Population-Based Prostate Cancer Screening With Magnetic Resonance Imaging or Ultrasonography: The IP1-PROSTAGRAM Study

Performance of an ultra-fast deep-learning accelerated MRI screening protocol for prostate cancer compared to a standard multiparametric protocol

OBJECTIVES

To establish and evaluate an ultra-fast MRI screening protocol for prostate cancer (PCa) in comparison to the standard multiparametric (mp) protocol, reducing scan time and maintaining adequate diagnostic performance.

MATERIALS AND METHODS

This prospective single-center study included consecutive biopsy-naïve patients with suspected PCa between December 2022 and March 2023. A PI-RADSv2.1 conform mpMRI protocol was acquired in a 3 T scanner (scan time: 25 min 45 sec). In addition, two deep-learning (DL) accelerated sequences (T2- and diffusion-weighted) were acquired, serving as a screening protocol (scan time: 3 min 28 sec). Two readers evaluated image quality and the probability of PCa regarding PI-RADSv2.1 scores in two sessions. The diagnostic performance of the screening protocol with mpMRI serving as the reference standard was derived. Inter- and intra-reader agreements were evaluated using weighted kappa statistics.

RESULTS

We included 77 patients with 97 lesions (mean age: 66 years; SD: 7.7). Diagnostic performance of the screening protocol was excellent with a sensitivity and specificity of 100%/100% and 89%/98% (cut-off ≥ PI-RADS 4) for reader 1 (R1) and reader 2 (R2), respectively. Mean image quality was 3.96 (R1) and 4.35 (R2) for the standard protocol vs. 4.74 and 4.57 for the screening protocol (p < 0.05). Inter-reader agreement was moderate (κ: 0.55) for the screening protocol and substantial (κ: 0.61) for the multiparametric protocol.

CONCLUSION

The ultra-fast screening protocol showed similar diagnostic performance and better imaging quality compared to the mpMRI in under 15% of scan time, improving efficacy and enabling the implementation of screening protocols in clinical routine.

CLINICAL RELEVANCE STATEMENT

The ultra-fast protocol enables examinations without contrast administration, drastically reducing scan time to 3.5 min with similar diagnostic performance and better imaging quality. This facilitates patient-friendly, efficient examinations and addresses the conflict of increasing demand for examinations at currently exhausted capacities.

KEY POINTS

Time-consuming MRI protocols are in conflict with an expected increase in examinations required for prostate cancer screening. An ultra-fast MRI protocol shows similar performance and better image quality compared to the standard protocol. Deep-learning acceleration facilitates efficient and patient-friendly examinations, thus improving prostate cancer screening capacity.

Screening guidelines for individuals at increased risk for prostate cancer

Individuals at increased risk for prostate cancer (PCa) are inconsistently defined in national and international guidelines. The National Comprehensive Cancer Network (NCCN) defines people at increased risk for PCa to include those with a concerning family history, West African/Caribbean/African-American individuals, and those who have germline mutations in known PCa-related genes. Recommendations for screening are also inconsistently defined in national and international guidelines. The NCCN and American Urological Association recommend that individuals at increased risk for PCa be screened with prostate-specific antigen and digital rectal exam starting at age 40. Defining increased risk groups and defining lifetime risk is an ongoing academic process that can be facilitated through patient registries of these cohorts at academic centers.

Organized prostate cancer screening program: a proposal from the Italian Society of Urology (SIU)

To contrast opportunistic PCa screening, the European Union Council suggested extending screening programs to PCa by recommending the implementation of a stepwise approach in the EU Countries to evaluate the feasibility and effectiveness of an organized program based on PSA testing in combination with additional MRI as a follow-up test. The objective of this expert-based document is to propose an organized PCa screening program according to the EU Council recommendations. The Italian Society of Urology (SIU) developed a team of experts with the aim to report 1) the most recent epidemiologic data about incidence, prevalence, and mortality of PCa; 2) the most important risk factors to identify categories of men with an increased risk to eventually develop the disease; 3) the most relevant studies presenting data on population-based screening; and 4) the current recommendations of the leading International Guidelines. According to previous evidence, the Panel proposed some indications to develop a new organized PCa screening program for asymptomatic men with a life-expectancy of at least fifteen years. The SIU Panel strongly supports the implementation of a pilot, organized PCa screening program inviting asymptomatic men in the age range of 50-55 years. Invited men who are already performing opportunistic screening will be randomized to continue opportunistic screening or to cross into the organized protocol. Men with PSA level ≤3 ng/mL and familiarity for PCa received a DRE as well as all those with PSA levels >3 ng/mL. All other men with PSA levels greater than 3 ng/mL proceed to secondary testing represented by mpMRI. Men with Prostate Imaging-Reporting and Data System (PI-RADS) lesions 3 and PSAD 0.15 ng/mL/cc or higher as well as those with PI-RADS 4-5 lesions proceed to targeted plus systematic prostate biopsy. The primary outcome of the proposed pilot PCa screening program will be the detection rate of clinically significant PCa defined as a tumor with a ISUP Grade Group ≥2. Main secondary outcomes will be the detection rate of aggressive PCa (ISUP Grade Group ≥4); the detection rate of insignificant PCa (ISUP Grade Group 1); the number of unnecessary prostate biopsy avoided, the metastasis-free survival, and the overall survival. Men will be invited over a one-year period. Preliminary analyses will be planned 2 and 5 years after the baseline enrollment. According to the recent EU Council recommendations on cancer screening, pilot studies evaluating the feasibility and effectiveness of PCa screening programs using PSA as the primary and mpMRI as the secondary screening test in selected cohorts of patients must be strongly promoted by scientific societies and supported by national governments.

Key learning on the promise and limitations of MRI in prostate cancer screening

MRI retains its ability to reduce the harm of prostate biopsies by decreasing biopsy rates and the detection of indolent cancers in population-based screening studies aiming to find clinically significant prostate cancers. Limitations of low positive predictive values and high reader variability in diagnostic performance require optimisations in patient selection, imaging protocols, interpretation standards, diagnostic thresholds, and biopsy methods. Improvements in diagnostic accuracy could come about through emerging technologies like risk calculators and polygenic risk scores to select men for MRI. Furthermore, artificial intelligence and workflow optimisations focused on streamlining the diagnostic pathway, quality control, and assurance measures will improve MRI variability. CLINICAL RELEVANCE STATEMENT: MRI significantly reduces harm in prostate cancer screening, lowering unnecessary biopsies and minimizing the overdiagnosis of indolent cancers. MRI maintains the effective detection of high-grade cancers, thus improving the overall benefit-to-harm ratio in population-based screenings with or without using serum prostate-specific antigen (PSA) for patient selection. KEY POINTS: • The use of MRI enables the harm reduction benefits seen in individual early cancer detection to be extended to both risk-stratified and non-stratified prostate cancer screening populations. • MRI limitations include a low positive predictive value and imperfect reader variability, which require standardising interpretations, biopsy methods, and integration into a quality diagnostic pathway. • Current evidence is based on one-time point use of MRI in screening; MRI effectiveness in multiple rounds of screening is not well-documented.

Prostate Cancer Early Detection in the European Union and UK

BACKGROUND AND OBJECTIVE

While prostate cancer (PCa) incidence and mortality rates continue to rise, early detection of PCa remains highly controversial, and the research landscape is rapidly evolving. Existing systematic reviews (SRs) and meta-analyses (MAs) provide valuable insights, but often focus on single aspects of early detection, hindering a comprehensive understanding of the topic. We aim to fill this gap by providing a comprehensive SR of contemporary SRs covering different aspects of early detection of PCa in the European Union (EU) and the UK.

METHODS

On June 1, 2023, we searched four databases (Medline ALL via Ovid, Embase, Web of Science, and Cochrane Central Register of Controlled Trials) and Google Scholar. To avoid repetition of previous studies, only SRs (qualitative, quantitative, and/or MAs) were considered eligible. In the data, common themes were identified to present the evidence systematically.

KEY FINDINGS AND LIMITATIONS

We identified 1358 citations, resulting in 26 SRs eligible for inclusion. Six themes were identified: (1) invitation: men at general risk should be invited at >50 yr of age, and testing should be discontinued at >70 yr or with <10 yr of life expectancy; (2) decision-making: most health authorities discourage population-based screening and instead recommend a shared decision-making (SDM) approach, but implementation of SDM in clinical practice varies widely; decision aids help men make more informed and value-consistent screening decisions and decrease men's intention to attempt screening, but these do not affect screening uptake; (3) acceptance: facilitators for men considering screening include social prompting by partners and clinician recommendations, while barriers include a lack of knowledge, low-risk perception, and masculinity attributes; (4) screening test and algorithm: prostate-specific antigen-based screening reduces PCa-specific mortality and metastatic disease in men aged 55-69 yr at randomisation if screened at least twice; (5) harms and benefits: these benefits come at the cost of unnecessary biopsies, overdiagnosis, and subsequent overtreatment; and (6) future of screening: risk-adapted screening including (prebiopsy) risk calculators, magnetic resonance imaging, and blood- and urine-based biomarkers could reduce these harms. To enable a comprehensive overview, we focused on SRs. These do not include the most recent prospective studies, which were therefore incorporated in the discussion.

CONCLUSIONS AND CLINICAL IMPLICATIONS

By identifying consistent and conflicting evidence, this review highlights the evidence-based foundations that can be built upon, as well as areas requiring further research and improvement to reduce the burden of PCa in the EU and UK.

PATIENT SUMMARY

This review of 26 reviews covers various aspects of prostate cancer screening such as invitation, decision-making, screening tests, harms, and benefits. This review provides insights into existing evidence, highlighting the areas of consensus and discrepancies, to guide future research and improve prostate cancer screening strategies in Europe.

Comparing the Performance of Digital Rectal Examination and Prostate-specific Antigen as a Screening Test for Prostate Cancer: A Systematic Review and Meta-analysis

BACKGROUND AND OBJECTIVE

Although digital rectal examination (DRE) is recommended in combination with prostate-specific antigen (PSA) for detection of prostate cancer (PCa), there are limited data to support its use as a screening/early detection test. Our objective was to assess the diagnostic value of DRE in screening for early detection of PCa.

