Presentation of Benefits and Harms in US Cancer Screening and Prevention Guidelines: Systematic Review

[Diagnostic efficacy of targeted biopsy combined with regional systematic biopsy in prostate cancer in patients with PI-RADS 4-5]

OBJECTIVE

To investigate the diagnostic efficacy of targeted biopsy combined with regional systematic biopsy in prostate cancer (PCa) in patients with prostate imaging reporting and data system v2.1 (PI-RADS v2.1) 4-5.

METHODS

From January 2023 to October 2023, patients who underwent prostate biopsy for the first time with total prostate specific antigen (tPSA) ≤ 20 ng/mL and had a multi-parametric magnetic resonance imaging (mpMRI) PI-RADS of 4-5 in Peking University First Hospital were prospectively collected. All the patients underwent transrectal ultrasound-guided cognitive fusion targeted biopsy (3 cores) followed by systematic biopsy (12 cores). Various hypothetical biopsy schemes were defined based on different biopsy sites. The detection effectiveness of targeted biopsy combined with regional systematic biopsy and other biopsy schemes for prostate cancer were compared using Cochran's Q and McNemar tests.

RESULTS

A total of 255 patients were enrolled, of whom 204 (80.0%) were detected with prostate adenocarcinoma and 187 (73.3%) were clinically significant with prostate cancer (csPCa). The detection rate of PCa with targeted biopsy was significantly lower than that of targeted biopsy combined with 12-core system biopsy (77.3% vs. 80.0%, P=0.016), and 71.4% (5/7) of the missed patients was csPCa. There was no significant difference in the detection rate between targeted biopsy combined with 4-core regional system biopsy and 12-core system biopsy (P>0.999), and 1 case of csPCa and clinically insignificant prostate cancer (cisPCa) were missed. There was no significant difference in the detection rate of PCa between targeted combined regional system biopsy and targeted combined lateral or traditional 6-core system biopsy and the number of cores were reduced. Missed diagnosis of targeted biopsy was correlated with the maximum diameter of the lesion (OR=0.086, 95%CI: 0.013-0.562, P=0.010). For the patients with PI-RADS 5, only 1 case of PCa was missed in 122 cases by targeted biopsy alone. For patients with PI-RADS 4, 6 PCa cases were missed among the 133 patients with targeted biopsy alone, and 1 case of csPCa and cisPCa were missed by targeted biopsy combined with regional system biopsy. The statistics of positive core counts for different biopsy schemes indicated that targeted combined regional systematic biopsy had a higher proportion of positive cores second only to targeted biopsy alone.

CONCLUSION

Targeted biopsy combined with regional systematic biopsy has high diagnostic efficacy in patients with PI-RADS 4-5 and can be considered as one of the improved schemes for combined biopsy. Targeted biopsy alone is also a feasible option for patients for patients with a PI-RADS score of 5.

Deaths and cardiopulmonary events following colorectal cancer screening-A systematic review with meta-analyses

BACKGROUND

Colorectal cancer screening programmes (CRCSPs) are implemented worldwide despite recent evidence indicating more physical harm occurring during CRCSPs than previously thought. Therefore, we aimed to review the evidence on physical harms associated with endoscopic diagnostic procedures during CRCSPs and, when possible, to quantify the risk of the most serious types of physical harm during CRCSPs, i.e. deaths and cardiopulmonary events (CPEs).

METHODS

Systematic review with descriptive statistics and random-effects meta-analyses of studies investigating physical harms following CRCSPs. We conducted a systematic search in the literature and assessed the risk of bias and the certainty of the evidence.

RESULTS

We included 134 studies for review, reporting findings from 151 unique populations when accounting for multiple screening interventions per study. Physical harm can be categorized into 17 types of harm. The evidence was very heterogeneous with inadequate measurement and reporting of harms. The risk of bias was serious or critical in 95% of assessments of deaths and CPEs, and the certainty of the evidence was very low in all analyses. The risk of death was assessed for 57 populations with large variation across studies. Meta-analyses indicated that 3 to 23 deaths occur during CRCSPs per 100,000 people screened. Cardiopulmonary events were assessed for 55 populations. Despite our efforts to subcategorize CPEs into 17 distinct subtypes, 41% of CPE assessments were too poorly measured or reported to allow quantification. We found a tendency towards lower estimates of deaths and CPEs in studies with a critical risk of bias.

DISCUSSION

Deaths and CPEs during CRCSPs are rare, yet they do occur during CRCSPs. We believe that our findings are conservative due to the heterogeneity and low quality of the evidence. A standardized system for the measurement and reporting of the harms of screening is warranted.

TRIAL REGISTRATION

PROSPERO Registration number CRD42017058844.

Rates of Downstream Procedures and Complications Associated With Lung Cancer Screening in Routine Clinical Practice : A Retrospective Cohort Study

BACKGROUND

Lung cancer screening (LCS) using low-dose computed tomography (LDCT) reduces lung cancer mortality but can lead to downstream procedures, complications, and other potential harms. Estimates of these events outside NLST (National Lung Screening Trial) have been variable and lacked evaluation by screening result, which allows more direct comparison with trials.

OBJECTIVE

To identify rates of downstream procedures and complications associated with LCS.

DESIGN

Retrospective cohort study.

SETTING

5 U.S. health care systems.

PATIENTS

Individuals who completed a baseline LDCT scan for LCS between 2014 and 2018.

MEASUREMENTS

Outcomes included downstream imaging, invasive diagnostic procedures, and procedural complications. For each, absolute rates were calculated overall and stratified by screening result and by lung cancer detection, and positive and negative predictive values were calculated.

RESULTS

Among the 9266 screened patients, 1472 (15.9%) had a baseline LDCT scan showing abnormalities, of whom 140 (9.5%) were diagnosed with lung cancer within 12 months (positive predictive value, 9.5% [95% CI, 8.0% to 11.0%]; negative predictive value, 99.8% [CI, 99.7% to 99.9%]; sensitivity, 92.7% [CI, 88.6% to 96.9%]; specificity, 84.4% [CI, 83.7% to 85.2%]). Absolute rates of downstream imaging and invasive procedures in screened patients were 31.9% and 2.8%, respectively. In patients undergoing invasive procedures after abnormal findings, complication rates were substantially higher than those in NLST (30.6% vs. 17.7% for any complication; 20.6% vs. 9.4% for major complications).

