Development of a PSA tracking system for patients wtih prostate cancer following definitive radiotherapy to enhance rural health.

2016 ◽  
Vol 34 (2_suppl) ◽  
pp. 39-39 ◽  
Author(s):  
Michael G. Chang ◽  
Kristine DeSotto ◽  
Paul Taibi ◽  
Sandra Troeschel
Keyword(s):  
Prostate Cancer ◽  
Detection System ◽  
Tracking System ◽  
Failure Detection ◽  
Phone Call ◽  
Therapeutic Window ◽  
Definitive Radiotherapy ◽  
Psa Testing ◽  
Query Tool

39 Background: Patients with prostate cancer (PC) may benefit from early intervention when they experience relapse/recur. About 50% of our PC patients are rural and experience barriers to care due to distance, cost, and convenience. We sought to create a PSA tracking system with the Veterans Administration’s (VA) Electronic Medical Record (EMR) that would provide a remote way to monitor disease progression after definitive radiotherapy (XRT) by annual PSA testing alone. Methods: Using VA’s EMR, we developed a query tool to identify all patients ever treated at our center with XRT for prostate cancer who were alive, had not been seen in our clinic in more than a year, did not have metastatic disease, and had a rising PSA of at least 0.5 ng/ml above nadir, or who had no PSA drawn within 15 months. Results: Among roughly 50,000 unique patients in the McGuire VAMC EMR, we found 1,858 patients treated with XRT for PC more than 5 years ago between 1997 and 2015. Of these 1,190 were still alive and 455 had not been seen by our clinic in 400 days or more. Of these 455 patients, 159 patients had not had a PSA drawn within 15 months and/or their most recent PSA was more than 0.5 ng/ml above nadir, triggering a chart review followed by either a phone call, repeat testing, in person follow up visit, or removal from follow up monitoring if clinically indicated. 296 patients were receiving appropriate care outside of our clinic and had no sign of significant rise in PSA. An analysis by the VA showed annual savings of $60,360 per year in fuel costs by avoiding unnecessary visits. Conclusions: The VA’s robust EMR and a new query tool can identify patients with prostate cancer who are lost to follow up or who needed intervention from among thousands of patients in the EMR, improving quality while reducing cost and unnecessary time and travel for rural and all patients. More importantly, our tool could be modified to improve survival for all VA patients with prostate cancer by creating a VA-wide PSA failure detection system. The system would alert providers to any patient who may benefit from early salvage radiotherapy or hormonal therapy before their disease progresses beyond the therapeutic window of benefit.

scholarly journals A proof-of-concept study on the use of prostate artery embolization prior to definitive radiotherapy in prostate cancer

2020 ◽  
Author(s):  
Jeffrey Peacock ◽  
Dhiraj Sikaria ◽  
Laura Maun-Garcia ◽  
Khosrow Javedan ◽  
Kosj Yamoah ◽  
...  
Keyword(s):  
Prostate Cancer ◽  
Radiation Treatment ◽  
Organs At Risk ◽  
Statistical Significance ◽  
Volume Reduction ◽  
Proof Of Concept ◽  
Artery Embolization ◽  
Definitive Radiotherapy ◽  
Prostate Artery Embolization

Abstract Backgrounds: Prostatic artery embolization (PAE) has been well studied as a clinically effective therapy for alleviating lower urinary tract symptoms (LUTS) in patients with benign prostatic hyperplasia (BPH). We demonstrate a proof of concept for PAE prior to definitive radiotherapy in patients with prostate cancer.Methods: From 12/2017 to 07/2019, 57 patients underwent PAE for LUTS and BPH. Nine of these patients had PAE for LUTS in the setting of localized prostate cancer prior to receiving radiation. Five of the nine patients received their entire radiotherapy course at our institution and had clinical follow up were included in the analysis. Median follow up was 18 months from the time of PAE. LUTS improvement quantified by IPSS was the primary endpoint and a two tail students T test was used to compare statistical significance. Side effects during radiation were quantified using the CTCAE scoring system. Pre- and post- PAE plans were compared in the five patients that by performing an isovolumetric expansion of the post PAE plan (treated plan) equivalent to the measured volume reduction after PAE. Patient 1 and 2 had prostate and seminal vesicle RT alone while patients 3-5 had prostate with elective nodal coverage. Mean doses to organs at risk were compared between the two plans.Results: The average IPSS score pre-PAE was 17.40 compared to post-PAE of 3.6 (p=0.02). The average IPSS score reduction after PAE was 13.8 (5-30). The average prostatic volume reduction after PAE was 23.14% (7.2% - 47.7%). There were no CTCAE grade 3 (severe) or higher during radiation treatment. Post-PAE plans in patient 1 and 2 had on average 16.7% and 39.8% decrease in mean dose across the bladder, rectum, and penile bulb compared to the pre-PAE plans. There were no appreciable differences in dosimetry in the patients 3-5 who had nodal coverage. There was no biochemical failure in any of the patients.Conclusion: We demonstrate a proof of concept that prostate artery embolization is useful as an adjunctive procedure to alleviate LUTS, achieve significant volume reduction prior to radiation therapy, and decrease radiation related toxicity in the treatment of prostate cancer.