METHODS

In August 2023, we queried the PubMed, Scopus, and Web of Science databases to identify prospective studies simultaneously investigating the diagnostic performance of DRE and PSA for PCa screening. The primary endpoints were the positive predictive value (PPV) and cancer detection rate (CDR) of DRE. Secondary endpoints included the PPV and CDR of both PSA alone and in combination with DRE. We conducted meta-regression analysis to compare the CDR and PPV of different screening strategies. This meta-analysis is registered on PROSPERO (CRD42023446940).

KEY FINDINGS AND LIMITATIONS

We identified eight studies involving 85,798 participants, of which three were randomized controlled trials and five were prospective diagnostic studies, that reported the PPV and CDR of both DRE and PSA for the same cohort. Our analysis revealed a pooled PPV of 0.21 (95% confidence interval [CI] 0.13-0.33) for DRE, which is similar to the PPV of PSA (0.22, 95% CI 0.15-0.30; p = 0.9), with no benefit from combining DRE and PSA (PPV 0.19, 95% CI 0.13-0.26; p = 0.5). However, the CDR of DRE (0.01, 95% CI: 0.01-0.02) was significantly lower than that of PSA (0.03, 95% CI 0.02-0.03; p < 0.05) and the combination of DRE and PSA (0.03, 95% CI 0.02-0.04; p < 0.05). The screening strategy combining DRE and PSA was not different to that of PSA alone in terms of CDR (p = 0.5) and PPV (p = 0.5).

CONCLUSIONS AND CLINICAL IMPLICATIONS

Our comprehensive review and meta-analysis indicates that both as an independent test and as a supplementary measure to PSA for PCa detection, DRE exhibits a notably low diagnostic value. The collective findings from the included studies suggest that, in the absence of clinical symptoms and signs, DRE could be potentially omitted from PCa screening and early detection strategies.

PATIENT SUMMARY

Our review shows that the screening performance of digital rectal examination for detection of prostate cancer is not particularly impressive, suggesting that it might not be necessary to conduct this examination routinely.

Fully Automated Deep Learning Model to Detect Clinically Significant Prostate Cancer at MRI

Background Multiparametric MRI can help identify clinically significant prostate cancer (csPCa) (Gleason score ≥7) but is limited by reader experience and interobserver variability. In contrast, deep learning (DL) produces deterministic outputs. Purpose To develop a DL model to predict the presence of csPCa by using patient-level labels without information about tumor location and to compare its performance with that of radiologists. Materials and Methods Data from patients without known csPCa who underwent MRI from January 2017 to December 2019 at one of multiple sites of a single academic institution were retrospectively reviewed. A convolutional neural network was trained to predict csPCa from T2-weighted images, diffusion-weighted images, apparent diffusion coefficient maps, and T1-weighted contrast-enhanced images. The reference standard was pathologic diagnosis. Radiologist performance was evaluated as follows: Radiology reports were used for the internal test set, and four radiologists' PI-RADS ratings were used for the external (ProstateX) test set. The performance was compared using areas under the receiver operating characteristic curves (AUCs) and the DeLong test. Gradient-weighted class activation maps (Grad-CAMs) were used to show tumor localization. Results Among 5735 examinations in 5215 patients (mean age, 66 years ± 8 [SD]; all male), 1514 examinations (1454 patients) showed csPCa. In the internal test set (400 examinations), the AUC was 0.89 and 0.89 for the DL classifier and radiologists, respectively (P = .88). In the external test set (204 examinations), the AUC was 0.86 and 0.84 for the DL classifier and radiologists, respectively (P = .68). DL classifier plus radiologists had an AUC of 0.89 (P < .001). Grad-CAMs demonstrated activation over the csPCa lesion in 35 of 38 and 56 of 58 true-positive examinations in internal and external test sets, respectively. Conclusion The performance of a DL model was not different from that of radiologists in the detection of csPCa at MRI, and Grad-CAMs localized the tumor. © RSNA, 2024 Supplemental material is available for this article. See also the editorial by Johnson and Chandarana in this issue.

Prostate Cancers in the Prostate-specific Antigen Interval of 1.8-3 ng/ml: Results from the Göteborg-2 Prostate Cancer Screening Trial

BACKGROUND AND OBJECTIVE

Magnetic resonance imaging(MRI) and targeted biopsies reduce overdiagnosis of prostate cancer(PC). It is uncertain how this strategy performs for low PSA levels. The objective was to investigate the PI-RADS distribution, frequency and characteristics of screen-detected PC with PSA of 1.8-<3ng/ml and 3-<10ng/ml.

METHODS

In the population-based Göteborg-2 screening study, 17 974 men choose to participate by having a PSA(2015-2020). One-third of the participants(n=6006) were randomized to Arm 3, men with a PSA ≥1.8ng/ml were recommended MRI. Men with positive MRI(PI-RADS3-5) had four targeted biopsies from each MRI-visible lesion. Clinically significant PC was defined as Gleason score ≥3+4.

KEY FINDINGS AND LIMITATIONS

6006 men were included. Median age was 55.9 years. 670(11%) had PSA of 1.8-<3ng/ml(low-PSA group), median PSA 2.1ng/ml, and 377(6.3%) had PSA of 3-<10ng/ml(high-PSA group), median PSA 3.9ng/ml. PI-RADS scores of 3, 4, and 5 were observed in 7.8%, 15%, and 1.0% in the low-PSA group, and in 6.9%, 17%, and 5.3% in the high-PSA group, respectively. PC was found in 64 men (41%, 95%CI 0.33-0.49) with positive MRI findings in the low-PSA group, 33(21%) had Gleason 6 and 31(20%) had Gleason ≥7. In the high-PSA group, PC was detected in 61men (56%, 95%CI 0.46-0.66), 26(24%) had Gleason 6 and 35(32%) had Gleason ≥7. Limitations include results from only a single screening round.

CONCLUSIONS AND CLINICAL IMPLICATIONS

A non-negligible number of men with PSA 1.8-3ng/ml have clinically significant PC. Whether a delay in the diagnosis of these tumors until they reached PSA ≥3ng/ml would impair their chance of cure remains to be evaluated.

Lifetime Health and Economic Outcomes of Biparametric Magnetic Resonance Imaging as First-Line Screening for Prostate Cancer : A Decision Model Analysis

BACKGROUND

Contemporary prostate cancer (PCa) screening uses first-line prostate-specific antigen (PSA) testing, possibly followed by multiparametric magnetic resonance imaging (mpMRI) for men with elevated PSA levels. First-line biparametric MRI (bpMRI) screening has been proposed as an alternative.

OBJECTIVE

To evaluate the comparative effectiveness and cost-effectiveness of first-line bpMRI versus PSA-based screening.

DESIGN

Decision analysis using a microsimulation model.

DATA SOURCES

Surveillance, Epidemiology, and End Results database; randomized trials.

TARGET POPULATION

U.S. men aged 55 years with no prior screening or PCa diagnosis.

TIME HORIZON

Lifetime.

PERSPECTIVE

U.S. health care system.

INTERVENTION

Biennial screening to age 69 years using first-line PSA testing (test-positive threshold, 4 µg/L) with or without second-line mpMRI or first-line bpMRI (test-positive threshold, PI-RADS [Prostate Imaging Reporting and Data System] 3 to 5 or 4 to 5), followed by biopsy guided by MRI or MRI plus transrectal ultrasonography.

OUTCOME MEASURES

Screening tests, biopsies, diagnoses, overdiagnoses, treatments, PCa deaths, quality-adjusted and unadjusted life-years saved, and costs.

RESULTS OF BASE-CASE ANALYSIS

For 1000 men, first-line bpMRI versus first-line PSA testing prevented 2 to 3 PCa deaths and added 10 to 30 life-years (4 to 11 days per person) but increased the number of biopsies by 1506 to 4174 and the number of overdiagnoses by 38 to 124 depending on the biopsy imaging scheme. At conventional cost-effectiveness thresholds, first-line PSA testing with mpMRI followed by either biopsy approach for PI-RADS 4 to 5 produced the greatest net monetary benefits.

RESULTS OF SENSITIVITY ANALYSIS

First-line PSA testing remained more cost-effective even if bpMRI was free, all men with low-risk PCa underwent surveillance, or screening was quadrennial.

LIMITATION

Performance of first-line bpMRI was based on second-line mpMRI data.

CONCLUSION

Decision analysis suggests that comparative effectiveness and cost-effectiveness of PCa screening are driven by false-positive results and overdiagnoses, favoring first-line PSA testing with mpMRI over first-line bpMRI.

PRIMARY FUNDING SOURCE

National Cancer Institute.

[Prostate cancer screening-current overview]

BACKGROUND

The harm-to-benefit ratio of prostate cancer (PCa) screening remains controversial mainly due to the unfavorable test characteristics of prostate-specific antigen (PSA) as a screening test.

METHODS

In this nonsystematic review, we present a current overview of the body of evidence on prostate cancer screening with a focus on the role of magnetic resonance imaging (MRI) of the prostate.

RESULTS

Evidence generated in large randomized controlled trials showed that PSA-based screening significantly decreases cancer-specific mortality. The main obstacle in developing and implementing PCa screening strategies is the resulting overdiagnosis and as a consequence overtreatment of indolent cancers. Opportunistic screening is characterized by an adverse benefit-to-harm ratio and should, therefore, not be recommended. The German Statutory Early Detection Program for prostate cancer, which consists of a digital rectal examination (DRE) as a stand-alone screening test, is not evidence-based, neither specific nor sensitive enough and results in unnecessary diagnostics. The European Commission recently urged member states to develop population-based and organized risk-adapted PSA-based screening programs, which are currently tested in the ongoing German PROBASE trial. Finetuning of the diagnostic pathway following PSA-testing seems key to improve its positive and negative predictive value and thereby making PCa screening more accurate. Incorporation of prostatic MRI into screening strategies leads to more accurate diagnosis of clinically significant prostate cancer, while diagnosis of indolent cancers is reduced. In the future, molecular liquid-based biomarkers have the potential to complement or even replace PSA in PCa screening and further personalize screening strategies. Active surveillance as an alternative to immediate radical therapy of demographically increasing PCa diagnoses can potentially further improve the benefit-to-harm ratio of organized screening.

CONCLUSION

Early detection of PCa should be organized on a population level into personalized and evidence-based screening strategies. Multiparametric MRI of the prostate may play a key role in this setting.