LIMITATION

Assessment of outcomes was retrospective and was based on procedural coding.

CONCLUSION

The results indicate substantially higher rates of downstream procedures and complications associated with LCS in practice than observed in NLST. Diagnostic management likely needs to be assessed and improved to ensure that screening benefits outweigh potential harms.

PRIMARY FUNDING SOURCE

National Cancer Institute and Gordon and Betty Moore Foundation.

Applications of implementation science frameworks, models and theories in disparities-focused cancer screening interventions: a scoping review protocol

BACKGROUND

Implementation science (IS) frameworks, models and theories (FMTs) have gained popularity in guiding the implementation and evaluation of evidence-based interventions (EBIs) for cancer screening. However, there are significant research gaps in understanding their applications in cancer health disparities contexts. This paper outlines a scoping review protocol designed to explore the utilisation of IS FMTs in cancer screening EBIs to inform intervention designs and adaptations.

METHODS AND ANALYSIS

This scoping review protocol adheres to Arksey and O'Malley's five-step methodological framework for conducting scoping studies. Search strategies were conducted in five bibliographic databases: Ovid MEDLINE, PubMed, Scopus, Web of Science and EMBASE. The search was run on 22 June 2023 with an English language filter and a date limit of 2001-current. Two reviewers will independently screen studies for inclusion and exclusion criteria. A third reviewer will be consulted, where appropriate at any of the review stages, to achieve consensus or resolve conflicts. Data will be collected, managed and analysed using Covidence. A narrative synthesis, based on Popay et al's methodology, will guide reporting and summarisation of results. The review will adhere to the PRISMA Extension for Scoping Reviews guidelines.

ETHICS AND DISSEMINATION

This scoping review is a novel approach for examining a growing corpus of research literature on IS FMT applications used in cancer screening EBIs. As a secondary analysis, this scoping review does not require approval from an institutional review board. We anticipate the review will produce insightful information (eg, challenges, key areas for future directions) on the applications of IS TMFs in designing, deploying and testing EBIs for populations experiencing cancer screening disparities. We will disseminate the results through journals and conferences targeting IS and cancer prevention researchers and practitioners.

Comparison of Magnetic Resonance Imaging-Based Radiomics Features with Nomogram for Prediction of Prostate Cancer Invasion

Objective

To explore the value of the magnetic resonance imaging (MRI) radiomics model in predicting prostate cancer (PCa) invasion.

Methods

Clinical data of 86 pathologically confirmed PCa patients in our hospital were collected, including 44 cases in the invasive group and 42 cases in the non-invasive group. All patients underwent MRI examinations, and the same parameters were used. The lesion area was manually delineated and the radiomics features were extracted from T2WI. The radiomics signature based on LASSO regression was established. Besides, logistic regression was used to identify independent clinical predictors, and a combined model incorporating the radiomics signature and independent clinical risk factor was constructed. Finally, the receiver operating characteristic curve (ROC) analysis and decision curve analysis (DCA) was performed to compare the prediction efficiency and clinical benefit of each model.

Results

A total of 867 radiomics features were obtained, and six of them were incorporated into the radiomics model. Multivariate logistic regression analysis exhibited the Gleason score as an independent clinical risk factor for PCa invasion. ROC results showed that the performance of the radiomics model was comparable to that of the clinical-radiomics model in predicting PCa invasion, and it was better than that of the single Gleason score. DCA also confirmed the considerable clinical application value of the radiomics and the clinical-radiomics models.

Conclusion

As a simple, non-invasive, and efficient method, the radiomics model has important predictive value for PCa invasion.

A Taxonomy of Non-honesty in Public Health Communication

This paper discusses the ethics of public health communication. We argue that a number of commonplace tools of public health communication risk qualifying as non-honest and question whether or not using such tools is ethically justified. First, we introduce the concept of honesty and suggest some reasons for thinking it is morally desirable. We then describe a number of common ways in which public health communication presents information about health-promoting interventions. These include the omission of information about the magnitude of benefits people can expect from health-promoting interventions, and failure to report uncertainty associated with the outcomes of interventions. Next we outline some forms of behaviour which are generally recognised by philosophers as being non-honest, including deception, manipulation, and so on. Finally, we suggest that many of the public health communicative practices identified earlier share features with the non-honest behaviours described and suggest this warrants reflection upon whether such non-honesty is justified by the goals of public health communication.

A Critical Analysis of the Magnetic Resonance Imaging Lesion Diameter Threshold for Adverse Pathology Features

To investigate the relationship between lesion size determined using multiparametric magnetic resonance imaging (mpMRI) and histopathological findings of specimens obtained after mpMRI fusion biopsy and radical prostatectomy (RP). We retrospectively analysed 290 patients with PCa who underwent an MRI fusion biopsy. We measured the diameter of suspicious tumour lesions on diffusion-weighted mpMRI and stratified the cohort into two groups. Group A included patients with a suspicious tumour lesion 10 mm and Group B included those with a suspicious tumour lesion > 10 mm. In Group B, the PI-RADS score determined in mpMRI was higher than Group A, and there was a statistically significant difference between the two groups in terms of clinical T-stage. The PCa detection rate and the number of positive cores were statistically significantly higher in Group B than in Group A. In addition, there was a statistically significant difference between the two groups in relation to the biopsy, the International Society of Urological Pathology (ISUP) grade values, and the presence of clinically significant PCa. In Group B, pathological T-stage and extraprostatic extension (EPE) and surgical margin (SM) positivity were found to be higher among the patients who underwent RP. In the multivariate analysis, the mpMRI lesion size being > 10 mm was found to be an independent predictive factor for SM and EPE positivity. The clinical results of this study support the modification of the lesion size threshold as 10 mm for use in the differentiation of PI-RADS scores 4 and 5.