Impact of timing of biochemical failure on the eventual development of clinical failure after definitive treatment with brachytherapy or external beam radiotherapy for prostate cancer.

2015 ◽  
Vol 33 (7_suppl) ◽  
pp. 53-53
Author(s):  
Jay P. Ciezki ◽  
Chandana A. Reddy ◽  
Eric A. Klein ◽  
James Ulchaker ◽  
Kenneth Angermeier ◽  
...  
Keyword(s):  
Prostate Cancer ◽  
External Beam Radiotherapy ◽  
Biochemical Failure ◽  
Definitive Treatment ◽  
External Beam ◽  
Clinical Failure ◽  
Psa Testing ◽  
Testing Frequency ◽  
Definitive Therapy

53 Background: Late treatment failure is often considered to be a rare event. We will assess the influence of the timing of biochemical failure (bF) after definitive brachytherapy (BT) or external beam radiotherapy (EBRT) for prostate cancer on its frequency and association with clinical failure (cF). Methods: Patients with prostate cancer treated between 1996 and 2009 with at least 5 years of follow-up (N= 2,293; 1,060 EBRT, 1,233 BT) were studied in the context of an IRB-approved inception cohort study. Those with a bF were reviewed to determine the timing of bF [< 5 years after treatment (bF<5) vs. > 5 years after treatment (bF>5)] and occurrence of cF post-bF. The bF definition used was the nadir + 2.0 ng/mL version. Results: Of the total patient population, 477 (21%) were noted to have bF- 244 (11%) bF<5 vs. 233 (10%) bF>5. The median follow-up after bF for the bF< 5 group is 41 months while in the bF> 5 group it is 22 months. In the BT group, 94 (8%) failed < 5 years and 87 (7%) failed > 5 years. In the EBRT group, 150 (14%) failed < 5 years and 146 (14%) failed > 5 years. The median PSA value (ng/mL) at the time of bF for all patients, EBRT, and BT in the bF<5 group was 3.70, 3.65, and 3.80, respectively (p=not significant). The median PSA value (ng/mL) at the time of bF for all patients, EBRT, and BT in the bF>5 group was 3.01, 3.01, and 3.04, respectively (p=not significant). Overall, 53.3% of patients in the bF<5 group developed cF while 27% of patients in the bF>5 group developed a cF. The actuarial five year rate of cF for the bF <5 group was 50% vs. 38% for the bF>5 group (p= 0.028). The detection of bF and cF was closely linked to PSA testing frequency ( p < 0.0001). Conclusions: The risk of bF does not appear to decrease >5 years post treatment. Late bF (i.e. >5 years after treatment) may still result in eventual cF. While cF is less common after bF > 5 years post definitive therapy, it still affects 27% of those with bF and is strongly associated with PSA testing frequency. The lower rate of cF after 5 years may relate to the shorter follow-up time for this group.

PSA request analysis: how should this be interpreted? What may be overlooked / PSA istem analizi: Nasıl yorumlanmalı? Gözden kaçanlar nelerdir?

