Risk of prostate cancer diagnosis and mortality in men with a benign initial transrectal ultrasound-guided biopsy set: a population-based study

Modifiable risk factors for subsequent lethal prostate cancer among men with an initially negative prostate biopsy

BACKGROUND

Previously suggested modifiable risk factors for prostate cancer could have resulted from detection bias because diagnosis requires a biopsy. We investigated modifiable risk factors for a subsequent cancer diagnosis among men with an initially negative prostate biopsy.

METHODS

In total, 10,396 participants of the Health Professionals Follow-up Study with an initial negative prostate biopsy after 1994 were followed for incident prostate cancer until 2017. Potential risk factors were based on previous studies in the general population. Outcomes included localised, advanced, and lethal prostate cancer.

RESULTS

With 1851 prostate cancer cases (168 lethal) diagnosed over 23 years of follow-up, the 20-year risk of any prostate cancer diagnosis was 18.5% (95% CI: 17.7-19.3). Higher BMI and lower alcohol intake tended to be associated with lower rates of localised disease. Coffee, lycopene intake and statin use tended to be associated with lower rates of lethal prostate cancer. Results for other risk factors were less precise but compatible with and of similar direction as for men in the overall cohort.

CONCLUSIONS

Risk factors for future prostate cancer among men with a negative biopsy were generally consistent with those for the general population, supporting their validity given reduced detection bias, and could be actionable, if confirmed.

Danish Prostate Registry (DanProst) - an Updated Version of the Danish Prostate Cancer Registry, Methodology, and Early Results

In 2016, we introduced the Danish Prostate Cancer Registry (DaPCaR) which was built on the National Pathology Register from 1995 to 2011. DaPCaR was laborious to use as most data had to be manually imputed with no regular updates. In here we present a new comprehensive centralized prostate registry called the Danish Prostate Registry (DanProst), which includes all men having undergone any histological evaluation of prostate tissue merged with laboratory-, treatment-, prescription data as well as vital status. Here the data included and the methodology of DanProst are described. DanProst is built upon all men with a histological assessment of the prostate from the Danish National Registry for Pathology. The primary histology and potential prostate cancer histological diagnosis for each unique individual is extracted and translated by newly made algorithms for topography, procedure, diagnostic conclusion, and pathological staging. Further information is added from DaPCaR, the CPR Registry, the Danish Cause of Death Registry, the Danish Cancer Registry, the National Patient Registry, the Danish Register of Laboratory Results for Research, and the Danish National Prescription Registry. The translation algorithms were validated based on the comparison with DaPCaR in the period 2010-2016. DanProst includes 190,422 men. A total of 95,152 (50%) men are diagnosed with prostate cancer until 2021. Median diagnostic PSA was 11 ng/ml, most men are diagnosed by ultrasound-guided biopsy (N = 63,751; 67%), and most frequently defined primary treatment was radical prostatectomy (N = 14,778; 19%). DanProst to DaPCaR coherency was > 99%, 95%, and 94% for the primary histological procedure, primary histological conclusion, and diagnostic histological conclusion, respectively. DanProst is a continuously updated, centrally kept, validated registry with automatic integration of data from other national registries, allowing for contemporary nationwide analysis in men with histological assessment of the prostate.

Risk of prostate cancer and death after benign transurethral resection of the prostate-A 20-year population-based analysis

BACKGROUND

The oncological risks after benign histology on a transurethral resection of the prostate (TURP) remain largely unknown. Here, the risk of prostate cancer incidence and mortality following a benign histological assessment of TURP is investigated in a population-based setting.

METHODS

Between 1995 and 2016, 64,059 men in Denmark underwent TURP without prior biopsy of the prostate; 42,558 of these men had benign histology. The risks of prostate cancer, prostate cancer with a Gleason score ≥ 3 + 4, and prostate cancer-specific death were assessed with competing risks. Specific risks for pre-TURP prostate-specific antigen (PSA) levels at 10 and 15 years were visualized by locally estimated scatterplot smoothing.

RESULTS

The median age at TURP was 72 years (interquartile range [IQR], 65-78 years), and the median follow-up was 15 years (IQR, 10-19 years). The 10-year risks of any prostate cancer and prostate cancer with a Gleason score ≥ 3 + 4 and the 15-year risk of prostate cancer death showed clear visual relations with increasing PSA. The 15-year cumulative incidence of prostate cancer-specific death after benign TURP was 1.4% (95% confidence interval [CI], 1.3%-1.6%) for all men and 0.8% (95% CI, 0.6%-1.1%) for men with PSA levels <10 ng/ml. The primary limitation was exclusion due to missing PSA data.

CONCLUSIONS

Men with low PSA levels and a benign TURP can be reassured about their cancer risk and do not need to be monitored differently than any other men. Patients with high PSA levels can be considered for further follow-up with prostate magnetic resonance imaging. These findings add to the literature suggesting that normal histology from the prostate entails a low risk of death from the disease.

LAY SUMMARY

There is little knowledge about the oncological risks after the surgical treatment of benign prostatic hyperplasia. This study shows a very low risk of adverse oncological outcomes in men with prostate-specific antigen (PSA) levels below 10 ng/ml at the time of transurethral resection of the prostate. Patients with higher PSA levels may need more extensive follow-up.