False-positive magnetic resonance imaging prostate cancer correlates and clinical implications

Background

False-positive (FP) multiparametric magnetic resonance imaging (MPMRI) obscures and swift needless biopsies in men with a high prostate-specific antigen.

Materials and Methods

This was a retrospective study, in which all patients who had been exposed to consecutive MP-MRI of the prostate combined with transrectal ultrasound-guided-magnetic resonance imaging fusion-guided prostate biopsy between 2017 and 2020 were involved in the study. The FP was measured as the number of biopsies that did not encompass prostate cancer divided by the whole number of biopsies.

Results

The percentage of FP cases was 51.1%, the highest percentage was found in Prostate Imaging-Reporting and Data System (PI-RADs) 3 (37.7%) and the lowest was detected in PI-RAD 5 (14.5%). Those with FP biopsies are younger, and their total prostate antigen (PSA) and PSA density (PSAD) are significantly lesser. The area under the curve PSAD, age, and total PSA are 0.76, 0.74, and 0.69, respectively. An optimum PSAD value of 0.135 was chosen as a cutoff because it showed the highest sum of sensitivity and specificity, 68% and 69%, respectively.

Conclusion

FP results of mpMRI were detected in more than half of our sample, more than one-third were presented in Pi-RAD3, improved imaging techniques to decrease FP rates are highly needed.

Heterogeneous Preferences for Colorectal Cancer Screening in Germany: Results of a Discrete Choice Experiment

OBJECTIVES

Colorectal cancer (CRC) screening tests differ in benefits, harms, and processes, making individual informed decisions preference based. The objective was to analyze the preferences of insurees in Germany for characteristics of CRC screening modalities.

METHODS

A generic discrete choice experiment with 2-alternative choice sets and 6 attributes (CRC mortality, CRC incidence, complications, preparation, need for transportation, and follow-up; 3 levels each) depicting characteristics of fecal testing, sigmoidoscopy, and colonoscopy was generated. Participants completed 8 choice tasks. Internal validity was tested using a within-set dominated pair. Between June and October 2020, written questionnaires were sent to a stratified random sample (n = 5000) of 50-, 55-, and 60-year-old insurees of the AOK (Allgemeine Ortskrankenkasse) Lower Saxony, who had previously received an invitation to participate in the organized screening program including evidence-based information. Preferences were analyzed using conditional logit, mixed logit, and latent-class model.

RESULTS

From 1282 questionnaires received (26% [1282 of 4945]), 1142 were included in the analysis. Approximately 42% of the respondents chose the dominated alternative in the internal validity test. Three heterogeneous preference classes were identified. Most important attributes were preparation (class 1; n = 505, 44%), CRC mortality (class 2; n = 347, 30%), and CRC incidence (class 3; n = 290, 25%). Contrary to a priori expectations, a higher effort was preferred for bowel cleansing (class 1) and accompaniment home (classes 1 and 2).

CONCLUSION

Internal validity issues of choice data need further research and warrant attention in future discrete choice experiment surveys. The observed preference heterogeneity suggests different informational needs, although the underlying reasons remained unclear.

Presentation of benefits and harms in cancer screening guidelines for Koreans: a systematic review protocol

INTRODUCTION

Cancer screening guidelines should be based on the best available evidence, presenting both the benefits and harms of screening in a manner applicable to stakeholders. How the potential benefits and harms of screening are presented determine the intent of guideline developers and the delivery of recommendations. Therefore, we will systematically review the cancer screening guidelines for Koreans to evaluate the presentation and detailed ways of the benefits and harms of the recommended cancer screening practices.

METHODS AND ANALYSIS

To identify cancer screening guidelines for Koreans, we will search international electronic databases, including MEDLINE, Embase and domestic literature databases (Korean Studies Information Service System, Research Information Sharing Service, KoreaMED, Korean Medical Database, National Assembly Library and Korea Institute of Science and Technology Information) as well as guideline databases (Guideline International Network, National Institute for Health and Care Excellence, Turning Research Into Practice medical database, WHO guidelines and Korean Medical Guideline Information Center), from inception to November 2022. We will include cancer screening guidelines for healthcare practitioners and patients. Furthermore, we will focus on the most updated guidelines when multiple versions of guidelines are available for a specific intervention and cancer pairs from the same development group. Two reviewers will independently and in duplicate conduct reference screening and data extraction. Data will be extracted based on recommendations from each guideline and how their benefits and harms are presented. The general characteristics of cancer screening guidelines, including cancer type, recommended screening methods, certainty of evidence, direction and strength of recommendation, will be collected. In addition, we will obtain key information on the presentation of the benefits and harms of screening interventions, including quantification of their relative and absolute effects of screening interventions. Finally, our findings will be presented descriptively, and a summary of the results will be provided.

ETHICS AND DISSEMINATION

Ethics approval is not required as we will only use published materials. We will disseminate our findings through publication in peer-reviewed journals.

CMTM6 as a candidate risk gene for cervical cancer: Comprehensive bioinformatics study

Background: CKLF like MARVEL transmembrane domain containing 6 (CMTM6) is an important programmed cell death 1 ligand 1 regulator (PD-L1). CMTM6 was reported as an important regulator of PD-L1 by promoting PD-L1 expression in tumor cells against T cells. However, the function of CMTM6 in cervical cancer is not well characterized. In addition, the role of CMTM6 in the induction of epithelial-mesenchymal transition (EMT) in the context of cervical cancer is unknown. Methods: In this study, we evaluated the role of CMTM6, including gene expression analysis, miRNA target regulation, and methylation characteristic, using multiple bioinformatics tools based on The Cancer Genome Atlas (TCGA) database. The expression of CMTM6 in cervical cancer tissues and non-cancerous adjacent tissues was assessed using immunohistochemistry. In vitro and in vivo function experiments were performed to explore the effects of CMTM6 on growth and metastasis of cervical cancer. Results: Human cervical cancer tissues showed higher expression of CMTM6 than the adjacent non-cancerous tissues. In vitro assays showed that CMTM6 promoted cervical cancer cell invasion, migration, proliferation, and epithelial-mesenchymal transition via activation of mitogen-activated protein kinase (MAPK) c-jun N-terminal kinase (JNK)/p38 signaling pathway. We identified transcription factors (TFs), miRNAs, and immune cells that may interact with CMTM6. Conclusion: These results indicate that CMTM6 is a potential therapeutic target in the context of cervical cancer.

