1
|
Josefsson A, Månsson M, Kohestani K, Spyratou V, Wallström J, Hellström M, Lilja H, Vickers A, Carlsson SV, Godtman R, Hugosson J. Performance of 4Kscore as a Reflex Test to Prostate-specific Antigen in the GÖTEBORG-2 Prostate Cancer Screening Trial. Eur Urol 2024; 86:223-229. [PMID: 38772787 DOI: 10.1016/j.eururo.2024.04.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 03/20/2024] [Accepted: 04/18/2024] [Indexed: 05/23/2024]
Abstract
BACKGROUND AND OBJECTIVE We investigated whether adding 4Kscore as a reflex test to prostate-specific antigen (PSA) could improve the screening algorithm for prostate cancer (PC). METHODS In the GÖTEBORG-2 PC screening trial, 38 000men (50-60 yr) were invited to PSA testing and, if elevated, followed by magnetic resonance imaging (MRI). For 571 men with PSA ≥3.0 ng/ml and evaluable outcomes, 4Kscore was calculated. The performance using a prespecified 4Kscore cutoff of 7.5% was evaluated. KEY FINDINGS AND LIMITATIONS The area under the curve for 4Kscore to identify intermediate- and high-risk PC was 0.84 (95% confidence interval 0.79-0.89), and the positive predictive value, and negative predictive value were 15% (0.12-0.20) and 99% (97-100%), respectively. Of the 54 men diagnosed with intermediate- or high-grade PC, two had a 4Kscore cutoff below 7.5%, both with organ-confined intermediate-risk PC. Per 1000 men with elevated PSA, adding 4Kscore would have resulted in avoidance of MRI for 408 (41%) men, biopsies for 95 (28% reduction) men, and diagnosis of 23 low-grade cancers (23% reduction) while delaying the diagnosis of four men with intermediate-grade cancers (4%). CONCLUSIONS AND CLINICAL IMPLICATIONS Including 4Kscore as a reflex test for men with elevated PSA reduces the need for MRI and biopsy markedly, and results in less overdiagnosis of low-grade PC at the cost of delaying the diagnosis of intermediate-grade PC in a few men. These results add further evidence for including new blood-based biomarkers in addition to PSA to improve the harm and benefit ratio of PC screening and reduce the need for resource-demanding MRI and biopsies.
Collapse
Affiliation(s)
- Andreas Josefsson
- Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Wallenberg Center for Molecular Medicine, Umeå University, Umeå, Sweden; Department of Urology and Andrology, Institute of Surgery and Perioperative Sciences, Umeå University, Umeå, Sweden.
| | - Marianne Månsson
- Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Kimia Kohestani
- Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Vasiliki Spyratou
- Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Jonas Wallström
- Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Mikael Hellström
- Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Radiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Hans Lilja
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Andrew Vickers
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sigrid V Carlsson
- Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Translational Medicine, Division of Urological Cancers, Medical Faculty, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Rebecka Godtman
- Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Jonas Hugosson
- Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| |
Collapse
|
2
|
Pellegrino F, Stabile A, Sorce G, Mazzone E, Cannoletta D, Cirulli GO, Quarta L, Leni R, Robesti D, Brembilla G, Gandaglia G, De Cobelli F, Montorsi F, Briganti A. Variability of mpMRI diagnostic performance according to the upfront individual patient risk of having clinically significant prostate cancer. Prostate 2024; 84:473-478. [PMID: 38149793 DOI: 10.1002/pros.24665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 11/30/2023] [Accepted: 12/15/2023] [Indexed: 12/28/2023]
Abstract
BACKGROUND To assess the variation of multiparametric magnetic resonance imaging (mpMRI) positive predictive value (PPV) according to each patient's risk of clinically significant prostate cancer (csPCa) based exclusively on clinical factors. METHODS We evaluated 999 patients with positive mpMRI (PI-RADS ≥ 3) receiving targeted (TBx) plus systematic prostate biopsy. We built a multivariable logistic regression analysis (MVA) using clinical risk factors to calculate the individual patients' risk of harboring csPCa at TBx. A second MVA tested the association between individual patients' clinical risk and mpMRI PPV accounting for the PI-RADS score. Finally, we plotted the PPV of each PI-RADS score by the individual patient pretest probability of csPCa using a LOWESS approach. RESULTS Overall, TBx found csPCa in 21%, 51%, and 80% of patients with PI-RADS 3, 4, and 5 lesions, respectively. At MVA, age, PSA, digital rectal examination (DRE), and prostate volume were significantly associated with the risk of csPCa at biopsy. DRE yielded the highest odds ratio (OR: 2.88; p < 0.001). The individual patient's clinical risk was significantly associated with mpMRI PPV (OR: 2.49; p < 0.001) using MVA. Plotting the mpMRI PPV according to the predicted clinical risks, we observed that for patients with clinical risk close to 0 versus patients with risk higher than 90%, the mpMRI PPV of PI-RADS 3, 4, and 5 ranged from 0% to 75%, from 0% to 96%, and from 45% to 100%, respectively. CONCLUSION mpMRI PPV varies according to the individual pretest patient's risk based on clinical factors. These findings should be considered in the decision-making process for patients with suspect MRI findings referred for a prostate biopsy. Moreover, our data support the need for further studies to create an individualized risk prediction tool.