Assessing the impact of MRI based diagnostics on pre-treatment disease classification and prognostic model performance in men diagnosed with new prostate cancer from an unscreened population

Introduction

Pre-treatment risk and prognostic groups are the cornerstone for deciding management in non-metastatic prostate cancer. All however, were developed in the pre-MRI era. Here we compared categorisation of cancers using either only clinical parameters or with MRI enhanced information in men referred for suspected prostate cancer from an unscreened population.

Patient and methods

Data from men referred from primary care to our diagnostic service and with both clinical (digital rectal examination [DRE] and systematic biopsies) and MRI enhanced attributes (MRI stage and combined systematic/targeted biopsies) were used for this study. Clinical vs MRI data were contrasted for clinico-pathological and risk group re-distribution using the European Association of Urology (EAU), American Urological Association (AUA) and UK National Institute for Health Care Excellence (NICE) Cambridge Prognostic Group (CPG) models. Differences were retrofitted to a population cohort with long-term prostate cancer mortality (PCM) outcomes to simulate impact on model performance. We further contrasted individualised overall survival (OS) predictions using the Predict Prostate algorithm.

Results

Data from 370 men were included (median age 66y). Pre-biopsy MRI stage reassignments occurred in 7.8% (versus DRE). Image-guided biopsies increased Grade Group 2 and ≥ Grade Group 3 assignments in 2.7% and 2.9% respectively. The main change in risk groups was more high-risk cancers (6.2% increase in the EAU and AUA system, 4.3% increase in CPG4 and 1.9% CPG5). When extrapolated to a historical population-based cohort (n = 10,139) the redistribution resulted in generally lower concordance indices for PCM. The 5-tier NICE-CPG system outperformed the 4-tier AUA and 3-tier EAU models (C Index 0.70 versus 0.65 and 0.64). Using an individualised prognostic model, changes in predicted OS were small (median difference 1% and 2% at 10- and 15-years’ respectively). Similarly, estimated treatment survival benefit changes were minimal (1% at both 10- and 15-years’ time frame).

Conclusion

MRI guided diagnostics does change pre-treatment risk groups assignments but the overall prognostic impact appears modest in men referred from unscreened populations. Particularly, when using more granular tiers or individualised prognostic models. Existing risk and prognostic models can continue to be used to counsel men about treatment option until long term survival outcomes are available.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-09955-w.

Effects of Magnetic Resonance Imaging Targeting on Overdiagnosis and Overtreatment of Prostate Cancer

BACKGROUND

It has been suggested that targeting prostate lesions identified on magnetic resonance imaging (MRI) will improve the sensitivity of prostate biopsy for high-grade disease. The clinical significance of high-grade tumors found on MRI but missed on systematic biopsy is open to question.

OBJECTIVE

To determine the risk of mortality for high-grade cancers identified by MRI targeting in men who had benign systematic biopsy findings.

DESIGN, SETTING, AND PARTICIPANTS

We used data from 999 men with negative systematic biopsy and concurrent MRI-targeted biopsy in the National Cancer Institute MRI study. The comparison group consisted of 3056 men followed for 11 yr after negative sextant biopsy in the European Randomized Trial of Screening for Prostate Cancer (ERSPC).

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

We calculated the number of patients needed to be diagnosed (NND) and treated (NNT) following targeted biopsy in order to prevent one prostate cancer death at 11 yr. We used a simple modeling approach that involved several assumptions, such as the proportion of the deaths in ERSPC preventable by earlier detection with MRI-guided biopsy. We then varied these assumptions to assess the effects on the results.

RESULTS AND LIMITATIONS

NND and NNT were 89 and 57 for the scenario involving assumptions favorable to MRI, and 169 and 127 for a more neutral set of assumptions, respectively. Results were only more encouraging for MRI targeting under unlikely scenarios, such as 100% sensitivity for MRI and a cure rate of 100% for treatment.

CONCLUSIONS

Although MRI may be of benefit overall, considering the decrease in overdiagnosis among men with negative MRI findings, targeting biopsy needles to MRI-detected lesions results in a large number of men diagnosed and treated per death prevented. Consideration should be given to changing guidelines on grading of MRI cores and those regarding treatment of MRI-detected high-grade prostate cancer.

PATIENT SUMMARY

We carried out a modeling study to assess how magnetic resonance imaging (MRI) scan results used to target prostate cancer lesions during biopsy can affect outcomes. The model results show that if MRI-visible tumors are targeted during prostate biopsy, a large number of men need to be diagnosed and treated for prostate cancer in order to avoid just one prostate cancer death.

Prostate Cancer Incidence and Mortality Following a Negative Biopsy in a Population Undergoing PSA Screening

OBJECTIVE

Transrectal ultrasound guided biopsy for diagnostic workup for prostate cancer (PCa) has a substantial false negative rate. We sought to estimate PCa incidence and mortality following negative biopsy in a cohort of men undergoing prostate cancer screening.

SUBJECTS AND METHODS

The Prostate, Lung, Colorectal and Ovarian (PLCO) cancer screening trial randomized participants 55-74 years to an intervention vs control arm. Intervention arm men received annual prostate-specific antigen (PSA) tests for 6 years and digital rectal exams (DRE) for 4 years. We examined the cohort of men with a positive PSA (> 4 ng/mL) or DRE screen followed within one year by a negative biopsy. PCa incidence and mortality rates from time of first negative biopsy were analyzed as a function of PSA level at diagnosis and other factors. Cumulative incidence and mortality rates accounting for competing risk were estimated. Multivariate proportional hazards regression was utilized to estimate hazard ratios (HRs) of PCa outcomes by PSA level, controlling for age and race.