Evaluation of Harms Reporting in U.S. Cancer Screening Guidelines

BACKGROUND

Cancer screening should be recommended only when the balance between benefits and harms is favorable. This review evaluated how U.S. cancer screening guidelines reported harms, within and across organ-specific processes to screen for cancer.

OBJECTIVE

To describe current reporting practices and identify opportunities for improvement.

DESIGN

Review of guidelines.

SETTING

United States.

PATIENTS

Patients eligible for screening for breast, cervical, colorectal, lung, or prostate cancer according to U.S. guidelines.

MEASUREMENTS

Information was abstracted on reporting of patient-level harms associated with screening, diagnostic follow-up, and treatment. The authors classified harms reporting as not mentioned, conceptual, qualitative, or quantitative and noted whether literature was cited when harms were described. Frequency of harms reporting was summarized by organ type.

RESULTS

Harms reporting was inconsistent across organ types and at each step of the cancer screening process. Guidelines did not report all harms for any specific organ type or for any category of harm across organ types. The most complete harms reporting was for prostate cancer screening guidelines and the least complete for colorectal cancer screening guidelines. Conceptualization of harms and use of quantitative evidence also differed by organ type.

LIMITATIONS

This review considers only patient-level harms. The authors did not verify accuracy of harms information presented in the guidelines.

CONCLUSION

The review identified opportunities for improving conceptualization, assessment, and reporting of screening process-related harms in guidelines. Future work should consider nuances associated with each organ-specific process to screen for cancer, including which harms are most salient and where evidence gaps exist, and explicitly explore how to optimally weigh available evidence in determining net screening benefit. Improved harms reporting could aid informed decision making, ultimately improving cancer screening delivery.

PRIMARY FUNDING SOURCE

National Cancer Institute.

Attributes in stated preference elicitation studies on colorectal cancer screening and their relative importance for decision-making among screenees: a systematic review

INTRODUCTION

The SIGMO study (Sigmoidoscopy as an evidence-based colorectal cancer screening test - a possible option?) examines screening eligible populations' preferences for colorectal cancer (CRC) screening in Germany using a discrete choice experiment (DCE). Attribute identification and selection are essential for the construction of choice tasks and should be evidence-based. As a part of the SIGMO study this systematic review provides an overview of attributes included in studies eliciting stated preferences for CRC screening tests and their relative importance for decision-making.

METHODS

Systematic search (November 2021) for English-language studies published since January 2000 in PubMed, Embase, Web of Science, Biomedical Reference Collection: Corporate Edition, LIVIVO and PsycINFO. DCEs and conjoint analysis ranking or rating tasks on screening eligible populations' preferences for stool testing, sigmoidoscopy, and/or colonoscopy were included. Attributes were extracted and their relative importance was calculated and ranked. Risk of bias (RoB) of included studies was assessed using a modified GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Study selection and RoB rating were carried out independently by two reviewers. Data were extracted by one reviewer and checked by another one.

RESULTS

A total of 23 publications on 22 studies were included. Overall RoB was rated as serious/critical for 21 studies and as moderate for 2 studies. Main reasons for high RoB were non-random sampling, low response rates, lack of non-responder analyses, and, to a lesser extent, weaknesses in the measurement instrument and data analysis. Extracted attributes (n = 120) referred to procedure-related characteristics (n = 42; 35%), structural characteristics of health care (n = 24; 20%), test characteristics (n = 23; 19%), harms (n = 16; 13%), benefits (n = 13; 11%), and level of evidence (n = 2; 2%). Most important attributes were reduction in CRC mortality (and incidence) (n = 7), test sensitivity (n = 7), out-of-pocket costs (n = 4), procedure (n = 3), and frequency (n = 2).

CONCLUSIONS

Health preference studies on CRC were found to have a high RoB. The composition of choice tasks revealed a lack of attributes on patient-important outcomes (like incidence reduction), while attributes not considered relevant for individual screening decisions (like sensitivity) were frequently used. Future studies eliciting stated preferences in cancer screening should apply the principles of informed decision-making in attribute identification and selection.

Making sense of harms and benefits: Assessing the numeric presentation of risk information in ACOG obstetrical clinical practice guidelines

OBJECTIVE

To assess the presentation of risk information in American College of Obstetricians and Gynecologists (ACOG) obstetrical Practice Bulletins.

METHODS

We reviewed B- and C-graded recommendations in Practice Bulletins published from January 2017 to March 2020. We calculated the proportion of recommendations and outcomes that were presented numerically and, of these, the proportion that were presented in accordance with best practices of risk communication - in absolute formats, or as absolute changes in risk from baseline risks. We categorized outcomes as harms or benefits to compare their risk presentation.

RESULTS

In 21 obstetrical Practice Bulletins, there were 125 recommendations, with 46 (37%) describing risks numerically. Sixteen of these 46 recommendations (35%) presented an absolute change in risk from a baseline risk. For harms, 65% were presented as absolute risks and 25% as relative risks. For benefits, this was 55% and 48% respectively.

CONCLUSION

Most recommendations do not present numeric risk information. Of those that do, most do not use absolute risk measures.

PRACTICE IMPLICATIONS

Obstetrical practice guidelines should present numerical risk information wherever possible to support recommendations, increasing the use of absolute risk formats and absolute changes from baseline risks to increase risk comprehension.

Dynamic evaluation of MRI-targeted, systematic and combined biopsy for prostate cancer diagnosis through 10 years of practice in a single institution

PURPOSE

To perform a dynamic evaluation of the prostate cancer (PCa) detection rate according to the biopsy strategy over 10 years of practice in a single institution that pioneered MRI-targeted fusion biopsy (MRI-TB).