Collapse
Affiliation(s)
- Francesco Pellegrino
- Division of Oncology/Unit of Urology, Soldera Prostate Cancer Lab, URI, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Armando Stabile
- Division of Oncology/Unit of Urology, Soldera Prostate Cancer Lab, URI, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Gabriele Sorce
- Division of Oncology/Unit of Urology, Soldera Prostate Cancer Lab, URI, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Elio Mazzone
- Division of Oncology/Unit of Urology, Soldera Prostate Cancer Lab, URI, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Donato Cannoletta
- Division of Oncology/Unit of Urology, Soldera Prostate Cancer Lab, URI, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Giuseppe Ottone Cirulli
- Division of Oncology/Unit of Urology, Soldera Prostate Cancer Lab, URI, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Leonardo Quarta
- Division of Oncology/Unit of Urology, Soldera Prostate Cancer Lab, URI, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Riccardo Leni
- Division of Oncology/Unit of Urology, Soldera Prostate Cancer Lab, URI, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Daniele Robesti
- Division of Oncology/Unit of Urology, Soldera Prostate Cancer Lab, URI, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Giorgio Brembilla
- Department of Radiology, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Giorgio Gandaglia
- Division of Oncology/Unit of Urology, Soldera Prostate Cancer Lab, URI, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Francesco De Cobelli
- Department of Radiology, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Francesco Montorsi
- Division of Oncology/Unit of Urology, Soldera Prostate Cancer Lab, URI, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Alberto Briganti
- Division of Oncology/Unit of Urology, Soldera Prostate Cancer Lab, URI, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| |
Collapse
|
3
|
Fredsøe J, Sandahl M, Vedsted P, Jensen JB, Ulhøi BP, Borre M, Sørensen KD, Pedersen BG. Results from the PRIMA Trial: Comparison of the STHLM3 Test and Prostate-specific Antigen in General Practice for Detection of Prostate Cancer in a Biopsy-naïve Population. Eur Urol Oncol 2023; 6:484-492. [PMID: 37537016 DOI: 10.1016/j.euo.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 06/27/2023] [Accepted: 07/07/2023] [Indexed: 08/05/2023]
Abstract
BACKGROUND Current management of prostate cancer (PC) lacks biomarker tests and diagnostic procedures that can accurately distinguish clinically significant and clinically insignificant PCs at an early stage of the disease. OBJECTIVE To compare the Stockholm 3 (STHLM3) test and prostate-specific antigen (PSA) as entry tests for magnetic resonance imaging (MRI) in a prospective study of PC diagnosis in general practice. DESIGN, SETTING, AND PARTICIPANTS Participants were biopsy-naïve men aged 50-69 yr who had a PSA test in general practice. Participants with PSA 1-10 ng/ml also had an STHLM3 test and were referred for MRI if the STHLM311 test was positive (risk ≥11%) and/or PSA ≥3 ng/ml, and to targeted MRI-guided biopsy (MRGB) if their Prostate Imaging-Reporting and Data System (PI-RADS) score was ≥3. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The primary outcome was the number of International Society of Urological Pathology grade group ≥2 (GG ≥2) cases detected with a positive STHLM311 test versus PSA ≥3 ng/ml. Post hoc analysis was performed using a higher STHLM3 test cutoff (risk ≥15%; positive STHLM315 test). RESULTS AND LIMITATIONS Between January 2018 and December 2021, we recruited 1905 men. The STHLM3 test was performed in 1134 participants. Of these, 437 underwent MRI and 117 underwent MRGB, which detected 38 (32.5%) GG ≥2 and 52 (44.4%) with GG 1 cases. In comparison to PSA ≥3 ng/ml, a positive STHLM311 test increased detection of GG ≥2 from 30 to 37 cases (23.3%, 95% confidence interval [CI] 5.6-52.2%) and detection of GG 1 from 37 to 50 cases (35.1%, 95%CI 11.6-66.7%). STHLM315 positivity did not differ from PSA ≥3 ng/ml regarding detection of GG ≥2 PC (30 vs 32; 6.6%, 95% CI -8.1% to 25.9%), GG 1 PC (37 vs 37; 0.0%, 95% CI -19.6% to 25.0%), or MRGB use (88 vs 