio but also the process used to create and launch new measures, revise existing measures, and retire obsolete measures. CONCLUSION AND RELEVANCE: In the following overview, we outline the current measure process, highlight important changes to the portfolio, and share opportunities to further increase the impact.

MRI-Targeted, Systematic, and Combined Biopsy for Prostate Cancer Diagnosis.

BACKGROUND: The use of 12-core systematic prostate biopsy is associated with diagnostic inaccuracy that contributes to both overdiagnosis and underdiagnosis of prostate cancer. Biopsies performed with magnetic resonance imaging (MRI) targeting may reduce the misclassification of prostate cancer in men with MRI-visible lesions. METHODS: Men with MRI-visible prostate lesions underwent both MRI-targeted and systematic biopsy. The primary outcome was cancer detection according to grade group (i.e., a clustering of Gleason grades). Grade group 1 refers to clinically insignificant disease; grade group 2 or higher, cancer with favorable intermediate risk or worse; and grade group 3 or higher, cancer with unfavorable intermediate risk or worse. Among the men who underwent subsequent radical prostatectomy, upgrading and downgrading of grade group from biopsy to whole-mount histopathological analysis of surgical specimens were recorded. Secondary outcomes were the detection of cancers of grade group 2 or higher and grade group 3 or higher, cancer detection stratified by previous biopsy status, and grade reclassification between biopsy and radical prostatectomy. RESULTS: A total of 2103 men underwent both biopsy methods; cancer was diagnosed in 1312 (62.4%) by a combination of the two methods (combined biopsy), and 404 (19.2%) underwent radical prostatectomy. Cancer detection rates on MRI-targeted biopsy were significantly lower than on systematic biopsy for grade group 1 cancers and significantly higher for grade groups 3 through 5 (P<0.01 for all comparisons). Combined biopsy led to cancer diagnoses in 208 more men (9.9%) than with either method alone and to upgrading to a higher grade group in 458 men (21.8%). However, if only MRI-target biopsies had been performed, 8.8% of clinically significant cancers (grade group ≥3) would have been misclassified. Among the 404 men who underwent subsequent radical prostatectomy, combined biopsy was associated with the fewest upgrades to grade group 3 or higher on histopathological analysis of surgical specimens (3.5%), as compared with MRI-targeted biopsy (8.7%) and systematic biopsy (16.8%). CONCLUSIONS: Among patients with MRI-visible lesions, combined biopsy led to more detection of all prostate cancers. However, MRI-targeted biopsy alone underestimated the histologic grade of some tumors. After radical prostatectomy, upgrades to grade group 3 or higher on histopathological analysis were substantially lower after combined biopsy. (Funded by the National Institutes of Health and others; Trio Study ClinicalTrials.gov number, NCT00102544.).

Why Does Magnetic Resonance Imaging-Targeted Biopsy Miss Clinically Significant Cancer?

PURPOSE: Multiple studies demonstrate magnetic resonance imaging (MRI)-targeted biopsy detects more clinically significant cancer than systematic biopsy; however, some clinically significant cancers are detected by systematic biopsy only. While these events are rare, we sought to perform a retrospective analysis of these cases to ascertain the reasons that MRI-targeted biopsy missed clinically significant cancer which was subsequently detected on systematic prostate biopsy. MATERIALS AND METHODS: Patients were enrolled in a prospective study comparing cancer detection rates by transrectal MRI-targeted fusion biopsy and systematic 12-core biopsy. Patients with an elevated prostate specific antigen (PSA), abnormal digital rectal examination, or imaging findings concerning for prostate cancer underwent prostate MRI and subsequent MRI-targeted and systematic biopsy in the same setting. The subset of patients with grade group (GG) ≥3 cancer found on systematic biopsy and GG ≤2 cancer (or no cancer) on MRI-targeted biopsy was classified as MRI-targeted biopsy misses. A retrospective analysis of the MRI and MRI-targeted biopsy real-time screen captures determined the cause of MRI-targeted biopsy miss. Multivariable logistic regression analysis compared baseline characteristics of patients with MRI-targeted biopsy misses to GG-matched patients whose clinically significant cancer was detected by MRI-targeted biopsy. RESULTS: Over the study period of 2007 to 2019, 2,103 patients met study inclusion criteria and underwent combined MRI-targeted and systematic prostate biopsies. A total of 41 (1.9%) men were classified as MRI-targeted biopsy misses. Most MRI-targeted biopsy misses were due to errors in lesion targeting (21, 51.2%), followed by MRI-invisible lesions (17, 40.5%) and MRI lesions missed by the radiologist (3, 7.1%). On logistic regression analysis, lower Prostate Imaging-Reporting and Data System (PI-RADSTM) score was associated with having clinically significant cancer missed on MRI-targeted biopsy. CONCLUSIONS: While uncommon, most MRI-targeted biopsy misses are due to errors in lesion targeting, which highlights the importance of accurate co-registration and targeting when using software-based fusion platforms. Additionally, some patients will harbor MRI-invisible lesions which are untargetable by MRI-targeted platforms. The presence of a low PI-RADS score despite a high PSA is suggestive of harboring an MRI-invisible lesion.