2016 ◽  
Vol 41 (2) ◽  
Author(s):  
Sema Nur Ayyıldız ◽  
Abdullah Çırakoğlu ◽  
Ali Ayyıldız ◽  
Erdal Benli
Keyword(s):  
Prostate Cancer ◽  
National Level ◽  
Specific Antigen ◽  
Diagnostic Uncertainty ◽  
Psa Testing ◽  
Number Of Patients ◽  
Organ Specific ◽  
Biopsy Examination ◽  
Urology Clinic

AbstractObjective: Prostate specific antigen is widely used for the diagnosis, treatment, and follow-up of prostate cancer. However, despite being organ-specific, PSA is not specific to cancer. As some patients with elevated PSA level have normal biopsy results and some others with low PSA levels have cancer diagnosed in biopsy examination, PSA creates diagnostic uncertainty both for clinicians and patients. Moreover, different PSA results received for the same subject at separate time points as well as smalllarge fluctuations in PSA levels perturb both sides. In a setting where there are so many unknowns we have PSA in our hands without any restrictions for ordering it. This study analyzed PSA orders, patient traffic, and economic burden within a 6-year period.Methods: The number of PSA tests and patient outcomes at a training and research hospital between October 2006 and May 2013 were evaluated.Results: Of 12107 tPSA orders, 73.6% were ordered by the urology clinic and 26.4% orders were made from other outpatient clinics. When patients at follow-up for prostate cancer are excluded because their tPSAs have to be more commonly checked, we detected that 28.22% of tests were ordered at intervals of less than 1 year. The average tPSA testing frequency was 91.84±1.21 days (0-330). The number of patients younger than 40 years who were tested for tPSA was 287. Of these, 25.43% were ordered by the urology clinic and the remaining by other medical branches.Conclusion: A state of chaos surrounds PSA order and interpretation. Neither patients nor physicians are aware of PSA-related outcomes. Therefore, each hospital should hold sessions on PSA testing and inform physicians about them. Furthermore, a detailed public education should be provided and seminars should be organized at the national level.

scholarly journals O34: WHO SHOULD BE FOLLOWING UP IN PATIENTS WITH PROSTATE CANCER USING PSAS?

2021 ◽  
Vol 108 (Supplement_1) ◽  
Author(s):  
M Lami ◽  
G Jackson
Keyword(s):  
Prostate Cancer ◽  
Primary Care ◽  
Medical Information ◽  
Statistical Testing ◽  
Care Needs ◽  
Psa Testing ◽  
Follow Up Care ◽  
Chi Squared ◽  
Recall System

Abstract Introdution Prostate cancer patients are usually followed up using serial PSA testing. NICE provides guidelines for PSA follow up however whether this should be in primary care or secondary care is ambiguous. Consequently, there is a concern that PSAs are being missed. The primary aim of this study was to understand whether PSAs were being missed. Method A retrospective study was carried out at Whitehill General Practice. Patients were identified using codes for prostate cancer through Egton Medical Information Systems (EMIS) software. Data for patients followed up with PSAs between 2015-2019 was collected manually from documentation. Chi-squared statistical testing was used. Result 47 patients had prostate cancer follow up with repeat PSAs. 45% patients were followed up solely by primary care whilst 40% had primary care follow up directed by specialists. 7 patients were excluded from further analysis. 35% of patients had missed PSAs, of which 18% had no reason documented. Furthermore, 19% had missed PSAs with solely primary care follow up. The difference in missed PSAs between solely primary care follow up versus those directed regularly by specialists was not significant (chi-squared 0.0177, p&gt;0.05). Conclusion PSAs are being missed because of a lack of a recall system. An ‘out of hospital’ recall system through a local administrative hub would allow for follow up standardisation. Involving patients in their follow up care should also be considered. By placing the responsibility centrally rather than to individual clinicians provides multiple fail safes to reduce missed follow ups. Take-home message An ‘out of hospital’ recall system through a local administrative hub would allow for follow up standardisation. Involving patients in their follow up care needs to also be considered.

10-Year Outcomes After Monitoring, Surgery, or Radiotherapy

2021 ◽  
pp. 43-48
Author(s):  
Philipp Dahm
Keyword(s):  
Prostate Cancer ◽  
Randomized Controlled Trial ◽  
Radiation Therapy ◽  
Controlled Trial ◽  
Specific Antigen ◽  
Active Monitoring ◽  
Risk Of Death ◽  
Psa Screening ◽  
Psa Testing

This chapter provides a summary of the landmark Prostate Testing for Cancer and Treatment (ProtecT) trial, a three-armed randomized controlled trial of men with clinically localized prostate cancer mostly diagnosed through prostate-specific antigen (PSA) screening comparing radical prostatectomy to radiation therapy or active monitoring. Active monitoring consisted mostly of regular PSA testing. After 10 years of follow-up, very few deaths from prostate cancer occurred, underscoring the very low risk of death from prostate cancer in patients diagnosed by PSA screening irrespective of treatment approach.