METHODS

This stage 4 IDEAL study prospectively included all consecutive patients who underwent transrectal prostate biopsy for clinically suspected PCa between January 2010 and November 2020. Patients with positive MRI (PIRADS score ≥ 3) underwent both MRI-TB and systematic biopsy (SB) while those with negative MRI (PIRADS score < 3) underwent SB only. The main outcome was the evolution of the detection rate of clinically relevant PCa (csPCa; grade ≥ 2). The secondary outcome was the change in PCa detection rate according to the biopsy method.

RESULTS

A total of 2942 men underwent prostate MRI and a prostate biopsy: 2322 underwent MRI-TB and 620 had SB only. The detection rate of csPCa increased 2.5-fold from 23 to 58%. The detection rate of PCa and csPCa was significantly higher in patients who underwent MRI-TB compared to those who underwent SB only (67% vs. 52% and 40% vs. 32%, respectively (P < 0.001 for both comparisons)). The number of csPCa diagnosed by MRI-TB increased linearly over the study period and represented the majority of PCa diagnoses after 2016.

CONCLUSION

Implementation of MRI-TB in patients with positive MRI led to improved detection of csPCa.

PI-RADS v2.1 Combined With Prostate-Specific Antigen Density for Detection of Prostate Cancer in Peripheral Zone

Purpose

To evaluate the diagnostic performance of combining the Prostate Imaging Reporting and Data System (PI-RADS) scoring system v2.1 with prostate-specific antigen density (PSAD) to detect prostate cancer (PCa).

Methods

A total of 266 participants with suspicion of PCa underwent multiparametric magnetic resonance imaging (mpMRI) in our hospital, after at least 4 weeks all patients underwent subsequent systematic transrectal ultrasound (TRUS)-guided biopsy or MRI-TRUS fusion targeted biopsy. All mpMRI images were scored in accordance with the PI-RADS v2.1, and univariate and multivariate logistic regression analyses were performed to determine significant predictors of PCa.

Results

A total of 119 patients were diagnosed with PCa in the biopsy, of them 101 patients were diagnosed with clinically significant PCa. The multivariate analysis revealed that PI-RADS v2.1 and PSAD were independent predictors for PCa. For peripheral zone (PZ), the area under the ROC curve (AUC) for the combination of PI-RADS score and PSAD was 0.90 (95% CI 0.83-0.96), which is significantly superior to using PI-RADS score (0.85, 95% CI 0.78-0.93, P=0.031) and PSAD alone (0.83, 95% CI 0.75-0.90, P=0.037). For transition zone (TZ), however, the combination model was not significantly superior to PI-RADS alone, with AUC of 0.94 (95% CI 0.89-0.99) vs. 0.93 (95% CI 0.88-0.97, P=0.186).

Conclusion

The combination of PI-RADS v2.1 with PSAD could significantly improve the diagnostic performance of PCa in PZ. Nevertheless, no significant improvement was observed regarding PCa in TZ.

Nomogram predicting prostate cancer in patients with negative prebiopsy multiparametric magnetic resonance

Aim: To build two nomograms for predicting the possibilities of prostate cancer (PCa) and clinically significant PCa (csPCa) in patients with negative prebiopsy multiparametric MRI (mpMRI). Methods: The independent predictors associated with PCa or csPCa in patients with negative mpMRI were determined and served in the construction of the two nomograms. Results: The nomogram predicting PCa consisted of age, positive digital rectal examination, free/total prostate-specific antigen (PSA) ratio and PSA density, while age, positive digital rectal examination and PSA density comprised the nomogram predicting csPCa. The negative predictive value of mpMRI for PCa and csPCa improved from 77.1 and 87.5% to 90.4 and 96.1%, respectively, in the training cohort (n = 376) and from 81.9 and 89.0% to 91.8 and 96.5%, respectively, in the validation cohort (n = 127) when combined with the two nomograms. Conclusion: The negative predictive value of negative mpMRI for the detection of PCa or csPCa was improved with the results of the nomograms.

Development and validation of a predictive model for determining clinically significant prostate cancer in men with negative magnetic resonance imaging after transrectal ultrasound-guided prostate biopsy

BACKGROUND

The interpretation of negative magnetic resonance imaging (MRI) screening results for clinically significant prostate cancer (csPCa) (International Society of Urological Pathology grade ≥group 2) is debatable and poses a clinical dilemma for urologists. No nomograms have been developed to predict csPCa in such populations. In this study, we aimed to develop and validate a model for predicting the probability of csPCa in men with negative MRI (PI-RADS score 1-2) results after transrectal ultrasound-guided systematic prostate biopsy.

METHODS

The development cohort consisted of 728 patients with negative MRI results who underwent subsequent prostate biopsy at our center between January 1, 2014 and December 31, 2017. The patients' clinicopathologic data were recorded. The Lasso regression was used for data dimension reduction and feature selection, then multivariable binary logistic regression was used to build a predictive model with regression coefficients. The model was validated in an independent cohort of 334 consecutive patients from January 1, 2018 and June 30, 2020. The performance of the predictive model was assessed with respect to discrimination, calibration, and decision curve analysis.

RESULTS

The predictors incorporated in this model included age, history of previous negative prostate biopsy, prostate specific antigen density (PSAD), and lower urinary tract symptoms, with PSAD being the strongest predictor. The model showed good discrimination with an area under the receiver operating characteristic curve of 0.875 (95% confidence interval, 0.816-0.933) and good calibration (unreliability test, p = .540). Decision curve analysis demonstrated that the model was clinically useful.

CONCLUSION

This study presents a good nomogram that can aid pre-biopsy risk stratification for the detection of csPCa, and that may help inform biopsy decisions in patients with negative MRI results.

Challenges in the Use of Artificial Intelligence for Prostate Cancer Diagnosis from Multiparametric Imaging Data

Simple Summary

Prostate Cancer is one of the main threats to men’s health. Its accurate diagnosis is crucial to properly treat patients depending on the cancer’s level of aggressiveness. Tumor risk-stratification is still a challenging task due to the difficulties met during the reading of multi-parametric Magnetic Resonance Images. Artificial Intelligence models may help radiologists in staging the aggressiveness of the equivocal lesions, reducing inter-observer variability and evaluation time. However, these algorithms need many high-quality images to work efficiently, bringing up overfitting and lack of standardization and reproducibility as emerging issues to be addressed. This study attempts to illustrate the state of the art of current research of Artificial Intelligence methods to stratify prostate cancer for its clinical significance suggesting how widespread use of public databases could be a possible solution to these issues.