The Effect of Image Resampling on the Performance of Radiomics-Based Artificial Intelligence in Multicenter Prostate MRI

BACKGROUND

Single center MRI radiomics models are sensitive to data heterogeneity, limiting the diagnostic capabilities of current prostate cancer (PCa) radiomics models.

PURPOSE

To study the impact of image resampling on the diagnostic performance of radiomics in a multicenter prostate MRI setting.

STUDY TYPE

Retrospective.

POPULATION

Nine hundred thirty patients (nine centers, two vendors) with 737 eligible PCa lesions, randomly split into training (70%, N = 500), validation (10%, N = 89), and a held-out test set (20%, N = 148).

FIELD STRENGTH/SEQUENCE

1.5T and 3T scanners/T2-weighted imaging (T2W), diffusion-weighted imaging (DWI), and apparent diffusion coefficient maps.

ASSESSMENT

A total of 48 normalized radiomics datasets were created using various resampling methods, including different target resolutions (T2W: 0.35, 0.5, and 0.8 mm; DWI: 1.37, 2, and 2.5 mm), dimensionalities (2D/3D) and interpolation techniques (nearest neighbor, linear, Bspline and Blackman windowed-sinc). Each of the datasets was used to train a radiomics model to detect clinically relevant PCa (International Society of Urological Pathology grade ≥ 2). Baseline models were constructed using 2D and 3D datasets without image resampling. The resampling configurations with highest validation performance were evaluated in the test dataset and compared to the baseline models.

STATISTICAL TESTS

Area under the curve (AUC), DeLong test. The significance level used was 0.05.

RESULTS

The best 2D resampling model (T2W: Bspline and 0.5 mm resolution, DWI: nearest neighbor and 2 mm resolution) significantly outperformed the 2D baseline (AUC: 0.77 vs. 0.64). The best 3D resampling model (T2W: linear and 0.8 mm resolution, DWI: nearest neighbor and 2.5 mm resolution) significantly outperformed the 3D baseline (AUC: 0.79 vs. 0.67).

DATA CONCLUSION

Image resampling has a significant effect on the performance of multicenter radiomics artificial intelligence in prostate MRI. The recommended 2D resampling configuration is isotropic resampling with T2W at 0.5 mm (Bspline interpolation) and DWI at 2 mm (nearest neighbor interpolation). For the 3D radiomics, this work recommends isotropic resampling with T2W at 0.8 mm (linear interpolation) and DWI at 2.5 mm (nearest neighbor interpolation).

EVIDENCE LEVEL

3 TECHNICAL EFFICACY: Stage 2.

Variation in harms and benefits of prostate-specific antigen screening for prostate cancer by socio-clinical risk factors: A rapid review

Objective

To analyse the latest evidence on the relative harms and benefits of screening and diagnostic pathways with close examination of (i) men aged 50 years or older, (ii) men whose ethnicity places them at higher risk and (iii) men with a family history.

Methods

We conducted a literature search using PubMed and Cochrane Central Register of Controlled Trials (CENTRAL) databases and other sources, from January 1990 to 25 January 2023. Two independent reviewers selected for randomised controlled trials (RCTs) and cohort studies which met our inclusion criteria.

Results

Twenty-eight articles were selected, from six trials, including the Göteborg trial-reported separately from European Randomised Study of Screening for Prostate Cancer (ERSPC). Prostate-specific antigen (PSA)-based screening led to the increased detection of low-grade cancer and reduction of advanced/metastatic disease but had contradictory effects on prostate cancer (PCa)-specific mortality (no difference or reduced), possibly due to issues of contamination or compliance. Screening men from a relatively young age (50-55) reduced risk of PCa-specific mortality in a subanalysis of an 18-year follow-up study and in a 17-year cohort study from the main Göteborg trial. Moreover, one Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial analysis reported a trend of reduced risk of PCa-specific mortality for men with a family history who were screened. [Correction added on 05 March 2024, after first online publication: "Cancer Screening Trial" has been added to the preceding sentence.] However, we did not find relevant studies for ethnicity.

Conclusion

Under current UK practice, the choice to conduct a PSA test relies on a shared decision-making approach guided by known risk factors. However, we found there was a lack of strong evidence on the harms and benefits of PSA screening by socio-clinical risk factors and suggest further research is required to understand the long-term impact of screening on high-risk populations in the current diagnostic setting.

The impact of pre-biopsy MRI and additional testing on prostate cancer screening outcomes: A rapid review

Objective

This work aims to examine the latest evidence on the impact of pre-biopsy MRI, in addition to prostate-specific antigen (PSA) testing, on health outcomes and quality of life.

Methods

We conducted a literature search including PubMed and Cochrane Central Register of Controlled Trials (CENTRAL) databases, with a limited scan of (i) guidelines and (ii) references from trial reports, from January 2005 to 25th January 2023. Two independent reviewers selected randomised controlled trials (RCT) and cohort studies which met our inclusion criteria.

Results

One hundred thirty-seven articles were identified, and seven trial articles were selected. Trial interventions were as follows: (i) PSA blood test, (ii) additional tests such as pre-biopsy multiparametric magnetic resonance imaging (mpMRI) and Biparametric MRI (bpMRI), and (iii) MRI targeted biopsy and standard biopsy. Compared with standard biopsy, MRI-based interventions led to increased detection of clinically significant cancers in three studies and decreased detection of clinically insignificant cancer (Gleason grade 3 + 3) in four studies. However, PROstate Magnetic resonance Imaging Study (PROMIS) and Stockholm3 with MRI (STHLM3-MRI) studies reported different trends depending on the scenario studied in PROMIS (MRI triage and MRI directed biopsy vs. MRI triage and standard biopsy) and thresholds used in STHLM3-MRI (≥0·11 and ≥0·15). MRI also helped 8%-49% of men avoid biopsy, in six out of seven studies, but not in STHLM3-MRI at ≥0.11. Interestingly, the proportion of men who experienced sepsis and UTI was low across studies.

Conclusion

This review found that a combination of approaches, centred on the use of pre-biopsy MRI, may improve the detection of clinically significant cancers and reduce (i) the diagnosis of clinically insignificant cancers and (ii) unnecessary biopsies, compared with PSA testing and standard biopsy alone. However, the impact of such interventions on longer term outcomes such as prostate cancer-specific mortality has not yet been assessed.

Combined MRI-TRUS fusion targeted and systematic biopsy versus systematic biopsy alone for the detection of prostate cancer: protocol for a prospective single-centre trial

INTRODUCTION

The classic way of diagnosing prostate cancer (PCa) is by conducting the 12-core systematic biopsy (SB). However, it has a low detection rate for clinically significant PCa (csPCa) and can lead to the detection of clinically insignificant PCa (cisPCa). Although MRI-transrectal ultrasound (MRI-TRUS) fusion targeted biopsy (TB) can effectively improve the detection rate of csPCa, it may still miss some cases. Therefore, we propose using a combination of TB and SB methods to enhance the detection rate of csPCa while minimising the detection rate of cisPCa.

METHODS AND ANALYSIS

This study is a prospective, single-centre investigation that aims to assess and compare the detection rate of csPCa using MRI-TRUS fusion TB combined with SB versus TRUS 12-core SB alone. Biopsy-naïve men with suspected PCa will be subjected to multiparametric MRI. Patients with Prostate Imaging Reporting and Data System (V.2.1) score ≥3 will be enrolled in the TB-SB combination group. The sample size is established as 660 participants, considering a 10% drop-out rate. The primary outcome is the detection rate of csPCa in men without prior biopsy using MRI-TRUS fusion TB combined with the standard TRUS-guided 12-core SB method. CsPCa will be defined as International Society of Urological Pathology Grade ≥2.

ETHICS AND DISSEMINATION

This study has been approved by the Ethics Committee at the Shanghai Tenth People's Hospital, an affiliated hospital of Tongji University School of Medicine. The research results will be published in a peer-reviewed international journal.

TRIAL REGISTRATION NUMBER

ChiCTR2000036089.

Cancer Detection Rate and Abnormal Interpretation Rate of Prostate MRI Performed for Clinical Suspicion of Prostate Cancer

PURPOSE

To report cancer detection rate (CDR) and abnormal interpretation rate (AIR) in prostate MRI performed for clinical suspicion of prostate cancer (PCa).

MATERIALS AND METHODS

This retrospective single-institution, three-center study included patients who underwent MRI for clinical suspicion of PCa between 2017 and 2021. Patients with known PCa were excluded. Patient-level Prostate Imaging-Reporting and Data System (PI-RADS) score was extracted from the radiology report. AIR was defined as number of abnormal MRI (PI-RADS score 3-5) / total number of MRIs. CDR was defined as number of clinically significant PCa (csPCa: Gleason score ≥7) detected at abnormal MRI / total number of MRI. AIR, CDR, and CDR adjusted for pathology confirmation rate were calculated for each of three centers and pre-MRI biopsy status (biopsy-naive and previous negative biopsy).

RESULTS

A total of 9,686 examinations (8,643 unique patients) were included. AIR, CDR, and CDR adjusted for pathology confirmation rate were 45.4%, 23.8%, and 27.6% for center I; 47.2%, 20.0%, and 22.8% for center II; and 42.3%, 27.2%, and 30.1% for center III, respectively. Pathology confirmation rate ranged from 81.6% to 88.0% across three centers. AIR and CDR for biopsy-naive patients were 45.5% to 52.6% and 24.2% to 33.5% across three centers, respectively, and those for previous negative biopsy were 27.2% to 39.8% and 11.7% to 14.2% across three centers, respectively.

CONCLUSION

We reported CDR and AIR in prostate MRI for clinical suspicion of PCa. CDR needs to be adjusted for pathology confirmation rate and pre-MRI biopsy status for interfacility comparison.

A hospital-based study of prostate biopsy results in Indian males

Introduction

The prostate is a gland belonging to the male reproductive system. Aging results in the dysfunction of the prostate that may present as inflammation, enlargement, and cancer. Additionally, the diseases of the prostate including cancers are slow in progression, and therefore, it is difficult to diagnose them early. Hence, it is increasingly important for physicians to recommend histopathological examination of the prostate gland to identify, manage, and treat prostate cancers. This study was conducted to assess prostate diseases among biopsy specimen collected from patients with signs of prostate diseases.