RESULTS

The negative biopsy cohort included 2855 men. Median (25th/75th) age at biopsy was 65 (61/69) years; biopsies occurred between 1994 and 2006. Median (25/75th) follow-up was 13.2 (6.5/16.8) years for incidence and 16.6 (12.3/19.2) years for mortality. 740 PCa cases were diagnosed, with 33 PCa deaths. Overall 20-year cumulative PCa incidence and mortality rates were 26.4% (95% CI: 24.8-28.1) and 1.2% (95% CI: 0.9-1.7), respectively. HRs for PCa incidence and mortality increased significantly with increasing PSA.

CONCLUSION

The mortality rate from PCa through 20 years following a negative biopsy is low.

Risk stratification in men with a negative prostate biopsy: an interim analysis of a prospective cohort study

OBJECTIVE

To investigate whether a risk score for prostate cancer (PCa) lifetime risk can be used to optimise triaging of patients with a negative prostate biopsy, but under sustained suspicion of PCa.

PATIENTS AND METHODS

In this prospective clinical study, we included, and risk scored patients who had a PCa-negative transrectal ultrasonography (TRUS)-guided prostate biopsy, but elevated prostate-specific antigen (PSA), a suspicious prostate digital rectal examination and/or a positive family history (FH) of PCa. The risk score estimated individual lifetime risk of PCa, based on a polygenic risk score (33 single nucleotide polymorphisms), age, and FH of PCa. Patients were followed, under urological supervision, for up to 4 years with annual controls, always including PSA measurements. Multiparametric magnetic resonance imaging (mpMRI) and/or prostate biopsy was performed at selected annual controls depending on risk score and at the urologist's/patient's discretion, which means that the follow-up differed based on the risk score.

RESULTS

We included 429 patients. After risk scoring, 376/429 (88%) patients were allocated to a normal-risk group (<30% PCa lifetime risk) and 53/429 (12%) to a high-risk group (≥30% PCa lifetime risk). The high-risk group had significantly different follow-up, with more biopsy and mpMRI sessions compared to the normal-risk group. PCa was detected in 89/429 (21%) patients, with 67/376 (18%) patients diagnosed in the normal-risk group and 22/53 (42%) in the high-risk group. There was no statistically significant difference in the cumulative incidence of PCa between the normal-risk group and the high-risk group after 4 years of follow-up. Currently, 67/429 (16%) patients are still being followed in this ongoing study.

CONCLUSION

In a 4-year perspective, our PCa lifetime risk score did not demonstrate significant prognostic value for triaging patients, with a negative TRUS-guided biopsy and sustained suspicion of PCa.

18F-choline PET/computed tomography and clinical parameters in the detection of significant prostate cancer in patients with increased prostate-specific antigen levels and previous negative biopsies

OBJECTIVES

The aim of this study is to assess the value of the F-choline PET/computed tomography (CT) in predicting significant prostate cancer (sPCa) in patients with persistently increased prostate-specific antigen (PSA) levels and previous negative biopsies. To study the possible predictive added value of F-choline PET/CT to clinical variables and biomarkers derived from PSA in detecting sPCa.

METHODS

We evaluated patients who underwent F-choline PET/CT because of ongoing suspicion of prostate cancer (PCa) due to elevated PSA levels (4-20 ng/mL) and at least one previous negative or no conclusive prostate biopsy for PCa. Age, PSA, free PSA, free/total PSA ratio, PSA velocity, PSA doubling time, PSA density and score risk were obtained. F-choline PET/CT was classified as negative/positive (PET-categorical). Additionally, we subclassified F-choline PET/CT according to the radiotracer uptake patterns (PET-pattern). The reference standard was the histological confirmation. Accuracy of PET/CT was evaluated. Univariate and multivariate logistic regression analyses were performed for metabolic and clinical variables.

RESULTS

A total of 78 patients were included in our study, 23 had PCa (15 with sPCa). The PET pattern showed the highest accuracy and was the most powerful predictor of sPCa. In this research, the prediction of sPCa was improved combining PET pattern and score risk.

CONCLUSION

F-choline PET/CT is a potential tool for predicting sPCa in patients with persistently increased PSA levels and previous negative biopsies, and also it could improve the performance of score risk in predicting sPCa.

What is the risk of prostate cancer mortality following negative systematic TRUS-guided biopsies? A systematic review

OBJECTIVE

To investigate the risk of prostate cancer-specific mortality (PCSM) following initial negative systematic transrectal ultrasound-guided (TRUS) prostate biopsies.

DESIGN

Systematic review.

DATA SOURCES

PubMed and Embase were searched using a string combination with keywords/Medical Subject Headings terms and free text in the search builder. Date of search was 13 April 2020.

STUDY SELECTION

Studies addressing PCSM following initial negative TRUS biopsies. Randomised controlled trials and population-based studies including men with initial negative TRUS biopsies reported in English from 1990 until present were included.

DATA EXTRACTION

Data extraction was done using a predefined form by two authors independently and compared with confirm data; risk of bias was assessed using the Newcastle-Ottawa Scale for cohort studies when applicable.

RESULTS

Four eligible studies were identified. Outcomes were reported differently in the studies as both cumulative incidence and Kaplan-Meier estimates have been used. Regardless of the study differences, all studies reported low estimated incidence of PCSM of 1.8%-5.2% in men with negative TRUS biopsies during the following 10-20 years. Main limitation in all studies was limited follow-up.