83; -5.7%, 95% CI -17.9% to 7.4%), but reduced MRI scans from 320 to 236 (-26.2%, 95% CI -33.1% to -18.9%). CONCLUSIONS The STHLM311 test improved sensitivity but not specificity for detection of GG ≥2 PC in the clinical setting of nonsystematic PC testing in general practice. Further studies are needed to validate a possible benefit of using a higher cutoff for STHLM3 positivity as an entry test for MRI. PATIENT SUMMARY We used a test called STHLM3 for detection of prostate cancer in general practice and compared its performance to the conventional PSA (prostate-specific antigen) test. We found that STHLM3 test results of 11% or above were not better at selecting men for MRI (magnetic resonance imaging) scans than the PSA test with a cutoff of 3 ng/ml or above. Analysis suggested that a higher cutoff for a positive STHLM3 test may improve selection of men for MRI scans, but further validation is needed.
Collapse
Affiliation(s)
- Jacob Fredsøe
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus N, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
| | - Mads Sandahl
- Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark; Department of Radiology, Aarhus University Hospital, Aarhus N, Denmark
| | - Peter Vedsted
- Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark; Research Unit for General Practice, Research Centre for Cancer Diagnosis in Primary Care, Aarhus C, Denmark
| | - Jørgen Bjerggaard Jensen
- Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark; Department of Urology, West Jutland Regional Hospital, Holstebro, Denmark
| | | | - Michael Borre
- Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark; Department of Urology, Aarhus University Hospital, Aarhus N, Denmark
| | - Karina Dalsgaard Sørensen
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus N, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark.
| | | |
Collapse
|
4
|
Tutrone R, Lowentritt B, Neuman B, Donovan MJ, Hallmark E, Cole TJ, Yao Y, Biesecker C, Kumar S, Verma V, Sant GR, Alter J, Skog J. ExoDx prostate test as a predictor of outcomes of high-grade prostate cancer - an interim analysis. Prostate Cancer Prostatic Dis 2023; 26:596-601. [PMID: 37193776 PMCID: PMC10449627 DOI: 10.1038/s41391-023-00675-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 04/17/2023] [Accepted: 04/27/2023] [Indexed: 05/18/2023]
Abstract
BACKGROUND Patient outcomes were assessed based on a pre-biopsy ExoDx Prostate (EPI) score at 2.5 years of the 5-year follow-up of ongoing prostate biopsy Decision Impact Trial of the ExoDx Prostate (IntelliScore). METHODS Prospective, blinded, randomized, multisite clinical utility study was conducted from June 2017 to May 2018 (NCT03235687). Urine samples were collected from 1049 men (≥50 years old) with a PSA 2-10 ng/mL being considered for a prostate biopsy. Patients were randomized to EPI vs. standard of care (SOC). All had an EPI test, but only EPI arm received results during biopsy decision process. Clinical outcomes, time to biopsy and pathology were assessed among low (<15.6) or high (≥15.6) EPI scores. RESULTS At 2.5 years, 833 patients had follow-up data. In the EPI arm, biopsy rates remained lower for low-risk EPI scores than high-risk EPI scores (44.6% vs 79.0%, p < 0.001), whereas biopsy rates were identical in SOC arm regardless of EPI score (59.6% vs 58.8%, p = 0.99). Also in the EPI arm, the average time from EPI testing to first biopsy was longer for low-risk EPI scores compared to high-risk EPI scores (216 vs. 69 days; p < 0.001). Similarly, the time to first biopsy was longer with EPI low-risk scores in EPI arm compared to EPI low-risk scores in SOC arm (216 vs 80 days; p < 0.001). At 2.5 years, patients with low-risk EPI scores from both arms had less HGPC than high-risk EPI score patients (7.9% vs 26.8%, p < 0.001) and the EPI arm found 21.8% more HGPC than the SOC arm. CONCLUSIONS This follow-up analysis captures subsequent biopsy outcomes and demonstrates that men receiving EPI low-risk scores (<15.6) significantly defer the time to first biopsy and remain at a very low pathologic risk by 2.5-years after the initial study. The EPI test risk stratification identified low-risk patients that were not found with the SOC.