Abstract

Many efforts have been carried out for the standardization of multiparametric Magnetic Resonance (mp-MR) images evaluation to detect Prostate Cancer (PCa), and specifically to differentiate levels of aggressiveness, a crucial aspect for clinical decision-making. Prostate Imaging—Reporting and Data System (PI-RADS) has contributed noteworthily to this aim. Nevertheless, as pointed out by the European Association of Urology (EAU 2020), the PI-RADS still has limitations mainly due to the moderate inter-reader reproducibility of mp-MRI. In recent years, many aspects in the diagnosis of cancer have taken advantage of the use of Artificial Intelligence (AI) such as detection, segmentation of organs and/or lesions, and characterization. Here a focus on AI as a potentially important tool for the aim of standardization and reproducibility in the characterization of PCa by mp-MRI is reported. AI includes methods such as Machine Learning and Deep learning techniques that have shown to be successful in classifying mp-MR images, with similar performances obtained by radiologists. Nevertheless, they perform differently depending on the acquisition system and protocol used. Besides, these methods need a large number of samples that cover most of the variability of the lesion aspect and zone to avoid overfitting. The use of publicly available datasets could improve AI performance to achieve a higher level of generalizability, exploiting large numbers of cases and a big range of variability in the images. Here we explore the promise and the advantages, as well as emphasizing the pitfall and the warnings, outlined in some recent studies that attempted to classify clinically significant PCa and indolent lesions using AI methods. Specifically, we focus on the overfitting issue due to the scarcity of data and the lack of standardization and reproducibility in every step of the mp-MR image acquisition and the classifier implementation. In the end, we point out that a solution can be found in the use of publicly available datasets, whose usage has already been promoted by some important initiatives. Our future perspective is that AI models may become reliable tools for clinicians in PCa diagnosis, reducing inter-observer variability and evaluation time.

Antenatal screening practices in the WHO European Region: a mixed methods study

Background

Literature suggests an increasing trend towards more screening tests, while awareness of potential harms of screenings has been reported to be sub-optimal. This paper aimed to characterize ANC screening practices within the 53 countries of the WHO Europe Region and compare these to evidenced-based recommendations from WHO and from other key reference sources.

Methods

From January 2019 to July 2019 we conducted a survey among key informants (KIs) in the 53 countries of the WHO European Region and a systematic review of literature. KIs were invited to answer an online structured questionnaire, available both in English and Russian. Published and unpublished guidelines, policies or cross-sectional studies on ANC screening practices were searched for in four electronic databases (MEDLINE, Global Health Library, Web of Science, Google) and also sent by KIs. Data obtained from both methods were analysed and triangulated by two independent authors.

Results

Overall 42 countries participated in the survey. Among these, 36 (86%) reported national guidelines on ANC screening, but only 26 (61.9%) reported up-to-date and comprehensive guidelines. All countries reported supplemental use other guidelines, with 19 (45.2%) using more than three. When looking at current evidence-based recommendations, only one (ultrasound before 24 weeks) was reported to be implemented in all countries. Overall, 35 (83.3%) countries reported using at least five not-recommended ANC screening practices, with 21 (50%) implementing ≥10 not-recommended ANC screening practices. The systematic review resulted in 11871 records, with 111 (90 guidelines, 4 policies, 17 cross-sectional studies) matching inclusion criteria. Findings from the systematic review were largely consistent with those of the online survey: among the most comprehensive national guidelines identified, only six (24%) had a concordance ≥75% with the reference recommendations, independently from their publication date, while the few existing cross-sectional studies highlighted large heterogeneity in the implementation of ANC practices among countries.

Conclusions

Guidance on and implementation of evidenced-based recommendations on ANC screening is suboptimal in the WHO European Region. It is necessary to increase the availability of evidence-based high-quality national guidelines and their concrete use in routine practice.

Categories of systematic influences applied to increase cancer screening participation: a literature review and analysis

BACKGROUND

Health authorities can influence citizens in subtle ways that render them more likely to participate in cancer screening programmes, and thereby possibly increase the beneficial effects. If the influences become too severe, the citizens' ability to make a personal choice may be lost on the way. The purpose of this analysis was to identify and categorize the influences while questioning whether they still permit the citizens to make their own choices regarding participation.

METHODS

A two-stringed approach was used to obtain empirical examples of systematic influences that aim to raise participation rates in cancer screening programmes: First, a systematic literature search was conducted on three databases. Second, relevant experts were contacted via internationally based e-mail lists and asked for examples of systematic influences in cancer screening. The present analysis was based on direct, conventional content analysis to address different categories of systematic influences.

RESULTS

The literature search yielded 19 included articles and the expert inquiry yielded 11 empirical examples of which content analysis of the empirical examples generated six major categories of systematic influence: (i) misleading presentation of statistics, (ii) misrepresentation of harms vs. benefits, (iii) opt-out systems, (iv) recommendation of participation, (v) fear appeals and (vi) influencing the general practitioners and other healthcare professionals.

CONCLUSION

The six categories of identified influences work through psychological biases and personal costs and are still in widely use. The use of these types of influence remains ethically questionable in cancer screening programmes since they might compromise informed decision making.