CONCLUSION

Only a few studies have investigated the risk of PCSM following initial negative biopsies and all studies included patients before the era of MRI of the prostate. However, the studies point to the fact that the risk of PCSM is low following initial negative TRUS biopsies, and that the level of prostate-specific antigen before biopsies holds prognostic information. This may be considered when advising patients about the need for further diagnostic evaluation.

PROSPERO REGISTRATION NUMBER

CRD42019134548.

Routine Use of Magnetic Resonance Imaging for Early Detection of Prostate Cancer Is Not Justified by the Clinical Trial Evidence

Guidelines now recommend multiparametric magnetic resonance imaging before prostate biopsy in the work-up for patients with elevated prostate specific-antigen. However, use of magnetic resonance imaging for early detection of prostate cancer is not justified by the clinical trial evidence.

First-in-human study of anticancer immunotherapy drug candidate mobilan: safety, pharmacokinetics and pharmacodynamics in prostate cancer patients

Toll-like receptor 5 (TLR5) controls endogenous immune responses to pathogens and is a promising target for pharmacological stimulation of anti-tumor immunity. Mobilan is an innovative gene therapy agent consisting of a non-replicating bicistronic adenovirus directing constitutive expression of human Toll-like receptor 5 (TLR5) and the secreted flagellin-based TLR5 agonist, 502s. In mice, Mobilan injection into prostate tumors resulted in autocrine TLR5 signaling, immune system activation, and suppression of tumor growth and metastasis. Here we report a first-in-human placebo-controlled clinical study of Mobilan aimed at evaluating safety, tolerability, pharmacokinetics and pharmacodynamics of a single intra-prostate injection of Mobilan in early stage prostate cancer patients. Mobilan was safe and well-tolerated at all tested doses; thus, the maximum tolerated dose was not identified. Injection of Mobilan induced signs of self-resolving inflammation not present in placebo-injected patients, including transient elevation of PSA and cytokine (G-CSF, IL-6) levels, and increased lymphoid infiltration in prostate tissue. The highest dose of Mobilan (10¹¹ viral particles) produced the best combination of safety and pharmacodynamic effects. Therefore, Mobilan is well-tolerated and induces the expected pharmacodynamic response in humans. These results support further clinical development of Mobilan as a novel immunotherapy for prostate cancer.

Educational level and first-time PSA testing in general practice

Introduction: Different patterns in the use of prostate-specific antigen (PSA) testing might explain socioeconomic differences in prostate cancer incidence and mortality. We examined the association between socioeconomic position, measured as education and first-time PSA testing in general practice.Material and Methods: A population-based cohort study of men aged 45-79 years without prior prostate cancer diagnosis living in the Capital Region of Denmark between 2000 and 2014. Information on socioeconomic indicators (education, income, cohabitation status and work market affiliation), prostate cancer diagnoses, and vital status were obtained from national registries. Date of first PSA test was obtained from the Copenhagen Primary Care Laboratory database. Temporal trends of PSA testing were calculated as annual age-standardised incidence rates and the association was examined by a multivariable Cox proportional hazards model.Results: The cohort consists of 431,997 men of which 105,476 (24%) had a first-time PSA test in the study period. Men with longer education, higher income, living with a partner, and employed had higher rates of PSA testing. For men with short education, the rate of PSA test was 28.3 tests per 1000 person-years compared to 31.2 tests among men with long education. The fully adjusted hazard ratio for a first PSA test among men with short education was 0.87 (95% CI, 0.85-0.89) compared to men with long education.Conclusion: The association between education and first-time PSA testing indicates socioeconomic disparities in health care utilisation, which could explain part of the observed socioeconomic difference in prostate cancer incidence and mortality.

DNA methylation in repeat negative prostate biopsies as a marker of missed prostate cancer

Background

Men often undergo repeat prostate biopsies because of suspicion of missed cancer. We assessed if (i) methylation of selected genes in prostate tissue vary with aging and (ii) methylation alterations in repeat biopsies predict missed prostate cancer.

Methods

We conducted a case-control study among men who underwent at least two negative prostate biopsies followed by a sampling either positive (cases n = 111) or negative (controls n = 129) for prostate cancer between 1995 and 2014 at the University Hospital (Turin, Italy). Two pathology wards were included for replication purposes. We analyzed methylation of GSTP1, APC, PITX2, C1orf114, GABRE, and LINE-1 in the first two negative biopsies. Conditional logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) of the association between genes methylation and prostate cancer.

Results

Age at biopsy and time interval between the two negative biopsies were not associated with methylation levels of the selected genes in neither cases nor controls. GSTP1 methylation in the first and in the second negative biopsy was associated with prostate cancer detection [OR per 1% increase: 1.14 (95% CI 1.01–1.29) for the second biopsy and 1.21 (95% CI 1.07–1.37) for the highest methylation level (first or second biopsy)]. A threshold > 10% for GSTP1 methylation corresponded to a specificity of 0.98 (positive likelihood ratio 7.87). No clear association was found for the other genes. Results were consistent between wards.

Conclusions

Our results suggest that GSTP1 methylation in negative prostate biopsies is stable over time and can predict missed cancer with high specificity.