National Survey of Patterns Employing Targeted MRI/US Guided Prostate Biopsy in the Diagnosis and Staging of Prostate Cancer.

BACKGROUND/AIMS: Targeted magnetic resonance imaging/ ultrasound (MRI/US) guided biopsy is an emerging technology that has the potential to change standard of care for the diagnosis and management of prostate cancer. This technology is rapidly proliferating, however quantitative analysis of these trends are unavailable. The objective of this study was to assess urologist opinions regarding implementing MRI/ US imaging into their practices. METHODS: A questionnaire was distributed using research electronic data capture and completed by 291 practicing urologists within the United States registered through the American Urological Association. The survey gathered information regarding demographics, changes in MRI use, opinions on targeted MRI/US guided biopsy, and barriers to implementation. The survey results were analyzed using ANOVA. RESULTS: Practice setting and geographic region were signifIcantly associated with implementation of MRI/US guided biopsy. Total 72% of urologists in academic centers report using MRI/US targeted biopsy, compared to 38% in solo private practice. In the northeast 68% of urologists report using MRI/US biopsy, compared to 44% in the western United States. CONCLUSION: While there are some reservations about employing MRI/US guided biopsy as standard of care in all prostate biopsies, the data suggests urologists support its use, and are making efforts to introduce targeted MRI/US guided biopsy into their practice. Regional and practice setting variations exist in implementation.

Association of urinary bladder paragangliomas with germline mutations in the SDHB and VHL genes.

OBJECTIVE: Our primary goal was to examine the clinical characteristics of a series of patients with urinary bladder paragangliomas (UBPGLs), focusing particularly on their genetic backgrounds. MATERIALS AND METHODS: We analyzed the medical records of patients who presented to the National Institutes of Health with UBPGL from 2000 to 2013 to determine their clinical characteristics and outcomes, biochemical phenotype, tumor size, and genetic background. RESULTS: Of the 27 patients with UBPGLs who were identified, 17 (63%) had underlying genetic mutations. Overall, 14 (51.9%) patients had a germline mutation in the succinate dehydrogenase subunit B gene (SDHB), and 3 (11.1%) had mutations in the von Hippel-Lindau gene (VHL). Of the 21 patients who had biochemical data available before their first operation, 19 (90.5%) presented with a noradrenergic biochemical phenotype; 7 (33.3%) patients had tumors that also secreted dopamine. In addition, 1 patient (4.8%) had elevated metanephrine levels, and 2 (9.5%) had normal biochemical data. In total, 13 (48.1%) patients in the series were diagnosed with metastatic disease, at either first presentation or follow-up; 6 of these patients (46.1%) had SDHB mutations. CONCLUSIONS: UBPGLs typically present with a noradrenergic phenotype and are frequently associated with underlying germline mutations. Patients presenting with these rare neuroendocrine tumors should be screened for these mutations. In addition, patients with UBPGLs should be followed up closely for metastatic development regardless of genetic background, as almost half of the patients in this series presented with metastatic disease and less than half of them had SDHB mutations.