Collapse
Affiliation(s)
- Ronald Tutrone
- Chesapeake Urology Research Associates, Baltimore, MD, USA.
| | - Ben Lowentritt
- Chesapeake Urology Research Associates, Baltimore, MD, USA
| | - Brian Neuman
- Chesapeake Urology Research Associates, Baltimore, MD, USA
| | | | | | - T Jeffrey Cole
- Exosome Diagnostics, a Bio-Techne Brand, Waltham, MA, USA
| | - Yiyuan Yao
- Exosome Diagnostics, a Bio-Techne Brand, Waltham, MA, USA
| | | | - Sonia Kumar
- Exosome Diagnostics, a Bio-Techne Brand, Waltham, MA, USA
| | - Vinita Verma
- Exosome Diagnostics, a Bio-Techne Brand, Waltham, MA, USA
| | - Grannum R Sant
- Exosome Diagnostics, a Bio-Techne Brand, Waltham, MA, USA
- Department of Urology, Tufts University, Medford, MA, USA
| | - Jason Alter
- Exosome Diagnostics, a Bio-Techne Brand, Waltham, MA, USA
| | - Johan Skog
- Exosome Diagnostics, a Bio-Techne Brand, Waltham, MA, USA
| |
Collapse
|
5
|
Lophatananon A, Light A, Burns-Cox N, Maccormick A, John J, Otti V, McGrath J, Archer P, Anning J, McCracken S, Page T, Muir K, Gnanapragasam VJ. Re-evaluating the diagnostic efficacy of PSA as a referral test to detect clinically significant prostate cancer in contemporary MRI-based image-guided biopsy pathways. JOURNAL OF CLINICAL UROLOGY 2023; 16:264-273. [PMID: 37614642 PMCID: PMC7614972 DOI: 10.1177/20514158211059057] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/25/2023]
Abstract
Introduction Modern image-guided biopsy pathways at diagnostic centres have greatly refined the investigations of men referred with suspected prostate cancer. However, the referral criteria from primary care are still based on historical prostate-specific antigen (PSA) cut-offs and age-referenced thresholds. Here, we tested whether better contemporary pathways and biopsy methods had improved the predictive utility value of PSA referral thresholds. Methods PSA referral thresholds, age-referenced ranges and PSA density (PSAd) were assessed for positive predictive value (PPV) in detection of clinically significant prostate cancer (csPCa - histological ⩾ Grade Group 2). Data were analysed from men referred to three diagnostics centres who used multi-parametric magnetic resonance imaging (mpMRI)-guided prostate biopsies for disease characterisation. Findings were validated in a separate multicentre cohort. Results: Data from 2767 men were included in this study. The median age, PSA and PSAd were 66.4 years, 7.3 ng/mL and 0.1 ng/mL2, respectively. Biopsy detected csPCa was found in 38.7%. The overall area under the curve (AUC) for PSA was 0.68 which is similar to historical performance. A PSA threshold of ⩾ 3 ng/mL had a PPV of 40.3%, but this was age dependent (PPV: 24.8%, 32.7% and 56.8% in men 50-59 years, 60-69 years and ⩾ 70 years, respectively). Different PSA cut-offs and age-reference ranges failed to demonstrate better performance. PSAd demonstrated improved AUC (0.78 vs 0.68, p < 0.0001) and improved PPV compared to PSA. A PSAd of ⩾ 0.10 had a PPV of 48.2% and similar negative predictive value (NPV) to PSA ⩾ 3 ng/mL and out-performed PSA age-reference ranges. This improved performance was recapitulated in a separate multi-centre cohort (n = 541). Conclusion The introduction of MRI-based image-guided biopsy pathways does not appear to have altered PSA diagnostic test characteristics to positively detect csPCa. We find no added value to PSA age-referenced ranges, while PSAd offers better PPV and the potential for a single clinically useful threshold (⩾0.10) for all age groups. Level of evidence IV.