Developing an effective strategy to improve the detection of significant prostate cancer by combining the 4Kscore and multiparametric MRI

OBJECTIVES

Recent years have seen the development of biomarkers and imaging technologies designed to improve the specificity of PSA. Widespread implementation of imaging technologies, such as mp-MRI raises considerable logistical challenges. Our objective was to evaluate a biopsy strategy that utilizes selective mp-MRI as a follow-up test to biomarkers to improve the detection of significant prostate cancer.

METHODS AND MATERIALS

We developed a conceptual approach based on the risk calculated from the 4Kscore using results from the US prospective validation study, multiplied by the likelihood ratio of mp-MRI from the PROMIS trial. The primary outcome was Gleason grade ≥ 7 (grade group ≥ 2) cancer on biopsy. Using decision curve analysis, the net benefit was determined for our model and compared with the use of the 4Kscore and mp-MRI independently at various thresholds for biopsy.

RESULTS

For a cut-point of 7.5% risk of high-grade disease, patients with <5% risk from a blood marker would not have risk of significant prostate cancer sufficiently increased by a positive mp-MRI to warrant biopsy; comparably, patients with a risk >23% would not have risk sufficiently reduced by a negative imaging study to forgo biopsy. From the 4Kscore validation study, 46% of men considered for biopsy in the US have risks 5% to 23%. Net benefit was highest for the combined strategy, followed by 4Kscore alone.

CONCLUSIONS

Selective mp-MRI in men with intermediate scores on a secondary blood test results in a biopsy strategy that is more scalable than mp-MRI for all men with elevated PSA. Prospective validation is required to demonstrate if the predicted properties of combined blood and imaging testing are empirically confirmed.

Analysis of PI-RADS 4 cases: Management recommendations for negatively biopsied patients

PURPOSE

To evaluate if subgroups of patients assigned to MRI category PI-RADS 4 regarding clinical and MRI imaging aspects have distinct risks of prostate cancer (PCa) to facilitate adequate clinical management of this population, especially after negative targeted biopsy.

METHODS

This prospective, IRB approved single center cross-sectional study includes 931 consecutive patients after mp-MRI at 3 T for PCa detection. 193 patients with PI-RADS assessment category 4 received subsequent combined targeted MRI/US fusion-guided and systematic 12-core TRUS-guided biopsy as reference standard and were finally analyzed. The primary endpoint was PCa detection of PI-RADS 4 with MRI subgroup analyses. Secondary endpoints were analyses of clinical data, location of PCa, and detection of targeted biopsy cores.

RESULTS

PCa was detected in 119 of 193 patients (62%) including clinically significant PCa (csPCa; Gleason score ≥3 + 4 = 7) in 92 patients (48%). MRI subgroup analysis revealed 95% PCa (73% csPCa) in unambiguous PI-RADS 4 index lesions without additional, interfering signs of prostatitis in the peripheral zone or overlaying signs of severe stromal hyperplasia in the transition zone according to PI-RADS v2. Transition zone confined PI-RADS-4-lesions with overlaying signs of stromal hyperplasia showed PCa only in 11% (4% csPCa). Targeted biopsy cores missed the csPCa index lesion in 7% of the patients. PSA density (PSAD) was significantly higher in PCa patients.

CONCLUSIONS

Small csPCa can reliably be detected with mp-MRI by experienced readers, but can be missed by targeted MR/US fusion biopsy alone. Targeted re-biopsy of unambiguous (peripheral) PI-RADS-4-lesions is recommended; whereas transition zone confined PI-RADS-4-lesions with overlaying signs of stromal hyperplasia might be followed-up by re-MRI primarily.

Individual prognosis at diagnosis in nonmetastatic prostate cancer: Development and external validation of the PREDICT Prostate multivariable model

BACKGROUND

Prognostic stratification is the cornerstone of management in nonmetastatic prostate cancer (PCa). However, existing prognostic models are inadequate-often using treatment outcomes rather than survival, stratifying by broad heterogeneous groups and using heavily treated cohorts. To address this unmet need, we developed an individualised prognostic model that contextualises PCa-specific mortality (PCSM) against other cause mortality, and estimates the impact of treatment on survival.

METHODS AND FINDINGS

Using records from the United Kingdom National Cancer Registration and Analysis Service (NCRAS), data were collated for 10,089 men diagnosed with nonmetastatic PCa between 2000 and 2010 in Eastern England. Median follow-up was 9.8 years with 3,829 deaths (1,202 PCa specific). Totals of 19.8%, 14.1%, 34.6%, and 31.5% of men underwent conservative management, prostatectomy, radiotherapy (RT), and androgen deprivation monotherapy, respectively. A total of 2,546 men diagnosed in Singapore over a similar time period represented an external validation cohort. Data were randomly split 70:30 into model development and validation cohorts. Fifteen-year PCSM and non-PCa mortality (NPCM) were explored using separate multivariable Cox models within a competing risks framework. Fractional polynomials (FPs) were utilised to fit continuous variables and baseline hazards. Model accuracy was assessed by discrimination and calibration using the Harrell C-index and chi-squared goodness of fit, respectively, within both validation cohorts. A multivariable model estimating individualised 10- and 15-year survival outcomes was constructed combining age, prostate-specific antigen (PSA), histological grade, biopsy core involvement, stage, and primary treatment, which were each independent prognostic factors for PCSM, and age and comorbidity, which were prognostic for NPCM. The model demonstrated good discrimination, with a C-index of 0.84 (95% CI: 0.82-0.86) and 0.84 (95% CI: 0.80-0.87) for 15-year PCSM in the UK and Singapore validation cohorts, respectively, comparing favourably to international risk-stratification criteria. Discrimination was maintained for overall mortality, with C-index 0.77 (95% CI: 0.75-0.78) and 0.76 (95% CI: 0.73-0.78). The model was well calibrated with no significant difference between predicted and observed PCa-specific (p = 0.19) or overall deaths (p = 0.43) in the UK cohort. Key study limitations were a relatively small external validation cohort, an inability to account for delayed changes to treatment beyond 12 months, and an absence of tumour-stage subclassifications.