Materials and Methods

This prospective study was conducted in the Department of Pathology, Deccan College of Medical Sciences, Owaisi Hospital, Hyderabad, between June 2012 and September 2014. All gross specimens (n = 300) of the prostate such as the needle biopsies of the prostate, transurethral resection of the prostate (TURP) chips, and excised specimens of the prostate were included in the study. Histopathological examinations of the biopsies were performed for nuclear size, chromatin material, nucleoli, membrane thickness, irregularity, cytoplasmic granularity, staining, and cell border conspicuity. The biopsies were also assessed for lobule formation, secretions, polymorphonuclear leukocytes, lymphocytes, macrophages, connective tissue stromal cells, their arrangements, and acellular connective tissue material.

Results

Of 300 total prostatic biopsies performed, 56 (18.66%) were identified as inflammatory lesions of the prostate (prostatitis), 98 (32.66%) revealed benign prostatic lesions (benign prostatic hyperplasia (BPH)), 112 (37.33%) were identified as BPH with premalignant lesions, and 34 (11.33%) were revealed as malignant tumors of the prostate. Chronic prostatitis (67.85%) was the common inflammatory lesion. The majority (91.42%) revealed epithelial lesions compared to stromal lesions (08.58%). BPH was predominantly (28.00%) noticed among patients in the age group of 61-70 years. Prostatic intraepithelial neoplasia (PIN) was observed majorly (53.35%) in the age group of 61-70 years. Most of the prostatic cancers were identified as adenocarcinomas. However, three variants were also categorized as small cell carcinoma, signet ring cell carcinoma, and transitional cell carcinomas.

Conclusions

The results reveal that prostatic adenocarcinomas are predominant among the study population. Additionally, prostatic diseases including cancer are commonly noticed among people belonging to the age group of 61-70 years. More than one-third of patients showed BPH with premalignant lesions, and a majority of the study population showed evidence of chronic prostatitis.

Multiparametric Magnetic Resonance Imaging in Prostate Cancer Screening at the Age of 45 Years: Results from the First Screening Round of the PROBASE Trial

BACKGROUND

Magnetic resonance imaging (MRI) has been suggested as a tool for guiding biopsy recommendations in prostate cancer (PC) screening.

OBJECTIVE

To determine the performance of multiparametric MRI (mpMRI) in young men at age 45 yr who participated in a PC screening trial (PROBASE) on the basis of baseline prostate-specific antigen (PSA).

DESIGN, SETTING, AND PARTICIPANTS

Participants with confirmed PSA ≥3 ng/ml were offered mpMRI followed by MRI/transrectal ultrasound fusion biopsy (FBx) with targeted and systematic cores. mpMRI scans from the first screening round for men randomised to an immediate PSA test in PROBASE were evaluated by local readers and then by two reference radiologists (experience >10 000 prostate MRI examinations) blinded to the histopathology. The PROBASE trial is registered as ISRCTN37591328 OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The local and reference Prostate Imaging-Data and Reporting System (PI-RADS) scores were compared, and the sensitivity, negative predictive value (NPV), and accuracy were calculated for both readings for different cutoffs (PI-RADS 3 vs 4).

RESULTS AND LIMITATIONS

Of 186 participants, 114 underwent mpMRI and FBx. PC was detected in 47 (41%), of whom 33 (29%) had clinically significant PC (csPC; International Society of Urological Pathology grade group ≥2). Interobserver reliability between local and reference PI-RADS scores was moderate (k = 0.41). At a cutoff of PI-RADS 4, reference reading showed better performance for csPC detection (sensitivity 79%, NPV 91%, accuracy of 85%) than local reading (sensitivity 55%, NPV 80%, accuracy 68%). Reference reading did not miss any PC cases for a cutoff of PI-RADS <3. If PI-RADS ≥4 were to be used as a biopsy cutoff, mpMRI would reduce negative biopsies by 68% and avoid detection of nonsignificant PC in 71% of cases.

CONCLUSIONS

Prostate MRI in a young screening population is difficult to read. The MRI accuracy of for csPC detection is highly dependent on reader experience, and double reading might be advisable. More data are needed before MRI is included in PC screening for men at age 45 yr.

PATIENT SUMMARY

Measurement of prostate specific antigen (PSA) is an effective screening test for early detection of prostate cancer (PC) and can reduce PC-specific deaths, but it can also lead to unnecessary biopsies and treatment. Magnetic resonance imaging (MRI) after a positive PSA test has been proposed as a way to reduce the number of biopsies, with biopsy only recommended for men with suspicious MRI findings. Our results indicate that MRI accuracy is moderate for men aged 45 years but can be increased by a second reading of the images by expert radiologists. For broad application of MRI in routine screening, double reading may be advisable.

Prostagram magnetic resonance imaging in a screening population: Prostate Imaging-Reporting and Data System or Likert?

OBJECTIVE

To compare biopsy recommendation rates and accuracy of the Prostate Imaging-Reporting and Data System, version 2 (PI-RADSv2) with the Likert scale for detection of clinically significant and insignificant prostate cancer in men screened within the Imperial Prostate 1 Prostate Cancer Screening Trial Using Imaging (IP1-PROSTAGRAM).

PATIENTS AND METHODS

Men aged 50-69 years were screened with Prostagram MRI. Scans were prospectively reported using both PI-RADSv2 (excluding dynamic contrast-enhanced sequence score) and 5-point Likert scores by expert uro-radiologists. Systematic and targeted transperineal biopsy was recommended if the scan was scored ≥ 3, based on either reporting system. The proportion of patients recommended for biopsy and detection rates for Grade Groups (GGs) 1 and ≥ 2 were compared. Receiver operating characteristic (ROC) analysis was performed to compare performance.

RESULTS

A total of 406 men underwent Prostagram MRI. The median (interquartile range) age and prostate-specific antigen level were 57 (53-61) years and 0.91 (0.56-1.74) ng/mL, respectively. At MRI score ≥ 3, more patients were recommended for biopsy based on Likert criteria (94/406; 23%, 95% confidence interval [CI] 19.2%-27.6%) compared to PI-RADSv2 (72/406; 18%, 95% CI 14.2%-21.9%; P = 0.03). For MRI scores ≥ 4, PI-RADSv2 and Likert scales led to 43/406 (11%, 95% CI 7.9%-14.1%) and 35/406 (9%, 95% CI 6.2%-11.9%) men recommended for biopsy (P = 0.40). For GG ≥ 2 detection, PIRADSv2 and Likert detected 22% (95% CI 11.4%-30.8%, 14/72) and 16% (95% CI 9.5%-25.3%, 15/94), respectively (P = 0.56). For GG1 cancers detection these were 11% (95% CI 4.3%-19.6%, seven of 72) vs 11% (95% CI 4.7%-17.8%, nine of 94; P = 1.00). The accuracy of PI-RADSv2 and Likert scale was similar (area under the ROC curve 0.64 vs 0.65, P = 0.95).

CONCLUSIONS

In reporting non-contrast-enhanced Prostagram MRI in a screening population, the PI-RADSv2 and Likert scoring systems were equally accurate; however, Likert scale use led to more men undergoing biopsy without a subsequent increase in significant cancer detection rates. To improve reporting of Prostagram MRI, either the PI-RADSv2 or a modified Likert scale or a standalone scoring system should be developed.

Design of a magnetic resonance imaging-based screening program for early diagnosis of prostate cancer: preliminary results of a randomized controlled trial-Prostate Cancer Secondary Screening in Sapienza (PROSA)

OBJECTIVES

The main objective is to propose an MRI-based screening protocol, investigating the role of MRI without the injection of contrast media (bi-parametric MRI, bpMRI) as a secondary prevention test for prostate cancer (PCa) early diagnosis, comparing MRI with the prostate specific antigen (PSA) test. For this reason, preliminary results of Prostate Cancer Secondary Screening in Sapienza (PROSA) are presented, to investigate the efficiency of an MRI-based screening protocol. PROSA is a prospective, randomized, single-center study. To date, 351 men have been enrolled and blindly randomized into two different arms: (A) Men underwent a bpMRI regardless of their PSA values (175); (B) Men followed as per clinical practice: those with increased PSA (61) were referred to bpMRI, while those with normal PSA (112) were not. Men who screened positive on MRI were directed to MR-directed targeted biopsy. On arm A, 4 clinically significant PCa have been detected, while none was found on arm B (p = 0.046). To evaluate the efficiency of the screening protocol, we calculated the experimental event rate (EER, 3.6%), control event rate (CER, 1.2%.), absolute risk reduction (ARR, 2.5%), and number needed to treat (NNT, 40.3). PROSA represents an interesting experience in the field of imaging-based PCa screening. The preliminary data from this trial highlight the promising role of non-contrast MRI as a screening tool for early detection of PCa. Further data will finally validate the most appropriate screening program.

CLINICAL RELEVANCE STATEMENT

PROSA depicts an interesting experience in the field of research focused on imaging-based prostate cancer screening. Its preliminary data highlight the promising role of non-contrast MRI as a screening tool for early detection of PCa.

KEY POINTS

• Promotion of an MRI-based screening protocol, investigating the role of non-contrast MRI as a secondary prevention test for prostate cancer early diagnosis, comparing MRI with PSA test. • Prostate Cancer Secondary Screening in Sapienza (PROSA) represents an interesting experience in the field of research focused on imaging-based prostate cancer screening; its preliminary results indicate that it is possible to use non-contrast MRI as a screening tool for early detection of PCa. • This new approach to PCa screening could facilitate the early diagnosis of clinically significant prostate cancer while reducing the number of unnecessary prostate biopsies and the detection of clinically insignificant prostate cancer.

Results of fusion prostate biopsy comparing with cognitive and systematic biopsy

PURPOSE

Our study aims to determine whether there are differences in the degree of detection of prostate cancer (PCa) and CsPCa between fusion prostate biopsy (FPB), cognitive biopsy (PCB), and randomized, systematic biopsy (SB).

METHODS

A retrospective analysis was carried out of 195 patients with suspected PCa at the San Cecilio University Clinical Hospital in Granada who underwent a prostate biopsy between January and December 2021. Patients were divided into three groups: group 1, patients undergoing FPB transperineally with ultrasound BK 3000 (N = 87); group 2, PCB (N = 59) transperineally; and group 3, transrectal SB (N = 49), the latter two, with an ultrasound BK Specto.