Collapse
Affiliation(s)
- Artitaya Lophatananon
- Division of Population Health, Health Services Research & Primary Care Centre, University of Manchester, UK
| | - Alexander Light
- Division of Urology, Department of Surgery, University of Cambridge, UK
- Department of Urology, Cambridge University Hospitals NHS Foundation Trust, UK
| | | | | | - Joseph John
- Department of Urology, Royal Devon and Exeter NHS Foundation Trust and University of Exeter, UK
| | - Vanessa Otti
- Department of Urology, Royal Devon and Exeter NHS Foundation Trust and University of Exeter, UK
| | - John McGrath
- Department of Urology, Royal Devon and Exeter NHS Foundation Trust and University of Exeter, UK
| | - Pete Archer
- Department of Urology, Southend Hospital, UK
| | | | - Stuart McCracken
- Department of Urology, South Tyneside and Sunderland NHS Trust, UK
| | - Toby Page
- Department of Urology, Newcastle Hospitals NHS Trust, UK
| | - Ken Muir
- Division of Population Health, Health Services Research & Primary Care Centre, University of Manchester, UK
| | - Vincent J Gnanapragasam
- Division of Urology, Department of Surgery, University of Cambridge, UK
- Department of Urology, Cambridge University Hospitals NHS Foundation Trust, UK
- Cambridge Urology Translational Research and Clinical Trials Office, Addenbrooke’s Hospital, UK
| |
Collapse
|
6
|
A Clinically Significant Prostate Cancer Predictive Model Using Digital Rectal Examination Prostate Volume Category to Stratify Initial Prostate Cancer Suspicion and Reduce Magnetic Resonance Imaging Demand. Cancers (Basel) 2022; 14:cancers14205100. [PMID: 36291883 PMCID: PMC9600141 DOI: 10.3390/cancers14205100] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 10/13/2022] [Accepted: 10/14/2022] [Indexed: 11/17/2022] Open
Abstract
A predictive model including age, PCa family history, biopsy status (initial vs repeat), DRE (normal vs abnormal), serum prostate-specific antigen (PSA), and DRE prostate volume ca-tegory was developed to stratify initial PCa suspicion in 1486 men with PSA > 3 ng/mL and/or abnormal DRE, in whom mpMRI followed; 2- to 4-core TRUS-guided biopsies where Prostate Imaging Report and Data System (PI-RADS) > 3 lesions and/or 12-core TRUS systematic biopsies were performed in one academic institution between 1 January 2016−31 December 2019. The csPCa detection rate, defined as International Society of Uro-Pathology grade group 2 or higher, was 36.9%. An external validation of designed BCN-RC 1 was carried out on 946 men from two other institutions in the same metropolitan area, using the same criteria of PCa suspicion and diagnostic approach, yielded a csPCa detection rate of 40.8%. The areas under the receiver operating characteristic curves of BCN-RC 1 were 0.823 (95% CI: 0.800−0.846) in the development cohort and 0.837 (95% CI: 0.811−0.863) in the validation cohort (p = 0.447). In both cohorts, BCN-RC 1 exhibited net benefit over performing mpMRI in all men from 8 and 12% risk thresholds, respectively. At 0.95 sensitivity of csPCa, the specificities of BCN-RC 1 were 0.24 (95% CI: 0.22−0.26) in the development cohort and 0.34 (95% CI: 0.31−0.37) in the validation cohort (p < 0.001). The percentages of avoided mpMRI scans were 17.2% in the development cohort and 22.3% in the validation cohort, missing between 1.8% and 2% of csPCa among men at risk of PCa. In summary, BCN-RC 1 can stratify initial PCa suspicion, reducing the demand of mpMRI, with an acceptable loss of csPCa.