CONCLUSIONS

'PREDICT Prostate' is an individualised multivariable PCa prognostic model built from baseline diagnostic information and the first to our knowledge that models potential treatment benefits on overall survival. Prognostic power is high despite using only routinely collected clinicopathological information.

Prostate Cancer: Treatments and Diagnosis

Prostate cancer is a disease in which malignant (cancer) cells form in the tissues of the prostate. Prostate tumors were responsible for nearly six thousand deaths in Spain in 2016 as the symptoms are very silent and appear like advanced cancer or when this cancer has proliferated to other organs and senses. Therefore, there are 4 characteristic stages of this type of cancer that are classified according to their extension in the body. To make the diagnosis of this type of disease there are methods that in many cases show to be effective and in others not depending on the stage in which you are. Therefore, the number of treatments against prostate cancer has been increasing over the years from medications that help prevent tumor proliferation to strong surgeries. These treatments are not a solution to fight cancer, they simply have the function of maintaining cancer and its proliferation in order to generate a suitable lifestyle for patients for a time. Currently, several investigations have focused on combating prostate cancer through clinical trials that promise to generate favorable and acceptable solutions for patients.

Population-based outcomes of men with a single negative prostate biopsy: Importance of continued follow-up among older patients

PURPOSE

To determine in Ontario-based men with a single negative transrectal ultrasound-guided prostate biopsy the long-term rates of prostate cancer-specific mortality, diagnosis, and treatment; number of repeat biopsies; and predictors of prostate cancer diagnosis and mortality.

MATERIALS AND METHODS

This was a population-based cohort study, using data from linked, validated health administrative databases, of all Ontario-based men with a negative first biopsy between January 1994 and October 2014. Patients were followed from time of first biopsy till death, administrative censoring, or end of study period. Cumulative incidence functions were used to calculate the study outcomes' cumulative incidences. Univariable and multivariable regression analyses using Fine and Gray's semiparametric proportional hazards model were used to assess predictors of prostate cancer diagnosis and mortality.

RESULTS

The study cohort included 95,675 men with a median age of 63.0years. Median follow-up was 8.1years. The 20-year cumulative rates of prostate cancer-specific mortality and diagnosis were 1.8% and 23.7%, respectively. Men ages 70 to 79 and 80 to 84 at initial biopsy had 20-year prostate cancer-specific mortality cumulative rates of 3.2% and 6.4% respectively. The 20-year cumulative rate of receiving radical prostatectomy was 7.6%. Higher socioeconomic status and urban residence were associated with higher diagnosis risks yet lower prostate cancer-specific mortality risks.

CONCLUSIONS

This is the first population-based study assessing long-term cancer outcomes in North American men with a single negative transrectal ultrasound-guided prostate biopsy. Following a negative initial biopsy, 23.7% of men are still diagnosed with and 1.8% die of prostate cancer within 20years. Cancer-specific mortality outcomes are significantly worse in older men, with prostate cancer mortality rates several times higher than the rest of the population.

Progression and treatment rates using an active surveillance protocol incorporating image-guided baseline biopsies and multiparametric magnetic resonance imaging monitoring for men with favourable-risk prostate cancer

OBJECTIVE

To assess early outcomes since the introduction of an active surveillance (AS) protocol incorporating multiparametric magnetic resonance imaging (mpMRI)-guided baseline biopsies and image-based surveillance.

PATIENTS AND METHODS

A new AS protocol mandating image-guided baseline biopsies, annual mpMRI and 3-monthly prostate-specific antigen (PSA) testing, but which retained protocol re-biopsies, was tested. Pathological progression, treatment conversion and triggers for non-protocol biopsy were recorded prospectively.

RESULTS

Data from 157 men enrolled in the AS protocol (median age 64 years, PSA 6.8 ng/mL, follow-up 39 months) were interrogated. A total of 12 men (7.6%) left the AS programme by choice. Of the 145 men who remained, 104 had re-biopsies either triggered by a rise in PSA level, change in mpMRI findings or by protocol. Overall, 23 men (15.9%) experienced disease progression; pathological changes were observed in 20 men and changes in imaging results were observed in three men. Of these 23 men, 17 switched to treatment, giving a conversion rate of 11.7% (<4% per year). Of the 20 men with pathological progression, this was detected in four of them after a PSA increase triggered a re-biopsy, while in 10 men progression was detected after an mpMRI change. Progression was detected in six men, however, solely after a protocol re-biopsy without prior PSA or mpMRI changes. Using PSA and mpMRI changes alone to detect progression was found to have a sensitivity and specificity of 70.0% and 81.7%, respectively.

CONCLUSION

Our AS protocol, with thorough baseline assessment and imaging-based surveillance, showed low rates of progression and treatment conversion. Changes in mpMRI findings were the principle trigger for detecting progression by imaging alone or pathologically; however, per protocol re-biopsy still detected a significant number of pathological progressions without mpMRI or PSA changes.