RESULTS

We found differences in favor of image-directed biopsies (FPB and PCB) with a percentage of positive biopsies of 52.8% and 50%, respectively, compared to 41.4% with SB, but without these differences being significant. Given the controversy in performing prostate biopsies in PI-RADS 3 lesions reported in the literature, a subanalysis was performed excluding the FPB performed for PI-RADS 3 lesions (PI-RADS 4 and 5 are included), finding significant differences when comparing FPB with PCB and SB (group 1, 64% vs group 2, 45.8%; p = 0.05) (group 1, 64% vs group 3, 42.9%; p = 0.035).

CONCLUSION

With the results obtained in our series, we conclude that the finding of a PI-RADS 3 lesion in mpMRI should not be an absolute criterion to indicate prostate biopsy. On the other hand, for PI-RADS 4 and 5 lesions, FPB is recommended, which in this case turns out to be superior to PCB and SB.

Use of Imaging and Biopsy in Prostate Cancer Diagnosis: A Survey From the Asian Prostate Imaging Working Group

OBJECTIVE

To elucidate the use of radiological studies, including nuclear medicine, and biopsy for the diagnosis and staging of prostate cancer (PCA) in clinical practice and understand the current status of PCA in Asian countries via an international survey.

MATERIALS AND METHODS

The Asian Prostate Imaging Working Group designed a survey questionnaire with four domains focused on prostate magnetic resonance imaging (MRI), other prostate imaging, prostate biopsy, and PCA backgrounds. The questionnaire was sent to 111 members of professional affiliations in Korea, Japan, Singapore, and Taiwan who were representatives of their working hospitals, and their responses were analyzed.

RESULTS

This survey had a response rate of 97.3% (108/111). The rates of using 3T scanners, antispasmodic agents, laxative drugs, and prostate imaging-reporting and data system reporting for prostate MRI were 21.6%-78.9%, 22.2%-84.2%, 2.3%-26.3%, and 59.5%-100%, respectively. Respondents reported using the highest b-values of 800-2000 sec/mm² and fields of view of 9-30 cm. The prostate MRI examinations per month ranged from 1 to 600, and they were most commonly indicated for biopsy-naïve patients suspected of PCA in Japan and Singapore and staging of proven PCA in Korea and Taiwan. The most commonly used radiotracers for prostate positron emission tomography are prostate-specific membrane antigen in Singapore and fluorodeoxyglucose in three other countries. The most common timing for prostate MRI was before biopsy (29.9%). Prostate-targeted biopsies were performed in 63.8% of hospitals, usually by MRI-ultrasound fusion approach. The most common presentation was localized PCA in all four countries, and it was usually treated with radical prostatectomy.

CONCLUSION

This survey showed the diverse technical details and the availability of imaging and biopsy in the evaluation of PCA. This suggests the need for an educational program for Asian radiologists to promote standardized evidence-based imaging approaches for the diagnosis and staging of PCA.

Endemic statistical paradoxes in epidemiologic studies distort knowledge on prostate cancer: mitigation and caution of fallacies in prostate cancer causal epidemiological studies

PURPOSE OF REVIEW

Many studies on epidemiology of prostate cancer (PCa) are based on a diagnosis of PCa using PSA (prostate-specific antigen) level. However, biases can distort the interpretation of the results, which in turn limits policy and decision making on public health prevention strategies or clinical guidelines. The main confusion is to interpret the posterior probability of the outcome following the exposure as a change in the prevalence of the disease outcome, whereas this change reflects only the predictive values of the PSA test induced by the exposure of interest.

RECENT FINDINGS

Many studies report potential causal factors involved in PCa risk. However, the lack of integration of how physiological changes in PSA values are associated with the exposures being investigated, they explain in part contradictory and controversial results on PCa risk factors in the literature.

SUMMARY

A strategy to perform case--control studies based on PSA stratification is suggested to avoid misinterpretation related to PSA misclassification. Real data are analysed, and we show that we can exploit the mechanism of selection biases using different modalities of controls recruitment based on biomarker stratification to distinguish real from false causal factors.

Prostate cancer screening-stepping forward with MRI

OBJECTIVE

To comprehensively review the literature on the integration of MRI as a diagnostic tool in prostate cancer screening and offer practical recommendations for optimising its use.

METHODS

Existing research studies, clinical guidelines and expert opinions were reviewed to support the optimisation standards for MRI use in screening. Consolidated screening principles were used to make appropriate recommendations regarding the integration of MRI into the diagnostic pathway.

RESULTS

To strike a balance between the potential benefits of early detection on mortality and minimising the harm of over-diagnosing indolent cancers, it is necessary to have a clear understanding of the context of MRI use. The key to optimisation is patient selections and MRI-targeted biopsies. For men at higher-than-average risk, it is essential to use screening-specific MRI protocols and establish accuracy levels and interpretation criteria. Optimisation of readings by the automation of data acquisition, image quality monitoring, post-processing, radiologist certification and deep-learning computer-aided software is needed. The optimal utilisation of MRI involves its integration into a multistep diagnostic pathway, supported by a quality-assured and cost-effective infrastructure that ensures community-wide access to imaging.

CONCLUSION

MRI in the prostate cancer screening pathway can bring substantial diagnostic benefits. By carefully considering its advantages, limitations and safety concerns and integrating it into a multistep diagnostic pathway, clinicians can improve outcomes while minimising harm to screening participants.

CLINICAL RELEVANCE STATEMENT

The manuscript discusses the role of MRI in prostate cancer screening, highlighting its potential to improve accuracy and reduce overdiagnosis. It emphasises the importance of optimising protocols and integrating MRI into a multistep diagnostic pathway for successfully delivering screening benefits.

KEY POINTS

• Population screening for prostate cancer is a new indication for prostate MRI that allows the detection of high-risk cancers while reducing the need for biopsies and associated harm. • To optimise prostate cancer screening using MRI, it is essential to redefine MRI protocols; establish accuracy levels, reliability and interpretation criteria; and optimise reading (including post-processing, image quality, radiologist certification, and deep-learning computer-aided software). • The optimal utilisation of MRI for prostate cancer screening would involve its integration into a multistep diagnostic pathway, supported by a quality-assured and cost-effective infrastructure that ensures community-wide access to imaging.

The influence of the operator's experience on the outcomes of fusion prostate biopsy

Introduction

Magnetic resonance imgaing (MRI) targeted biopsy is the gold standard for prostate cancer (PCa) diagnosis. In this study, we examined the association between the operator's experience and the improvement in the precision of the MRI prostate biopsy procedure and the detection of PCa.

Material and methods

We included consecutive patients who underwent prostate fusion biopsy. Data on biopsy duration, prostate-specific antigen (PSA) value, lesion size, number of samples taken, number of cores involved, and International Society of Urological Pathology (ISUP) grade were subjected to statistical analysis, with the study group divided into three consecutive time periods (tertiles).

Results

There were statistically significant differences in biopsy duration between tertiles (p <0.001). The greatest difference in the involved/taken cores ratio occurred between the first and third tertile (p = 0.002). The difference between the first and second tertile was insignificant (p = 0.4), while the difference between the second and third tertile was statistically significant (p = 0.004). The differences between tertiles in Prostate Imaging and Reporting Data System v2.1 were also significant (p = 0.003). The PSA value (p = 0.036) was statistically significant, unlike prostate volume (p = 0.16), digital rectal examination (DRE) (p = 0.7), and ISUP grade (p = 0.7). There was no statistical difference between tested tertiles in the number of detected PCa ISUP ≥2 (Z = 0.191; p = 0.8).

Conclusions

The abilities and precision of the operator increase with the increase in the number of procedures performed. The biopsy duration is shortened, and the detection of PCa during the procedure seems to improve with the operator's experience.

Perceived patient burden and acceptability of MRI in comparison to PSA and ultrasound: results from the IP1-PROSTAGRAM study

BACKGROUND

The IP1-PROSTAGRAM study showed that a short, non-contrast MRI detected more significant cancers with similar rates of biopsy compared to PSA. Herein, we compare the expected and perceived burden of PSA, MRI and ultrasound as screening tests.

METHODS

IP1-PROSTAGRAM was a prospective, population-based, paired screening study of 408 men conducted at seven UK primary care practices and two imaging centres. The screening tests were serum PSA, non-contrast MRI and ultrasound. If any test was screen-positive, a prostate biopsy was performed. Participants completed an Expected Burden Questionnaire (EBQ) and Perceived Burden Questionnaire (PBQ) before and after each screening test.

RESULTS

The overall level of burden for MRI and PSA was minimal. Few men reported high levels of anxiety, burden, embarrassment or pain following either MRI or PSA. Participants indicated an overall preference for MRI after completing all screening tests. Of 408 participants, 194 (47.5%) had no preference, 106 (26.0%) preferred MRI and 79 (19.4%) preferred PSA. This indicates that prior to screening, participants preferred MRI compared to PSA (+6.6%, 95% CI 4.4-8.4, p = 0.02) and after completing screening, the preference for MRI was higher (+21.1%, 95% CI 14.9-27.1, p < 0.001). The proportion of participants who strongly agreed with repeating the test was 50.5% for ultrasound, 65% for MRI and 68% for PSA. A larger proportion of participants found ultrasound anxiety-inducing, burdensome, embarrassing and painful compared to both MRI and PSA.

CONCLUSIONS

Prostagram MRI and PSA are both acceptable as screening tests among men aged 50-69 years. Both tests were associated with minimal amounts of anxiety, burden, embarrassment and pain. The majority of participants preferred MRI over PSA and ultrasound.

REGISTRATION

This study was registered on clinicaltrials.gov at https://clinicaltrials.gov/ct2/show/NCT03702439 .

Semisupervised Learning with Report-guided Pseudo Labels for Deep Learning-based Prostate Cancer Detection Using Biparametric MRI

Purpose

To evaluate a novel method of semisupervised learning (SSL) guided by automated sparse information from diagnostic reports to leverage additional data for deep learning-based malignancy detection in patients with clinically significant prostate cancer.