Collapse
|
7
|
Gnanapragasam VJ, Greenberg D, Burnet N. Urinary symptoms and prostate cancer-the misconception that may be preventing earlier presentation and better survival outcomes. BMC Med 2022; 20:264. [PMID: 35922801 PMCID: PMC9351095 DOI: 10.1186/s12916-022-02453-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 06/28/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Prostate cancer is an epidemic of the modern age, and despite efforts to improve awareness, it remains the case that mortality has hardly altered over the decades, driven largely by late presentation. There is a strong public perception that male urinary symptoms is one of the key indicators of prostate cancer, and this continues to be part of messaging from national guidelines and media health campaigns. This narrative, however, is not based on evidence and may be seriously hampering efforts to encourage early presentation. DISCUSSION Anatomically, prostate cancer most often arises in the peripheral zone, while urinary symptoms result from compression of the urethra by prostatic enlargement more centrally. Biopsy studies show that mean prostate volume is actually lower in men found to have (early) prostate cancer compared to those with benign biopsies. This inverse relationship between prostate size and the probability of cancer is so strong that PSA density (PSA corrected for prostate volume) is known to be significantly more accurate in predicting a positive biopsy than PSA alone. Thus, this disconnect between scientific evidence and the current perception is very striking. There is also evidence that using symptoms for investigating possible cancer may lead to higher proportions of men presenting with locally advanced or metastatic disease compared to PSA testing or screening programmes. Concerns about overwhelming health care services if men are encouraged to get tested without symptoms may also be overstated, with recent newer approaches to reduce over-investigation and treatment. In this article, we explore the link between urinary symptoms and prostate cancer and propose that public and professional messaging needs to change. CONCLUSION If rates of earlier diagnosis are to improve, we call for strong clear messaging that prostate cancer is a silent disease especially in the curable stages and men should come forward for testing regardless of whether or not they have symptoms. This should be done in parallel with other ongoing efforts to raise awareness including targeting men at highest risk due to racial ancestry or family history. While the current resurgence in interest and debate about prostate cancer screening is timely, change of this message by guideline bodies, charities and the media can be a first simple step to improving earlier presentation and hence cures rates.
Collapse
Affiliation(s)
- Vincent J Gnanapragasam
- Department of Urology, Cambridge University Hospitals Trust, Cambridge, UK.
- Division of Urology, Department of Surgery, University of Cambridge, Cambridge, CB2 0QQ, UK.
- Cambridge Urology Translational Research and Clinical Trials Office, Cambridge Biomedical Campus, Cambridge, UK.
| | - David Greenberg
- (Retired) Public Health England, Public Health England, National Cancer Registration and Analysis Service (Eastern Office), England, UK
| | - Neil Burnet
- The Christie NHS Foundation Trust, Manchester, UK
| |
Collapse
|
8
|
External Validation of the Prostate Biopsy Collaborative Group Risk Calculator and the Rotterdam Prostate Cancer Risk Calculator in a Swedish Population-based Screening Cohort. EUR UROL SUPPL 2022; 41:1-7. [PMID: 35813248 PMCID: PMC9257644 DOI: 10.1016/j.euros.2022.04.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2022] [Indexed: 11/24/2022] Open
Abstract
Background External validation of risk calculators (RCs) is necessary to determine their clinical applicability beyond the setting in which these were developed. Objective To assess the performance of the Rotterdam Prostate Cancer RC (RPCRC) and the Prostate Biopsy Collaborative Group RC (PBCG-RC). Design, setting, and participants We used data from the prospective, population-based STHLM3 screening study, performed in 2012–2015. Participants with prostate-specific antigen ≥3 ng/ml who underwent systematic prostate biopsies were included. Outcome measurements and statistical analysis Probabilities for clinically significant prostate cancer (csPCa), defined as International Society of Urological Pathology grade ≥2, were calculated for each participant. External validity was assessed by calibration, discrimination, and clinical usefulness for both original and recalibrated models. Results and limitations Out of 5841 men, 1054 (18%) had csPCa. Distribution of risk predictions differed between RCs; median risks for csPCa using the RPCRC and PBCG-RC were 3.3% (interquartile range [IQR] 2.1–7.1%) and 20% (IQR 15–28%), respectively. The correlation between RC risk estimates on individual level was moderate (Spearman’s r = 0.55). Using the RPCRC’s recommended risk threshold of ≥4% for finding csPCa, 36% of participants would get concordant biopsy recommendations. At 10% risk cut-off, RCs agreed in 23% of cases. Both RCs showed good discrimination, with areas under the curves for the RPCRC of 0.74 (95% confidence interval [CI] 0.72–0.76) and the PBCG-RC of 0.70 (95% CI 0.68–0.72). Calibration was adequate using the PBCG-RC (calibration slope: 1.13 [95% CI 1.03–1.23]), but the RPCRC underestimated the risk of csPCa (calibration slope: 0.73 [0.68–0.79]). The PBCG-RC showed a net benefit in a decision curve analysis, whereas the RPCRC showed no net benefit at clinically relevant risk threshold levels. Recalibration improved clinical benefit, and differences between RCs decreased. Conclusions Assessment of calibration is essential to ensure the clinical value of risk prediction tools. The PBCG-RC provided clinical benefit in its current version online. On the contrary, the RPCRC cannot be recommended in this setting. Patient summary Predicting the probability of finding prostate cancer on biopsy differed between two assessed risk calculators. After recalibration, the agreement of the models improved, and both were shown to be clinically useful.