Multicentre evaluation of magnetic resonance imaging supported transperineal prostate biopsy in biopsy-naïve men with suspicion of prostate cancer

OBJECTIVES

To analyse the detection rates of primary magnetic resonance imaging (MRI)-fusion transperineal prostate biopsy using combined targeted and systematic core distribution in three tertiary referral centres.

PATIENTS AND METHODS

In this multicentre, prospective outcome study, 807 consecutive biopsy-naïve patients underwent MRI-guided transperineal prostate biopsy, as the first diagnostic intervention, between 10/2012 and 05/2016. MRI was reported following the Prostate Imaging-Reporting and Data System (PI-RADS) criteria. In all, 236 patients had 18-24 systematic transperineal biopsies only, and 571 patients underwent additional targeted biopsies either by MRI-fusion or cognitive targeting if PI-RADS ≥3 lesions were present. Detection rates for any and Gleason score 7-10 cancer in targeted and overall biopsy were calculated and predictive values were calculated for different PI-RADS and PSA density (PSAD) groups.

RESULTS

Cancer was detected in 68% of the patients (546/807) and Gleason score 7-10 cancer in 49% (392/807). The negative predictive value of 236 PI-RADS 1-2 MRI in combination with PSAD of <0.1 ng/mL/mL for Gleason score 7-10 was 0.91 (95% confidence interval ± 0.07, 8% of study population). In 418 patients with PI-RADS 4-5 lesions using targeted plus systematic biopsies, the cancer detection rate of Gleason score 7-10 was significantly higher at 71% vs 59% and 61% with either approach alone (P < 0.001). For 153 PI-RADS 3 lesions, the detection rate was 31% with no significant difference to systematic biopsies with 27% (P > 0.05). Limitations include variability of multiparametric MRI (mpMRI) reading and Gleason grading.

CONCLUSION

MRI-based transperineal biopsy performed at high-volume tertiary care centres with a significant experience of prostate mpMRI and image-guided targeted biopsies yielded high detection rates of Gleason score 7-10 cancer. Prostate biopsies may not be needed for men with low PSAD and an unsuspicious MRI. In patients with high probability lesions, combined targeted and systematic biopsies are recommended.

The role of the multiparametric MRI in the diagnosis of prostate cancer in biopsy-naïve men

PURPOSE OF REVIEW

To review the role of prebiopsy multiparametric MRI in biopsy-naïve men for the detection of clinically significant prostate cancer.

RECENT FINDINGS

Recent level 1 evidence shows that multiparametric MRI has high sensitivity and negative predictive value for the detection of clinically significant prostate cancer in biopsy-naïve men. Concurrent developments include important work in the standardization of MRI reporting. The low specificity and positive predictive value of MRI means that biopsy is still necessary following MRI. MRI-targeted prostate biopsy has emerged as an alternative diagnostic test to transrectal ultrasound guided prostate biopsy, though its exact role in biopsy-naïve men and the optimal technique remain to be defined.

SUMMARY

There is the potential for MRI to be used as a triage test to allow a proportion of men to avoid biopsy and remain on prostate-specific antigen surveillance. MRI-suspicious areas can be sampled more intensively using MRI-targeted biopsy that can be carried out in a variety of ways. Future work should focus on the cost-effectiveness of introducing a prebiopsy MRI pathway in biopsy-naïve men and addressing the training needs for such a change. VIDEO ABSTRACT: http://links.lww.com/COU/A11.

Stopping screening, when and how?

Screening for prostate cancer (PC) is still controversial despite randomized trials has found that PC mortality is decreased. The major concern is the high rate of over-diagnosis and subsequent harms that may follow in many men who never would have had any symptoms during life-time if not screened. The high rate of over-diagnosis is driven by the large reservoir of small non-significant cancers that increases with age and found in more than half of men over 70 years, the low specificity of prostate specific antigen (PSA) but also by current "blind" biopsy technique that risk accidentally to hit these small non-significant cancers. The risk of over-diagnosis is increasing with age and the trade-off by screening men in high age is probably higher. At what age harms exceeds benefits is not established but modelling studies has demonstrated that after 65-70 years the quality adjusted life-years (QALYs) gained are decreasing but still on the positive side if screening is continued up to 75 years. A dilemma is that most PC deaths occur in men after the age 80 and the effect of screening seems not to last as long as was thought, already 10 years after termination of screening PC mortality has caught up in the screening arm to a level similar to that in the control group. In the European Randomised Study of Screening for Prostate Cancer (ERSPC) screening was terminated between 71 and 75 years and the first effect of screening on mortality was discernible after 7 years and has been relatively stable around 20% since 9 years after study start. It seems questionable from any standpoint to invite men for screening with an expected life length below 10 years, which is the expected life-length of an averaged 78-year-old man in 2018. However, the balance between harms and benefits specifically in the age 70-80 need more attention as also costs need. Permanent side-effects from (unnecessary) treatments and their impact on quality of life must be evaluated better and related to age and individual variations. In future better screening methods with more specific markers and introduction of imaging will hopefully decrease the present large risk of over-diagnosis in elderly men and thereby expand efficient screening to men in the age group >70 who actually is the high risk group of dying from PC.