Materials and Methods

This retrospective study included 7756 prostate MRI examinations (6380 patients) performed between January 2014 and December 2020 for model development. An SSL method, report-guided SSL (RG-SSL), was developed for detection of clinically significant prostate cancer using biparametric MRI. RG-SSL, supervised learning (SL), and state-of-the-art SSL methods were trained using 100, 300, 1000, or 3050 manually annotated examinations. Performance on detection of clinically significant prostate cancer by RG-SSL, SL, and SSL was compared on 300 unseen examinations from an external center with a histopathologically confirmed reference standard. Performance was evaluated using receiver operating characteristic (ROC) and free-response ROC analysis. P values for performance differences were generated with a permutation test.

Results

At 100 manually annotated examinations, mean examination-based diagnostic area under the ROC curve (AUC) values for RG-SSL, SL, and the best SSL were 0.86 ± 0.01 (SD), 0.78 ± 0.03, and 0.81 ± 0.02, respectively. Lesion-based detection partial AUCs were 0.62 ± 0.02, 0.44 ± 0.04, and 0.48 ± 0.09, respectively. Examination-based performance of SL with 3050 examinations was matched by RG-SSL with 169 manually annotated examinations, thus requiring 14 times fewer annotations. Lesion-based performance was matched with 431 manually annotated examinations, requiring six times fewer annotations.

Conclusion

RG-SSL outperformed SSL in clinically significant prostate cancer detection and achieved performance similar to SL even at very low annotation budgets.Keywords: Annotation Efficiency, Computer-aided Detection and Diagnosis, MRI, Prostate Cancer, Semisupervised Deep Learning Supplemental material is available for this article. Published under a CC BY 4.0 license.

Clinical performance of magnetic resonance imaging and biomarkers for prostate cancer diagnosis in men at high genetic risk

OBJECTIVES

To evaluate different scenarios for the management of early diagnosis of cancer (PCa) in men at high genetic risk, using recently developed blood and urinary molecular biomarkers in combination with clinical information alongside multiparametric magnetic resonance imaging (mpMRI).

PATIENTS AND METHODS

A total of 322 patients with a high genetic risk (familial or personal history of cancers or a predisposing germline variant) were included in this study. The primary outcome was the detection rates of PCa (positive biopsy) or clinically significant PCa (biopsy with International Society of Urological Pathology [ISUP] grade >1). Clinical parameters included age, body mass index, ancestry, and germline mutational status, mpMRI, prostate-specific antigen density (PSAD), Prostate Health Index and urinary markers (Prostate Cancer Associated 3, SelectMdx™ and T2:ERG score) were assessed. Sensitivity (Se) and specificity (Sp) for each marker at their recommended cut-off for clinical practice were calculated. Comparison between diagnoses accuracy of each procedure and scenario was computed using mutual information based and direct effect contribution using a supervised Bayesian network approach.

RESULTS

A mpMRI Prostate Imaging-Reporting and Data System (PI-RADS) score ≥3 showed higher Se than mpMRI PI-RADS score ≥4 for detection of PCa (82% vs 61%) and for the detection of ISUP grade >1 lesions (96% vs 80%). mpMRI PI-RADS score ≥3 performed better than a PSA level of ≥3 ng/mL (Se 96%, Sp 53% vs Se 91%, Sp 8%) for detection of clinically significant PCa. In case of negative mpMRI results, the supervised Bayesian network approach showed that urinary markers (with the same accuracy for all) and PSAD of ≥0.10 ng/mL/mL were the most useful indicators of decision to biopsy.

CONCLUSIONS

We found that screening men at high genetic risk of PCa must be based on mpMRI without pre-screening based on a PSA level of >3 ng/mL, to avoid missing too many ISUP grade >1 tumours and to significantly reduce the number of unnecessary biopsies. However, urinary markers or a PSAD of ≥0.10 ng/mL/mL when mpMRI was negative increased the detection of ISUP grade >1 cancers. We suggest that a baseline mpMRI be discussed for men at high genetic risk from the age of 40 years.

An Evaluation of Screening Pathways Using a Combination of Magnetic Resonance Imaging and Prostate-specific Antigen: Results from the IP1-PROSTAGRAM Study

BACKGROUND

The use of prostate-specific antigen (PSA) testing to screen for prostate cancer has been fraught with under- and overdiagnosis. Short, noncontrast magnetic resonance imaging (MRI) might detect more grade group ≥2 cancers with similar rates of biopsy.

OBJECTIVE

To evaluate strategies that combined PSA and MRI to select men based in the community for a prostate biopsy.

DESIGN, SETTING, AND PARTICIPANTS

IP1-PROSTAGRAM was a prospective, population-based, paired cohort study of 408 men aged 50-69 yr conducted at seven UK primary care practice and two imaging centres (from October 10, 2018 to May 15, 2019).

INTERVENTION

All participants underwent screening with a PSA test, MRI (T2-weighted and diffusion), and transrectal ultrasound (b-mode and elastography). If any test was screen positive, a systematic 12-core biopsy was performed. Additional image-fusion targeted biopsies were taken if the MRI or ultrasound was positive.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

We conducted an analysis, set out in the statistical plan a priori, comparing 13 different pathways including PSA-alone, MRI-alone, and a range of PSA thresholds and MRI scores. The performance of each pathway was evaluated focusing on the trade-offs between biopsy referral rates and detection of grade group ≥2 cancers. A targeted biopsy was performed only where the PROSTAGRAM MRI showed a lesion score of 3, 4, or 5.

RESULTS AND LIMITATIONS

The standard PSA pathway (PSA ≥3 ng/ml + systematic biopsy) would lead to 10% of men being referred for a biopsy and a 1.0% detection rate of grade group ≥2 cancers. Pathways that relied on MRI alone set at a threshold score of 3 for a biopsy led to higher biopsy rates, but with benefit of high cancer detection rates. The pathway that combined an initial low PSA threshold (≥1.0 ng/ml) and MRI score ≥4 accurately identified a high rate of grade group ≥2 cancers (2.5%, 95% confidence interval 1.3-4.6) while recommending fewer patients for a biopsy (7.1%, 95% confidence interval 4.9-10.2). The results are pertinent to only one screening round, the impact of repeat screening rounds is not evaluated, and the required MRI capacity is currently lacking.

CONCLUSIONS

Our results highlight the trade-off that exists between reducing excessive numbers of biopsies and maintaining grade group ≥2 cancer detection rates. A pathway that combines PSA ≥1 ng/ml and MRI score ≥4 maintains the detection of grade group ≥2 cancers while recommending fewer men for biopsies and would be the preferred strategy to evaluate in future studies at the first screening round.

PATIENT SUMMARY

The IP1-PROSTAGRAM study shows that PROSTAGRAM magnetic resonance imaging in men with a prostate-specific antigen level of ≥1.0 ng/ml could be a promising pathway to evaluate in future screening trials.

Textural Features of MR Images Correlate with an Increased Risk of Clinically Significant Cancer in Patients with High PSA Levels

BACKGROUND

Prostate cancer, which is associated with gland biology and also with environmental risks, is a serious clinical problem in the male population worldwide. Important progress has been made in the diagnostic and clinical setups designed for the detection of prostate cancer, with a multiparametric magnetic resonance diagnostic process based on the PIRADS protocol playing a key role. This method relies on image evaluation by an imaging specialist. The medical community has expressed its desire for image analysis techniques that can detect important image features that may indicate cancer risk.

METHODS

Anonymized scans of 41 patients with laboratory diagnosed PSA levels who were routinely scanned for prostate cancer were used. The peripheral and central zones of the prostate were depicted manually with demarcation of suspected tumor foci under medical supervision. More than 7000 textural features in the marked regions were calculated using MaZda software. Then, these 7000 features were used to perform region parameterization. Statistical analyses were performed to find correlations with PSA-level-based diagnosis that might be used to distinguish suspected (different) lesions. Further multiparametrical analysis using MIL-SVM machine learning was used to obtain greater accuracy.

RESULTS

Multiparametric classification using MIL-SVM allowed us to reach 92% accuracy.

CONCLUSIONS

There is an important correlation between the textural parameters of MRI prostate images made using the PIRADS MR protocol with PSA levels > 4 mg/mL. The correlations found express dependence between image features with high cancer markers and hence the cancer risk.

Multi-reader evaluation of different image quality scoring systems in prostate MRI

OBJECTIVES

To evaluate different image quality scoring systems in the assessment of factors limiting diagnostic accuracy of prostate MRI.

METHODS

This retrospective IRB-approved study included 281 patients undergoing prostate MRI prior to biopsy. Four readers (2 experienced, 2 novice) independently reviewed all MRI examinations (n = 295) and assigned scores for subjective image quality (1-5; 1:poor, 5:excellent), the PI-QUAL and the PSHS scoring system. The original PI-RADS scores were extracted from the report and transperineal template saturation biopsy served as histopathological reference.

RESULTS

Inter-reader agreement was found to be good, with PSHS showing highest agreement (kappa: 0.65). The PSHS scoring system performed well assessing the influence of image quality on sensitivity of MR for clinically-significant cancer for the experienced readers using a PI-RADS score cut-off ≥ 3/≥4, as did the PI-QUAL scoring system with a PI-RADS cut-off ≥ 4. For the less experienced radiologist, this was true for PSHS (clinically-significant and all cancers) and PI-QUAL scores (clinically-significant cancers) for a PI-RADS score ≥ 3. PSHS scores were positively associated with the detection of clinically-significant cancer based on a PI-RADS cut-off ≥ 4, OR 1.86 (95 % CI 1.22-2.82), and had the highest Somers' D.

CONCLUSIONS

The PSHS scoring system performed well in assessing the effect of image quality on detection rates, as did the PI-QUAL system. Since both systems focus on different aspects of image quality, their incorporation into prostate MRI reports could further enhance standardization and allow for a reliable assessment of image quality as a potential confounder in prostate MRI.

INTEGRATING PROSTATE SPECIFIC ANTIGEN DENSITY BIOMARKER INTO DEEP LEARNING PROSTATE MRI LESION SEGMENTATION MODELS

Prostate cancer lesion segmentation in multi-parametric magnetic resonance imaging (mpMRI) is crucial for pre-biopsy diagnosis and targeted biopsy guidance. Deep convolution neural networks have been widely utilized for lesion segmentation. However, these methods fail to achieve a high Dice coefficient because of the large variations in lesion size and location within the gland. To address this problem, we integrate the clinically-meaningful prostate specific antigen density (PSAD) biomarker into the deep learning model using feature-wise transformations to condition the features in latent space, and thus control the size of lesion prediction. We tested our models on a public dataset with 214 annotated mpMRI scans and compared the segmentation performance to a baseline 3D U-Net model. Results demonstrate that integrating the PSAD biomarker significantly improves segmentation performance in both Dice coefficient and centroid distance metric.