Myosin 1C isoform A is a novel candidate diagnostic marker for prostate cancer

Early diagnosis of prostate cancer is a challenging issue due to the lack of specific markers. Therefore, a sensitive diagnostic marker that is expressed or upregulated exclusively in prostate cancer cells would facilitate diagnostic procedures and ensure a better outcome. We evaluated the expression of myosin 1C isoform A in 5 prostate cell lines, 41 prostate cancer cases, and 11 benign hyperplasias. We analyzed the expression of 12 surface molecules on prostate cancer cells by flow cytometry and analyzed whether high or low myosin 1C isoform A expression could be attributed to a distinct phenotype of prostate cancer cells. Median myosin 1C isoform A expression in prostate cancer samples and cancer cell lines was 2 orders of magnitude higher than in benign prostate hyperplasia. Based on isoform A expression, we could also distinguish clinical stage 2 from clinical stage 3. Among cell lines, PC-3 cells with the highest myosin 1C isoform A level had diminished numbers of CD10/CD13-positive cells and increased numbers of CD29 (integrin β1), CD38, CD54 (ICAM1) positive cells. The surface phenotype of clinical samples was similar to prostate cancer cell lines with high isoform A expression and could be described as CD10-/CD13- with heterogeneous expression of other markers. Both for cell lines and cancer specimens we observed the strong correlation of high myosin 1C isoform A mRNA expression and elevated levels of CD29 and CD54, suggesting a more adhesive phenotype for cells with high isoform A expression. Compared to normal tissue, prostate cancer samples had also reduced numbers of CD24- and CD38-positive cells. Our data suggest that a high level of myosin 1C isoform A is a specific marker both for prostate cancer cells and prostate cancer cell lines. High expression of isoform A is associated with less activated (CD24/CD38 low) and more adhesive (CD29/CD54 high) surface phenotype compared to benign prostate tissue.

Reactions to Recommendations and Evidence About Prostate Cancer Screening Among White and Black Male Veterans

U.S. clinical guidelines recommend that prior to screening for prostate cancer with Prostate Specific Antigen (PSA), men should have an informed discussion about the potential benefits and harms of screening. Prostate cancer disproportionately affects Black men. To understand how White and Black men reacted to a draft educational pamphlet about the benefits and harms of PSA screening, we conducted race-specific focus groups at a midwestern VA medical center in 2013 and 2015. White and Black men who had been previously screened reviewed the draft pamphlet using a semistructured focus group facilitator guide. Forty-four men, ages 55-81, participated in four White and two Black focus groups. Three universal themes were: low baseline familiarity with prostate cancer, surprise and resistance to the recommendations not to test routinely, and negative emotions in response to ambiguity. Discussions of benefits and harms of screening, as well as intentions for exercising personal agency in prevention and screening, diverged between White and Black focus groups. Discussion in White groups highlighted the potential benefits of screening, minimized the harms, and emphasized personal choice in screening decisions. Participants in Black groups devoted almost no discussion to benefits, considered harms significant, and emphasized personal and collective responsibility for preventing cancer through diet, exercise, and alternative medicine. Discussion in Black groups also included the role of racism and discrimination in healthcare and medical research. These findings contribute to our understanding of how men's varied perspectives and life experiences affect their responses to prostate cancer screening information.

Diagnostic performance of MRI/TRUS fusion-guided biopsies vs. systematic prostate biopsies in biopsy-naïve, previous negative biopsy patients and men undergoing active surveillance

BACKGROUND

We aimed to assess the detection rate of overall PCa and csPCa, and the clinical impact of MRI/TRUS fusion targeted biopsy (FUSION-TB) compared to TRUS guided systematic biopsy (SB) in patients with different biopsy settings.

METHODS

Three hundred and five patients were submitted to FUSION-TB, divided into three groups: biopsy naïve patients, previous negative biopsies and patients under active surveillance (AS). All patients had a single suspicious index lesion at mpMRI. Within these groups, we enrolled men underwent both to FUSION-TB and SB in the same session. Overall detection rate of PCa and csPCa for the two biopsy methods were compared separately between the three groups of patients.

RESULTS

No differences were observed between the three groups concerning clinical and radiological characteristics. We found no differences in terms of overall PCa detection (66% vs. 63.8%, P=0.617) and csPCa detection (56.4% vs. 51.1%; P=0.225) concerning biopsy naïve patients. In patients previously submitted to a negative biopsy, FUSION-TB showed higher detection rate of csPCa compared to SB alone (41,3% vs. 27% respectively, P=0.038). In patients under AS, no differences were observed between FUSION-TB and SB in terms of overall PCa (50% vs. 73.1%) and csPCa (30.8% vs. 26.9%, respectively; P=0.705) detection.

CONCLUSIONS

Our results suggest that in men with previously negative biopsy, FUSION-TB showed significantly higher diagnostic performance for clinically significant PCa as compared to SB. Combination of FUSION-TB and SB should be recommended in AS population to offer higher chance of csPCa diagnosis.

Current Challenges When Using Numbers in Patient Decision Aids: Advanced Concepts

BACKGROUND

Decision aid developers have to convey complex task-specific numeric information in a way that minimizes bias and promotes understanding of the options available within a particular decision. Whereas our companion paper summarizes fundamental issues, this article focuses on more complex, task-specific aspects of presenting numeric information in patient decision aids.

METHODS

As part of the International Patient Decision Aids Standards third evidence update, we gathered an expert panel of 9 international experts who revised and expanded the topics covered in the 2013 review working in groups of 2 to 3 to update the evidence, based on their expertise and targeted searches of the literature. The full panel then reviewed and provided additional revisions, reaching consensus on the final version.

RESULTS

Five of the 10 topics addressed more complex task-specific issues. We found strong evidence for using independent event rates and/or incremental absolute risk differences for the effect size of test and screening outcomes. Simple visual formats can help to reduce common judgment biases and enhance comprehension but can be misleading if not well designed. Graph literacy can moderate the effectiveness of visual formats and hence should be considered in tool design. There is less evidence supporting the inclusion of personalized and interactive risk estimates.

DISCUSSION

More complex numeric information. such as the size of the benefits and harms for decision options, can be better understood by using incremental absolute risk differences alongside well-designed visual formats that consider the graph literacy of the intended audience. More research is needed into when and how to use personalized and/or interactive risk estimates because their complexity and accessibility may affect their feasibility in clinical practice.