Clinical impact of disseminated tumor cells in patients with non-metastatic prostate cancer treated by definitive radiotherapy

2006 ◽  
Vol 24 (18_suppl) ◽  
pp. 4575-4575
Author(s):  
A. Berg ◽  
A. Berner ◽  
W. Lilleby ◽  
Ø. S. Bruland ◽  
S. D. Fosså ◽  
...  
Keyword(s):  
Prostate Cancer ◽  
Clinical Outcome ◽  
Tumor Cells ◽  
Cumulative Risk ◽  
Disseminated Tumor Cells ◽  
Clinical Relapse ◽  
End Points ◽  
Definitive Radiotherapy

4575 Background: Detection of disseminated tumor cells (DTCs) in bone marrow (BM) has been proven to be an independent prognostic factor in breast cancer. To our knowledge, we here present the first larger study of radically treated prostate cancer (PC) with sufficiently long-term follow-up where the association between DTCs at diagnosis and clinical outcome has been studied. Methods: We screened 272 cT1–4pN0M0 PC patients for DTCs in BM-aspirates between 1994 and 2004. Monoclonal antibodies against cytokeratins (AE1/AE3) and standardized immunocytochemical methods were applied for detection. BM-status was compared with clinical and histopathological factors at diagnosis in all patients and with long-term clinical outcome in 131 patients. They all started treatment including definitive radiotherapy (RT) before June, 2000 and had a relatively poor prognosis defined as cT3–4 or Gleason score (GS) ≥ 7B (4 + 3) or PSA ≥ 10 μg/l. Kaplan-Meier plots were generated by BM-status with the following end-points: Overall death, cause-specific death, distant metastases (DM) as first clinical relapse, local failure as first clinical relapse and biochemical failure. Results: DTCs were detected in 18% of the patients and were significantly associated with increasing percentage Gleason grade 4/5 (p = .035, Mann-Whitney) but not with dichotomized GS, tumor-stage or PSA. In the follow-up cohort (median observation time 6.9 years), the 7-year cumulative risk of DM was 21% in BM-positive patients vs. 6% in BM-negative patients (p = .069, log rank). No association was found between DTCs and other end-points. A sub-group analysis of 73 patients with GS ≥ 7B yielded a 34% 7-year cumulative risk of DM in BM-positive patients vs. 10% in BM-negative patients (p = .039, log rank). DTCs did not predict DM in 55 patients with GS ≤ 7A (3 + 4). In a multivariate analysis, dichotomized GS (RR = 7.8 [95% confidence interval (CI) = 1.0–60.7], p = .049) and BM-status (RR = 3.0 [95% CI = .9–9.4], p = .066) had independent impact on DM. Conclusions: The presence of DTCs in BM at diagnosis of non-metastatic PC is associated with the histological differentiation of the primary tumor and seems to predict development of DM after definitive RT. No significant financial relationships to disclose.

The impact of screening for prostate cancer on the development of metastatic disease.

2011 ◽  
Vol 29 (7_suppl) ◽  
pp. 192-192
Author(s):  
J. P. Ciezki ◽  
C. A. Reddy ◽  
P. Kupelian ◽  
E. A. Klein
Keyword(s):  
Prostate Cancer ◽  
High Risk ◽  
Metastatic Disease ◽  
Multivariable Analysis ◽  
Routine Screening ◽  
Meaningful Improvement ◽  
Psa Testing ◽  
Increased Risk ◽  
The Impact