[Systematic or targeted fusion-guided biopsy]

BACKGROUND

Early detection of prostate cancer (PCa) is associated with a high risk for detecting low-risk disease. In the primary biopsy indication, systematic biopsy leads to an increased detection of clinically insignificant PCa, and significant prostate cancers are not detected with sufficient sensitivity, especially without prior magnetic resonance imaging (MRI). Similar data have recently become available for PCa screening.

OBJECTIVES

In light of the current literature, this article aims to discuss the data on systematic and combined targeted and systematic multiparametric MRI (mpMRI)-guided fusion biopsy to improve PCa diagnosis in clinically suspected cancer even in screening using multivariable risk stratification.

MATERIALS AND METHODS

Literature review on mpMRI and MRI/TRUS fusion biopsy (TRUS: transrectal ultrasonography) for tumor detection in suspected prostate cancer and PCa screening was performed.

RESULTS

Multiparametric MRI as a reflex test after prostate-specific antigen (PSA) determination (PSA cut-off 4 ng/ml) in combination with targeted biopsy alone reduces the detection of clinically nonsignificant tumors in early detection by half. On the other hand, in the form of a target saturation or in combination with a systematic biopsy, the sensitivity for the detection of cancers of International Society of Urogenital Pathology (ISUP) grade groups 2 or higher can be improved. Similar results are also shown in PCa screening with a PSA cut-off of 3 ng/ml.

CONCLUSIONS

The evidence for performing a targeted fusion biopsy alone is currently insufficient. Therefore, the combination of mpMRI-guided targeted and systematic biopsy continues to be the recommended standard for prostate cancer diagnosis.

The Severity of Pain in Prostate Biopsy Depends on the Biopsy Sector

BACKGROUND: The pain experienced by a patient during a prostate fusion biopsy is cumulative and can also be modulated by many factors. The aim of the study was to assess the association between the degree of pain intensity during prostate biopsy and the region of the biopted organ. MATERIALS AND METHODS: The study included a group of 143 patients who underwent prostate fusion biopsy under local analgesia followed by blockage of the periprostatic nerve. After a biopsy, the patients completed the original questionnaire about the pain experienced during the procedure. RESULTS: There was a statistically significant difference in pain score between cores taken in the apex (median 5 (IQR 2–5)), medium level (median 1 (IQR 1–2)), and prostate base (median 1 (IQR 1–3)) (p < 0.001). The malignancy scale ISUP ≥ 2 (p = 0.038) and lower PSA value (r = −0.17; p = 0.046) are associated with higher pain during procedure. Biopsy time was correlated with discomfort (r = 0.19; p = 0.04). Age (p = 0.65), lesion size (p = 0.29), PI-RADS score (p = 0.86), prostate volume (p = 0.22), and the number of cores (p = 0.56) did not correspond to the pain scale. CONCLUSIONS: The apex is the most sensitive sector of the prostate. ISUP ≥ 2 and patients with low PSA levels more often indicated higher values on the pain rating scale.

Efficacy of plasma atherogenic index in predicting malignancy in the presence of Prostate Imaging-Reporting and Data System 3 (PI-RADS 3) prostate lesions

PURPOSE

Plasma atherogenic index (PAI) was shown to be positively correlated with the presence of malignity in patients with suspicious findings for renal cell cancer and colon cancer in reported studies. In this study, we aimed to evaluate whether there is an association with the presence of malignity in patients PI-RADS 3 prostate lesions and PAI.

METHODS

This retrospective study reviewed the data of 139 patients who underwent transrectal ultrasonography-guided systematic and cognitive fusion prostate biopsy for PI-RADS 3 lesions in multiparametric magnetic resonance imaging. The patients were divided to two groups as malign (n = 33) and benign (n = 106). The association between age, body mass index, comorbidities, smoking status, prostate-specific antigen (PSA), PSA density, free/total PSA, prostate weight, lesion diameter, triglyceride value, high-density lipoprotein-cholesterol value, PAI value data and presence of malignity were investigated by descriptive, multivariate and receiver-operating characteristic (ROC) analysis.

RESULTS

PSA, PSAD, lesion diameter and PAI value were statistically significantly higher in the malignant group compared to the benign group, and the free/total PSA ratio was lower. In multivariate logistic regression analysis, PSA > 9.9 ng/ml, free/total PSA < 12.1%, lesion diameter > 13.5 mm and PAI > 0.13 were identified as independent risk factors for presence of prostate malignancy.

CONCLUSION

PAI was found to be a predictive parameter for prostate cancer in PI-RADS 3 prostate lesions. Our study can open new thoughts about PAI as metric to assess the prostate cancer risk.

Exploring new frontiers in prostate cancer research: Report from the 2022 Coffey-Holden prostate cancer academy meeting

INTRODUCTION

The 2022 Coffey-Holden Prostate Cancer Academy (CHPCA) Meeting, "Exploring New Frontiers in Prostate Cancer Research," was held from June 23 to 26, 2022, at the University of California, Los Angeles, Luskin Conference Center, in Los Angeles, CA.

METHODS

The CHPCA Meeting is an annual discussion-oriented scientific conference organized by the Prostate Cancer Foundation, that focuses on emerging and next-step topics deemed critical for making the next major advances in prostate cancer research and clinical care. The 2022 CHPCA Meeting included 35 talks over 10 sessions and was attended by 73 academic investigators.

RESULTS

Major topic areas discussed at the meeting included: prostate cancer diversity and disparities, the impact of social determinants on research and patient outcomes, leveraging real-world and retrospective data, development of artificial intelligence biomarkers, androgen receptor (AR) signaling biology and new strategies for targeting AR, features of homologous recombination deficient prostate cancer, and future directions in immunotherapy and nuclear theranostics.

DISCUSSION

This article summarizes the scientific presentations from the 2022 CHPCA Meeting, with the goal that dissemination of this knowledge will contribute to furthering global prostate cancer research efforts.

Seminar: Revisiting the value of PSA-based prostate cancer screening Essay No 5: Should men undergo MRI before prostate biopsy? (Pro)

Prostate cancer is the commonest cancer in men in Europe and many countries worldwide, and the second commonest cause of cancer-related death. A screening programme to detect clinically relevant prostate cancer at a time when it can be cured, without burdensome overdiagnosis and subsequent overtreatment, is a laudable goal. We will set out the advances in MRI imaging, and the progress in MRI for men prior to biopsy, discussing whether MRI has a place before biopsy, or as a primary screening tool, in a modern approach to prostate cancer screening.

Circulating Chromosome Conformation Signatures Significantly Enhance PSA Positive Predicting Value and Overall Accuracy for Prostate Cancer Detection

BACKGROUND

Prostate cancer (PCa) has a high lifetime prevalence (one out of six men), but currently there is no widely accepted screening programme. Widely used prostate specific antigen (PSA) test at cut-off of 3.0 ng/mL does not have sufficient accuracy for detection of any prostate cancer, resulting in numerous unnecessary prostate biopsies in men with benign disease and false reassurance in some men with PCa. We have recently identified circulating chromosome conformation signatures (CCSs, Episwitch^® PCa test) allowing PCa detection and risk stratification in line with standards of clinical PCa staging. The purpose of this study was to determine whether combining the Episwitch PCa test with the PSA test will increase its diagnostic accuracy.

METHODS

n = 109 whole blood samples of men enrolled in the PROSTAGRAM screening pilot study and n = 38 samples of patients with established PCa diagnosis and cancer-negative controls from Imperial College NHS Trust were used. Samples were tested for PSA, and the presence of CCSs in the loci encoding for of DAPK1, HSD3B2, SRD5A3, MMP1, and miRNA98 associated with high-risk PCa identified in our previous work.

RESULTS

PSA > 3 ng/mL alone showed a low positive predicted value (PPV) of 0.14 and a high negative predicted value (NPV) of 0.93. EpiSwitch alone showed a PPV of 0.91 and a NPV of 0.32. Combining PSA and Episwitch tests has significantly increased the PPV to 0.81 although reducing the NPV to 0.78. Furthermore, integrating PSA, as a continuous variable (rather than a dichotomised 3 ng/mL cut-off), with EpiSwitch in a new multivariant stratification model, Prostate Screening EpiSwitch (PSE) test, has yielded a remarkable combined PPV of 0.92 and NPV of 0.94 when tested on the independent prospective cohort.

CONCLUSIONS

Our results demonstrate that combining the standard PSA readout with circulating chromosome conformations (PSE test) allows for significantly enhanced PSA PPV and overall accuracy for PCa detection. The PSE test is accurate, rapid, minimally invasive, and inexpensive, suggesting significant screening diagnostic potential to minimise unnecessary referrals for expensive and invasive MRI and/or biopsy testing. Further extended prospective blinded validation of the new combined signature in a screening cohort with low cancer prevalence would be the recommended step for PSE adoption in PCa screening.

Landmarks in the evolution of prostate biopsy

Approaches and techniques used for diagnostic prostate biopsy have undergone considerable evolution over the past few decades: from the original finger-guided techniques to the latest MRI-directed strategies, from aspiration cytology to tissue core sampling, and from transrectal to transperineal approaches. In particular, increased adoption of transperineal biopsy approaches have led to reduced infectious complications and improved antibiotic stewardship. Furthermore, as image fusion has become integral, these novel techniques could be incorporated into prostate biopsy methods in the future, enabling 3D-ultrasonography fusion reconstruction, molecular targeting based on PET imaging and autonomous robotic-assisted biopsy.