The use of transrectal ultrasound-guided biopsy following the introduction of prostate-specific antigen testing in Denmark: a population-based analysis

OBJECTIVE

Incidence rates of prostate cancer in Denmark resemble those of countries that endorse prostate-specific antigen (PSA) screening. So far, no studies have described the consequences of PSA testing on diagnostic activity on a population level. The aim of this study was to describe the frequency of systematic transrectal ultrasound-guided biopsy (TRUS-gb) activity, including rebiopsy rates, in Denmark between 1995 and 2011.

MATERIALS AND METHODS

All men who underwent TRUS-gb during the period were identified in the Danish Prostate Cancer Registry. In total, 83,041 biopsy sets from 64,430 individuals were identified. The diagnostic rate and the frequency of rebiopsy were analyzed. Age, histology and PSA were compared at the time of biopsy.

RESULTS

The number of TRUS-gb per 100,000 men per year increased 4.6-fold. The mean number of TRUS-gb procedures per individual increased from 1.08 in 1995 to 1.46 in 2011 (p = .0001), and the proportion of men with negative initial biopsy sets who underwent rebiopsy increased from 22% in 1995 to 41% in 2004, later decreasing to 31% in 2009.

CONCLUSIONS

The diagnostic activity in Denmark and the rebiopsy rates in men with initial negative TRUS-gb have increased substantially, and guidelines for the management of men with a negative initial biopsy are highly warranted.

Magnetic resonance imaging in the early detection of prostate cancer and review of the literature on magnetic resonance imaging-stratified clinical pathways

INTRODUCTION

With level 1 evidence now available on the diagnostic accuracy of multiparametric magnetic resonance imaging (MRI) we must now utilise this data in developing an MRI-stratified diagnostic pathway for the early detection of prostate cancer. Areas covered: A literature review was conducted and identified seven randomised control trials (RCT's) assessing the diagnostic accuracy of such a pathway against the previously accepted systematic/random trans-rectal ultrasound guided (TRUS) biopsy pathway. The studies were heterogeneous in their design. Five studies assessed the addition of MRI-targeted biopsies to a standard care systematic TRUS biopsy pathway. Three of these studies showed either an increase in their diagnostic accuracy or the potential to remove systematic biopsies. Two studies looked specifically at a targeted biopsy only pathway and although the results were again mixed, there was no decrease in the diagnostic rate and overall significantly fewer biopsy cores were taken in the MRI group. Expert commentary: Results from these RCT's together with multiple retrospective and prospective studies point towards either an improved diagnostic rate for clinically significant cancer and/or a reduction in the need for systematic biopsies with a MRI-stratified pathway. The challenge for the urological community will be to implement pre-biopsy MRI into a routine clinical pathway with likely independent monitoring of standards.

Serum metabolomics can predict the outcome of first systematic transrectal prostate biopsy in patients with PSA <10 ng/ml

AIM

To assess the predictive value of metabolomic analysis for the presence of prostate cancer (PCa) at first systematic biopsy.

PATIENTS & METHODS

Ninety serum samples from patients with suspicion for PCa were included. Targeted and nontargeted metabolomic analysis was performed.

RESULTS

Six metabolites were combined into a predictive score. A cutoff value of 0.528 for the metabolomic score showed a good accuracy for the prediction of PCa at biopsy (Area under the curve (AUC): 0.779; p < 0.001). These results were validated in a subgroup of patients, showing similar accuracy (p = 0.1). For patients with prostate specific antigen (PSA) less than 10 ng/ml, the score showed a Se 80.95%, Sp 64.52% for the detection of PCa at biopsy.

CONCLUSION

Metabolomic analysis can predict the outcome of the first systematic biopsy.

Diagnostic value of MRI-based PSA density in predicting transperineal sector-guided prostate biopsy outcomes

PURPOSE

Prostate-specific antigen (PSA) density (PSAD) has potential to increase the diagnostic utility of PSA, yet has had poor uptake in clinical practice. We aimed to determine the diagnostic value of magnetic resonance imaging-derived PSAD (MR-PSAD) in predicting transperineal sector-guided prostate biopsy (TPSB) outcomes.

MATERIALS AND METHODS

Men presenting for primary TPSB from 2007 to 2014 were considered. Histological outcomes were assessed and defined as: presence of any cancer or significant cancer defined as presence of Gleason 4 and/or maximum tumour core length (MCCL) ≥ 4 mm (G4); or Gleason 4 and/or MCCL ≥ 6 mm (G6). Sensitivity, specificity and positive and negative predictive values were calculated, and receiver operating characteristics (ROC) curves were generated to compare MR-PSAD and PSA.

RESULTS

Six hundred fifty-nine men were evaluated with mean age 62.5 ± 9 years, median PSA 6.7 ng/ml (range 0.5-40.0), prostate volume 40 cc (range 7-187) and MR-PSAD 0.15 ng/ml/cc (range 0.019-1.3). ROC area under the curve (95% CI) was significantly better for MR-PSAD than PSA for all cancer definitions (p < 0.001): 0.73 (0.70-0.76) versus 0.61 (0.57-0.64) for any cancer; 0.75 (0.71-0.78) versus 0.66 (0.62-0.69) for G4; and 0.77 (0.74-0.80) versus 0.68 (0.64-0.71) for G6. Sensitivities for MR-PSAD < 0.1 ng/ml/cc were 85.0, 89.9 and 91.9% for any, G4 and G6 cancer, respectively.

CONCLUSION

MR-PSAD may be better than total PSA in determining risk of positive biopsy outcome. Its use may improve risk stratification and reduce unnecessary biopsies.