192 Background: Routine screening for prostate cancer (CaP) was first advocated in 1993 in the US. Opponents of screening argue that the implementation of routine screening has not resulted in a meaningful improvement in survival. Since we are essentially unable to cure metastatic disease, the best measure of the efficacy of screening may not be overall survival but instead its ability to lessen the metastatic disease burden of the screened population. We assess the effect of screening on this endpoint. Methods: From 1986-1996, 1,721 patients with CaP were definitively treated with radical prostatectomy (RP) or radiotherapy (RT) at our institution. The cohort was divided into a pre screening era group (1986-1992; PRE, n=575) and a post screening era group (1993-1996; POST, n=1,146). Due to the potential for an imbalance in follow up time between the two groups, all patients were censored at ten years. Kaplan- Meier analysis was used to calculate the ten year metastases free survival rates (MFSR). Cox proportional hazards regression was used to examine if screening era along with disease, treatment, and follow-up characteristics was associated with an increased risk of developing metastatic disease. Results: The median follow up for all patients was 10 yrs (range: 0.1-10), 9.6 yrs (range: 0.1-10) for PRE patients, and 10 yrs (range: 0.1-10) for POST patients. The distribution by NCCN risk classification for the PRE patients was 44% high risk (H), 21% intermediate risk (I) and 28% low risk (L) vs. 36% H, 27% I, and 37% L for the POST patients (p < 0.0001). Within 10 years of treatment, 13% of all patients had developed metastatic disease. The 10 year MFSR for high risk PRE vs POST patients was 58% vs. 82% (p < 0.0001), 79% vs. 93% for I (p < 0.0001), and 90% vs. 98% (p = 0.0001) for L patients. On multivariable analysis, screening era (p < 0.0001, HR = 4.6, 95% CI = 3.4-6.1), T-stage, biopsy Gleason score, and post-treatment PSA testing frequency were significant. Conclusions: Screening for CaP results in a significant decrease in the risk of a patient developing metastatic disease within 10 years of treatment even after controlling for severity of disease. This risk reduction may yield improved quality of life and a cost savings to the medical care system. No significant financial relationships to disclose.

scholarly journals Screening for Prostate Cancer With Prostate-Specific Antigen Testing: American Society of Clinical Oncology Provisional Clinical Opinion

2012 ◽  
Vol 30 (24) ◽  
pp. 3020-3025 ◽  
Author(s):  
Ethan Basch ◽  
Thomas K. Oliver ◽  
Andrew Vickers ◽  
Ian Thompson ◽  
Philip Kantoff ◽  
...  
Keyword(s):  
Prostate Cancer ◽  
Life Expectancy ◽  
Specific Antigen ◽  
Risk Of Bias ◽  
Evidence Based ◽  
Limited Data ◽  
Strength Of Evidence ◽  
Psa Testing ◽  
American Society

Purpose An American Society of Clinical Oncology (ASCO) provisional clinical opinion (PCO) offers timely clinical direction to the ASCO membership after publication or presentation of potentially practice-changing data from major studies. This PCO addresses the role of prostate-specific antigen (PSA) testing in the screening of men for prostate cancer. Clinical Context Prostate cancer is the second leading cause of cancer deaths among men in the United States. The rationale for screening men for prostate cancer is the potential to reduce the risk of death through early detection. Recent Data Evidence from a 2011 Agency for Healthcare Research and Quality systematic review primarily informs this PCO on the benefits and harms of PSA-based screening. An update search was conducted to March 16, 2012, for additional evidence related to the topic. Results In one randomized trial, PSA testing in men who would not otherwise have been screened resulted in reduced death rates from prostate cancer, but it is uncertain whether the size of the effect was worth the harms associated with screening and subsequent unnecessary treatment. Although there are limitations to the existing data, there is evidence to suggest that men with longer life expectancy may benefit from PSA testing. Adverse events associated with prostate biopsy are low for the majority of men; however, several population-based studies have shown increasing rates of infectious complications after prostate biopsy, which is a concern. Provisional Clinical Opinion On the basis of identified evidence and the expert opinion of the panel ( Table 1 provides a description of how recommendations and evidence are rated): In men with a life expectancy ≤ 10 years,* it is recommended that general screening for prostate cancer with total PSA be discouraged, because harms seem to outweigh potential benefits. Type and strength of recommendation. Evidence based: strong. Strength of evidence. Moderate: based on five randomized clinical trials (RCTs) with intermediate to high risk of bias, moderate follow-up, and limited data on subgroup populations. In men with a life expectancy > 10 years,* it is recommended that physicians discuss with their patients whether PSA testing for prostate cancer screening is appropriate for them. PSA testing may save lives but is associated with harms, including complications, from unnecessary biopsy, surgery, or radiation treatment. Type and strength of recommendation. Evidence based: strong. Strength of evidence. For benefit, moderate; for harm, strong: based on five RCTs (and several cohort studies) with intermediate to high risk of bias, moderate follow-up, indirect data, inconsistent results, and limited data on subgroup populations. It is recommended that information written in lay language be available to clinicians and their patients to facilitate the discussion of the benefits and harms associated with PSA testing before the routine ordering of a PSA test. Type and strength of recommendation. Informal consensus: strong. Strength of evidence. Indeterminate: evidence was not systematically reviewed to inform this recommendation; however, randomized trials are available on the topic. *Calculation of life expectancy is based on a variety of individual factors and circumstances. A number of life expectancy calculators (eg, http://www.socialsecurity.gov/OACT/population/longevity.html) are available in the public domain; however, ASCO does not endorse any one calculator over another. NOTE. ASCO PCOs reflect expert consensus based on clinical evidence and literature available at the time they are written and are intended to assist physicians in clinical decision making and identify questions and settings for further research. Because of the rapid flow of scientific information in oncology, new evidence may have emerged since the time a PCO was submitted for publication. PCOs are not continually updated and may not reflect the most recent evidence. PCOs cannot account for individual variation among patients and cannot be considered inclusive of all proper methods of care or exclusive of other treatments. It is the responsibility of the treating physician or other health care provider, relying on independent experience and knowledge of the patient, to determine the best course of treatment for the patient. Accordingly, adherence to any PCO is voluntary, with the ultimate determination regarding its application to be made by the physician in light of each patient's individual circumstances. ASCO PCOs describe the use of procedures and therapies in clinical practice and cannot be assumed to apply to the use of these interventions in the context of clinical trials. ASCO assumes no responsibility for any injury or damage to persons or property arising out of or related to any use of ASCO PCOs or for any errors or omissions.