Collapse
|
9
|
Comparative Analysis of PSA Density and an MRI-Based Predictive Model to Improve the Selection of Candidates for Prostate Biopsy. Cancers (Basel) 2022; 14:cancers14102374. [PMID: 35625978 PMCID: PMC9139805 DOI: 10.3390/cancers14102374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 04/28/2022] [Accepted: 05/09/2022] [Indexed: 02/01/2023] Open
Abstract
This study is a head-to-head comparison between mPSAD and MRI-PMbdex. The MRI-PMbdex was created from 2432 men with suspected PCa; this cohort comprised the development and external validation cohorts of the Barcelona MRI predictive model. Pre-biopsy 3-Tesla multiparametric MRI (mpMRI) and 2 to 4-core transrectal ultrasound (TRUS)-guided biopsies for suspicious lesions and/or 12-core TRUS systematic biopsies were scheduled. Clinically significant PCa (csPCa), defined as Gleason-based Grade Group 2 or higher, was detected in 934 men (38.4%). The area under the curve was 0.893 (95% confidence interval [CI]: 0.880−0.906) for MRI-PMbdex and 0.764 (95% CI: 0.774−0.783) for mPSAD, with p < 0.001. MRI-PMbdex showed net benefit over biopsy in all men when the probability of csPCa was greater than 2%, while mPSAD did the same when the probability of csPCa was greater than 18%. Thresholds of 13.5% for MRI-PMbdex and 0.628 ng/mL2 for mPSAD had 95% sensitivity for csPCa and presented 51.1% specificity for MRI-PMbdex and 19.6% specificity for mPSAD, with p < 0.001. MRI-PMbdex exhibited net benefit over mPSAD in men with prostate imaging report and data system (PI-RADS) <4, while neither exhibited any benefit in men with PI-RADS 5. Hence, we can conclude that MRI-PMbdex is more accurate than mPSAD for the proper selection of candidates for prostate biopsy among men with suspected PCa, with the exception of men with a PI-RAD S 5 score, for whom neither tool exhibited clinical guidance to determine the need for biopsy.