Prostate cancer risk, screening and management in patients with germline BRCA1/2 mutations

Mutations in the BRCA1 and BRCA2 tumour suppressor genes are associated with prostate cancer risk; however, optimal screening protocols for individuals with these mutations have been a subject of debate. Several prospective studies of prostate cancer incidence and screening among BRCA1/2 mutation carriers have indicated at least a twofold to fourfold increase in prostate cancer risk among carriers of BRCA2 mutations compared with the general population. Moreover, BRCA2 mutations are associated with more aggressive, high-grade disease characteristics at diagnosis, more aggressive clinical behaviour and greater prostate cancer-specific mortality. The risk for BRCA1 mutations seems to be attenuated compared with BRCA2. Prostate-specific antigen (PSA) measurement or prostate magnetic resonance imaging (MRI) alone is an imperfect indicator of clinically significant prostate cancer; therefore, BRCA1/2 mutation carriers might benefit from refined risk stratification strategies. However, the long-term impact of prostate cancer screening is unknown, and the optimal management of BRCA1/2 carriers with prostate cancer has not been defined. Whether timely localized therapy can improve overall survival in the screened population is uncertain. Long-term results of prospective studies are awaited to confirm the optimal screening strategies and benefits of prostate cancer screening among BRCA1/2 mutation carriers, and whether these approaches ultimately have a positive impact on survival and quality of life in these patients.

Prostate cancer in transgender women: considerations for screening, diagnosis and management

Transgender individuals represent 0.55% of the US population, equivalent to 1.4 million transgender adults. In transgender women, feminisation can include a number of medical and surgical interventions. The main goal is to deprive the phenotypically masculine body of androgens and simultaneously provide oestrogen therapy for feminisation. In gender-confirming surgery (GCS) for transgender females, the prostate is usually not removed. Due to limitations of existing cohort studies, the true incidence of prostate cancer in transgender females is unknown but is thought to be less than the incidence among cis-gender males. It is unclear how prostate cancer develops in androgen-deprived conditions in these patients. Six out of eleven case reports in the literature presented with metastatic disease. It is thought that androgen receptor-mediated mechanisms or tumour-promoting effects of oestrogen may be responsible. Due to the low incidence of prostate cancer identified in transgender women, there is little evidence to drive specific screening recommendations in this patient subpopulation. The treatment of early and locally advanced prostate cancer in these patients warrants an individualised thoughtful approach with input from patients' reconstructive surgeons. Both surgical and radiation treatment for prostate cancer in these patients can profoundly impact the patient's quality of life. In this review, we discuss the evidence surrounding screening and treatment of prostate cancer in transgender women and consider the current gaps in our knowledge in providing evidence-based guidance at the molecular, genomic and epidemiological level, for clinical decision-making in the management of these patients.

[The cancer epidemic : Global significance of cancer and the situation in oncological imaging]

A significant increase in the incidence of cancer is expected worldwide. In Europe, cancer will soon be the leading cause of death, ahead of cardiovascular disease. Concerted efforts at the scientific, medical, societal, and political levels are required to address this problem on a global scale. High-quality oncological imaging is of particular importance in this regard. Access to it has been shown to have a significant impact on quality of care and survival. Imaging is an essential component of screening and early detection. In clinical oncology, imaging is essential for multidisciplinary diagnostics and personalized therapy. Likewise, imaging is necessary in translational and clinical research. Imaging techniques are also themselves the subject of research and development and, associated with this, are also of great importance as an economic factor. This article aims to provide insights into the global problem of oncology and the contribution that oncological imaging can make to its management.

Prostate MRI versus PSA screening for prostate cancer detection (the MVP Study): a randomised clinical trial

OBJECTIVES

Our objective was to compare prostate cancer detection rates between patients undergoing serum prostate-specific antigen (PSA) vs magnetic resonance imaging (MRI) for prostate cancer screening.

DESIGN

Phase III open-label randomised controlled trial.

SETTING

Single tertiary cancer centre in Toronto, Canada.

PARTICIPANTS

Men 50 years of age and older with no history of PSA screening for ≥3 years, a negative digital rectal exam and no prior prostate biopsy.

INTERVENTIONS

Patients were recommended to undergo a prostate biopsy if their PSA was ≥2.6 ng/mL (PSA arm) or if they had a PIRADS score of 4 or 5 (MRI arm). Patients underwent an end-of-study PSA in the MRI arm.

PRIMARY AND SECONDARY OUTCOME MEASURES

Adenocarcinoma on prostate biopsy. Prostate biopsy rates and the presence of clinically significant prostate cancer were also compared.

RESULTS

A total of 525 patients were randomised, with 266 in the PSA arm and 248 in the MRI arm. Due to challenges with accrual and study execution during the COVID-19 pandemic, the study was terminated early. In the PSA arm, 48 patients had an abnormal PSA and 28 (58%) agreed to undergo a prostate biopsy. In the MRI arm, 25 patients had a PIRADS score of 4 or 5 and 24 (96%) agreed to undergo a biopsy. The relative risk for MRI to recommend a prostate biopsy was 0.52 (95% CI 0.33 to 0.82, p=0.005), compared with PSA. The cancer detection rate for patients in the PSA arm was 29% (8 of 28) vs 63% (15 of 24, p=0.019) in the MRI arm, with a higher proportion of clinically significant cancer detected in the MRI arm (73% vs 50%). The relative risk for detecting cancer and clinically significant with MRI compared with PSA was 1.89 (95% CI 0.82 to 4.38, p=0.14) and 2.77 (95% CI 0.89 to 8.59, p=0.07), respectively.

CONCLUSIONS

Prostate MRI as a stand-alone screening test reduced the rate of prostate biopsy. The number of clinically significant cancers detected was higher in the MRI arm, but this did not reach statistical significance. Due to early termination, the study was underpowered. More patients were willing to follow recommendations for prostate biopsy based on MRI results.

TRIAL REGISTRATION NUMBER

NCT02799303.

Comparison of Multiparametric and Fast MRI Protocols in Detecting Clinically Significant Prostate Cancer and a Detailed Cost Analysis

BACKGROUND

Due to the long acquisition time and high cost of multiparametric magnetic resonance imaging (mpMRI), biparametric and, more recently, fast prostate magnetic resonance imaging (fpMRI) protocols have been described. However, there is insufficient data about the diagnostic performance and cost of fpMRI.

PURPOSE

To compare the diagnostic performances and cost analysis of fpMRI and mpMRI in clinically significant prostate cancer (csPCA).

STUDY TYPE

Retrospective.

POPULATION

A total of 103 patients (63 had csPCA) with a mean age of 66.83 (± 7.22) years were included.

FIELD STRENGTH/SEQUENCE

A 1.5-T; T1- and T2-weighted turbo spin-echo imaging (T1WI and T2WI), echo-planar diffusion-weighted images, and dynamic contrast-enhanced T1W imaging.

ASSESSMENT

Three readers independently evaluated the fpMRI and mpMRI images in different sessions blinded to all patient information. Diagnostic performances of fpMRI and mpMRI were evaluated. Kappa coefficient (κ) was used to determine the interreader and intrareader agreement. A detailed cost analysis was performed for each protocol.

STATISTICAL TESTS

Receiver operating characteristics analysis, area under the curve (AUC), and κ test were used. Diagnostic performance parameters were also calculated.

RESULTS

Of the 63 malignant index lesions (csPCA), 53/63 of those (84.1%) originated from the peripheral zone and 10/63 lesions (15.9%) originated from the transition zone. The AUC values for fpMRI were 0.878 for reader 1, 0.937 for reader 2, and 0.855 for reader 3. For mpMRI, the AUC values were 0.893 for reader 1, 0.94 for reader 2, and 0.862 for reader 3. Inter and intrareader agreements were moderate to substantial (κ range, 0.5-0.79). The total cost per examination was calculated as €12.39 and €30.10 for fpMRI and mpMRI, respectively.

DATA CONCLUSIONS

Fast MRI protocol has similar diagnostic performance with mpMRI in detecting csPCA, and fpMRI can be considered an alternative protocol that could create a lower financial burden on health-care systems.

LEVEL OF EVIDENCE

4 TECHNICAL EFFICACY STAGE: 6.

Prostate MRI Qualification: AJR Expert Panel Narrative Review

Prostate MRI is now established as a first-line investigation for individuals presenting with suspected localized or locally advanced prostate cancer. Successful delivery of the MRI-directed pathway for prostate cancer diagnosis relies on high-quality imaging as well as the interpreting radiologist's experience and expertise. Radiologist certification in prostate MRI may help limit interreader variability, optimize outcomes, and provide individual radiologists with documentation of meeting predefined standards. This AJR Expert Panel Narrative Review summarizes existing certification proposals, recognizing variable progress across regions in establishing prostate MRI certification programs. To our knowledge, Germany is the only country with a prostate MRI certification process that is currently available for radiologists. However, prostate MRI certification programs have also recently been proposed in the United States and United Kingdom and by European professional society consensus panels. Recommended qualification processes entail a multifaceted approach, incorporating components such as minimum case numbers, peer learning, course participation, continuing medical education credits, and feedback from pathology results. Given the diversity in health care systems, including in the provision and availability of MRI services, national organizations will likely need to take independent approaches to certification and accreditation. The relevant professional organizations should begin developing these programs or continue existing plans for implementation.

CURRENT ROLE OF MAGNETIC RESONANCE IMAGING IN THE SCREENING, DIAGNOSIS, AND TREATMENT OF PROSTATE CANCER

Prostate cancer is the most common cancer in men. Diagnosis of prostate cancer poses a significant challenge, due to several different key parameters that need to be evaluated, such as age, history of prostate specific antigen (PSA), clinical examination and more recently magnetic resonance imaging (MRI). The current diagnostic pathway for prostate cancer has resulted in overdiagnosis and overtreatment as well as underdiagnosis and missed diagnoses in many men. Multiparametric MRI (mp-MRI) of the prostate has been identified as a test that could alleviate these diagnostic errors. Before prostate cancer treatment pathological confirmation is mandatory. Prostate biopsy is an invasive procedure with rare but not negligible potential complications. There are several methods of prostate biopsy of which most common are systemic or planar prostate biopsy and cognitive or targeted MRI-guided prostate biopsy. Multiparametric MRI has demonstrated better accuracy and reproducibility in detecting, locating and evaluating prostate cancer and also sparing some men unnecessary biopsies. Recent studies have shown a mpMRI benefit for better procedure planning regarding prostate cancer location, extent of disease and length of the urethra. There are still some challenges ahead, such as ensuring high-quality execution and reporting of mpMRI and ensuring that this diagnostic pathway is cost-effective. According to the latest urological clinical guidelines mpMRI became fundamental tool in management of prostate cancer. The aim of this study is to give a brief insight in use of mpMRI in prostate cancer diagnosis and treatment.