scholarly journals Guy’s and St Thomas NHS Foundation active surveillance prostate cancer cohort: a characterisation of a prostate cancer active surveillance database

BMC Cancer ◽  
2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Salonee Shah ◽  
Kerri Beckmann ◽  
Mieke Van Hemelrijck ◽  
Ben Challacombe ◽  
Rick Popert ◽  
...  
Keyword(s):  
Prostate Cancer ◽  
Active Surveillance ◽  
Specific Antigen ◽  
Future Research ◽  
Low Grade ◽  
Intermediate Risk ◽  
Psa Testing ◽  
Diagnostic Characteristics ◽  
Diagnostic Biopsy

Abstract Background The routine clinical use of serum prostatic specific antigen (PSA) testing has allowed earlier detection of low-grade prostate cancer (PCa) with more favourable characteristics, leading to increased acceptance of management by active surveillance (AS). AS aims to avoid over treatment in men with low and intermediate-risk PCa and multiple governing bodies have described several AS protocols. This study provides a descriptive profile of the Guy’s and St Thomas NHS Foundation Trust (GSTT) AS cohort as a platform for future research in AS pathways in PCa. Methods Demographic and baseline characteristics were retrospectively collected in a database for patients at the GSTT AS clinic with prospective collection of follow-up data from 2012. Seven hundred eighty-eight men being monitored at GSTT with histologically confirmed intermediate-risk PCa, at least 1 follow-up appointment and diagnostic characteristics consistent with AS criteria were included in the profile. Descriptive statistics, Kaplan-Meier survival curves and multivariable Cox proportion hazards regression models were used to characterize the cohort. Discussion A relatively large proportion of the cohort includes men of African/Afro-Caribbean descent (22%). More frequent use of magnetic resonance imaging and trans-perineal biopsies at diagnosis was observed among patients diagnosed after 2012. Those who underwent trans-rectal ultrasound diagnostic biopsy received their first surveillance biopsy 20 months earlier than those who underwent trans-perineal diagnostic biopsy. At 3 years, 76.1% men remained treatment free. Predictors of treatment progression included Gleason score 3 + 4 (Hazard ratio (HR): 2.41, 95% Confidence interval (CI): 1.79–3.26) and more than 2 positive cores taken at biopsy (HR: 2.65, CI: 1.94–3.62). A decreased risk of progressing to treatment was seen among men diagnosed after 2012 (HR: 0.72, CI: 0.53–0.98). Conclusion An organised biopsy surveillance approach, via two different AS pathways according to the patient’s diagnostic method, can be seen within the GSTT cohort. Risk of patients progressing to treatment has decreased in the period since 2012 compared with the prior period with more than half of the cohort remaining treatment free at 5 years, highlighting that the fundamental aims of AS at GSTT are being met. Thus, this cohort is a good resource to investigate the AS treatment pathway.

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