Collapse
|
10
|
Morote J, Campistol M, Triquell M, Celma A, Regis L, de Torres I, Semidey ME, Mast R, Santamaria A, Planas J, Trilla E. Improving the Early Detection of Clinically Significant Prostate Cancer in Men in the Challenging Prostate Imaging-Reporting and Data System 3 Category. EUR UROL SUPPL 2022; 37:38-44. [PMID: 35243388 PMCID: PMC8883194 DOI: 10.1016/j.euros.2021.12.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Prostate Imaging-Reporting and Data System (PI-RADS) category 3 is a challenging scenario for detection of clinically significant prostate cancer (csPCa) and some tools can improve the selection of appropriate candidates for prostate biopsy. OBJECTIVE To assess the performance of the European Randomized Study of Screening for Prostate Cancer (ERSPC) magnetic resonance imaging (MRI) model, the new Proclarix test, and prostate-specific antigen density (PSAD) in selecting candidates for prostate biopsy among men in the PI-RADS 3 category. DESIGN SETTING AND PARTICIPANTS We conducted a head-to-head prospective analysis of 567 men suspected of having PCa for whom guided and systematic biopsies were scheduled between January 2018 and March 2020 in a single academic institution. A PI-RADS v.2 category 3 lesion was identified in 169 men (29.8%). OUTCOME MEASUREMENT AND STATISTICAL ANALYSIS csPCa, insignificant PCa (iPCa), and unnecessary biopsy rates were analysed. csPCa was defined as grade group ≥2. Receiver operating characteristic (ROC) curves, decision curve analysis curves, and clinical utility curves were plotted. RESULTS AND LIMITATIONS PCa was detected in 53/169 men (31.4%) with a PI-RADS 3 lesion, identified as csPCa in 25 (14.8%) and iPCa in 28 (16.6%). The area under the ROC curve for csPCa detection was 0.703 (95% confidence interval [CI] 0.621-0.768) for Proclarix, 0.657 (95% CI 0.547-0.766) for the ERSPC MRI model, and 0.612 (95% CI 0.497-0.727) for PSAD (p = 0.027). The threshold with the highest sensitivity was 10% for Proclarix, 1.5% for the ERSPC MRI model, and 0.07 ng/ml/cm3 for PSAD, which yielded sensitivity of 100%, 91%, and 84%, respectively. Some 21.3%, 26.2%, and 7.1% of biopsies would be avoided with Proclarix, PSAD, and the ERSPC MRI model, respectively. Proclarix showed a net benefit over PSAD and the ERSPC MRI model. Both Proclarix and PSAD reduced iPCa overdetection from 16.6% to 11.3%, while the ERSPC MRI model reduced iPCa overdetection to 15.4%. CONCLUSIONS Proclarix was more accurate in selecting appropriate candidates for prostate biopsy among men in the PI-RADS 3 category when compared to PSAD and the ERSPC MRI model. Proclarix detected 100% of csPCa cases and would reduce prostate biopsies by 21.3% and iPCa overdetection by 5.3%. PATIENT SUMMARY We compared three methods and found that the Proclarix test can optimise the detection of clinically significant prostate cancer in men with a score of 3 on the Prostate Imaging-Reporting and Data System for magnetic resonance imaging scans.
Collapse
Affiliation(s)
- Juan Morote
- Department of Urology, Vall d’Hebron Hospital, Barcelona, Spain
- Prostate Cancer Research Group, Vall d’Hebron Research Institute, Barcelona, Spain
- Department of Radiology, Vall d’Hebron Hospital, Barcelona, Spain
| | - Miriam Campistol
- Prostate Cancer Research Group, Vall d’Hebron Research Institute, Barcelona, Spain
| | - Marina Triquell
- Prostate Cancer Research Group, Vall d’Hebron Research Institute, Barcelona, Spain
| | - Anna Celma
- Department of Urology, Vall d’Hebron Hospital, Barcelona, Spain
- Prostate Cancer Research Group, Vall d’Hebron Research Institute, Barcelona, Spain
| | - Lucas Regis
- Department of Urology, Vall d’Hebron Hospital, Barcelona, Spain
- Prostate Cancer Research Group, Vall d’Hebron Research Institute, Barcelona, Spain
| | - Inés de Torres
- Prostate Cancer Research Group, Vall d’Hebron Research Institute, Barcelona, Spain
- Department of Pathology, Vall d’Hebron Hospital, Barcelona, Spain
- Universitat Autònoma of Barcelona, Barcelona, Spain
| | - Maria E. Semidey
- Prostate Cancer Research Group, Vall d’Hebron Research Institute, Barcelona, Spain
- Department of Radiology, Vall d’Hebron Hospital, Barcelona, Spain
- Department of Pathology, Vall d’Hebron Hospital, Barcelona, Spain
| | - Richard Mast
- Department of Radiology, Vall d’Hebron Hospital, Barcelona, Spain
| | - Anna Santamaria
- Prostate Cancer Research Group, Vall d’Hebron Research Institute, Barcelona, Spain
| | - Jacques Planas
- Department of Urology, Vall d’Hebron Hospital, Barcelona, Spain
- Prostate Cancer Research Group, Vall d’Hebron Research Institute, Barcelona, Spain
| | - Enrique Trilla
- Department of Urology, Vall d’Hebron Hospital, Barcelona, Spain
- Universitat Autònoma of Barcelona, Barcelona, Spain
| |
Collapse
|