Predictors of Women's Awareness of the Benefits and Harms of Mammography Screening and Associations with Confusion, Ambivalence, and Information Seeking

In recent years, there has been a shift toward promoting informed decision making for mammography screening for average-risk women in their 40s. Professional organizations such as the American Cancer Society and U.S. Preventive Services Task Force recommend that women weigh the potential benefits and harms of mammography prior to initiating screening. This decision-making process assumes that women are aware of both the benefits and harms of screening, yet little is known about the prevalence and antecedents of such awareness. Moreover, it is conceivable that women who are aware of both the benefits and harms may interpret this information as conflicting - which could be concerning, as researchers have documented adverse effects of exposure to conflicting health information in prior research. Using data from a population-based survey of U.S. women aged 30-59 (N = 557), the current study found that awareness of mammography's harms is relatively low compared to awareness of benefits. Health news exposure and interpersonal communication about health were associated with greater awareness of harms. In addition, women's awareness of both the benefits and harms was positively associated with confusion about breast cancer screening recommendations, ambivalence about getting a mammogram, and mammogram-related information seeking from online sources. Implications for cancer screening communication are discussed.

Study protocol for a single-centre non-inferior randomised controlled trial on a novel three-dimensional matrix positioning-based cognitive fusion-targeted biopsy and software-based fusion-targeted biopsy for the detection rate of clinically significant prostate cancer in men without a prior biopsy

INTRODUCTION

The classical pathway for diagnosing prostate cancer is systematic 12-core biopsy under the guidance of transrectal ultrasound, which tends to underdiagnose the clinically significant tumour and overdiagnose the insignificant disease. Another pathway named targeted biopsy is using multiparametric MRI to localise the tumour precisely and then obtain the samples from the suspicious lesions. Targeted biopsy, which is mainly divided into cognitive fusion method and software-based fusion method, is getting prevalent for its good performance in detecting significant cancer. However, the preferred targeted biopsy technique in detecting clinically significant prostate cancer between cognitive fusion and software-based fusion is still beyond consensus.

METHODS AND ANALYSIS

This trial is a prospective, single-centre, randomised controlled and non-inferiority study in which all men suspicious to have clinically significant prostate cancer are included. This study aims to determine whether a novel three-dimensional matrix positioning cognitive fusion-targeted biopsy is non-inferior to software-based fusion-targeted biopsy in the detection rate of clinically significant cancer in men without a prior biopsy. The main inclusion criteria are men with elevated serum prostate-specific antigen above 4-20 ng/mL or with an abnormal digital rectal examination and have never had a biopsy before. A sample size of 602 participants allowing for a 10% loss will be recruited. All patients will undergo a multiparametric MRI examination, and those who fail to be found with a suspicious lesion, with the anticipation of half of the total number, will be dropped. The remaining participants will be randomly allocated to cognitive fusion-targeted biopsy (n=137) and software-based fusion-targeted biopsy (n=137). The primary outcome is the detection rate of clinically significant prostate cancer for cognitive fusion-targeted biopsy and software-based fusion-targeted biopsy in men without a prior biopsy. The clinically significant prostate cancer will be defined as the International Society of Urological Pathology grade group 2 or higher.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the ethics committee of Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China. The results of the study will be disseminated and published in international peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT04271527).

Harms and Benefits of Cancer Screening

In recommending and offering screening, health services make a health claim ('it's good for you'). This article considers ethical aspects of establishing the case for cancer screening, building a service programme, monitoring its operation, improving its quality and integrating it with medical progress. The value of (first) screening is derived as a function of key parameters: prevalence of the target lesion in the detectable pre-clinical phase, the validity of the test and the respective net utilities or values attributed to four health states-true positives, false positives, false negatives and true negatives. Decision makers as diverse as public regulatory agencies, medical associations, health insurance funds or individual screenees can legitimately come up with different values even when presented with the same evidence base. The main intended benefit of screening is the reduction of cause-specific mortality. All-cause mortality is not measurably affected. Overdiagnosis and false-positive tests with their sequelae are the main harms. Harms and benefits accrue to distinct individuals. Hence the health claim is an invitation to a lottery with benefits for few and harms to many, a violation of the non-maleficence principle. While a public decision maker may still propose a justified screening programme, respect for individual rights and values requires preference-sensitive, autonomy-enhancing educational materials-even at the expense of programme effectiveness. Opt-in recommendations and more 'consumer-oriented' qualitative research are needed.

Effect of lesion diameter and prostate volume on prostate cancer detection rate of magnetic resonance imaging: Transrectal-ultrasonography-guided fusion biopsies using cognitive targeting

OBJECTIVE

This study aimed to evaluate the effect of prostate volume and lesion size on the clinically significant prostate cancer (csPCa) detection rates of transrectal ultrasonography (TRUS)-guided prostate biopsies, performed by a cognitive targeting method for sampling peripheral zone lesions.

MATERIAL AND METHODS

We retrospectively enrolled 219 consecutive patients, who underwent multiparametric magnetic resonance imaging with a 3-T scanner and had peripheral zone lesions suspected for prostate cancer. All of these patients underwent combined cognitive targeted biopsy of suspicious lesions and TRUS-guided systematic biopsy. The detection rates of csPCa according to different lesion diameters (<5 mm, 5-9.9 mm, and ≥10 mm) and prostate volumes (<30 mL, 30-49.9 mL, 50-79.9 mL, and ≥80 mL) were calculated per lesion basis. In addition, subgroup analysis of csPCa detection rates was performed according to Prostate Imaging Reporting and Data System scores of lesions.

RESULTS

The csPCa detection rates according to lesion diameters <5 mm, 5-9.9 mm, and ≥10 mm were 4%, 9.8%, and 33.1%, respectively, and were significantly lower for lesions <10 mm (p<0.001). The csPCa detection rates were 61.5%, 24.1%, 16.2%, and 6.9%, respectively, for prostate volumes <30 mL, 30-49.9 mL, 50-79.9 mL, and ≥80 mL, and were significantly higher for prostate volumes <30 mL (p<0.001).

CONCLUSIONS

Clinicians should be very careful when they prefer cognitive targeted prostatic biopsy in patients with periferal zone lesions less than 10 mm and with prostate volumes greater than 30 mL, because of significantly low csPCa detection rates.

Discussions of Potential Mammography Benefits and Harms among Patients with Limited Health Literacy and Providers: "Oh, There are Harms?"

Starting breast cancer screening at age 40 versus 50 may increase potential harms frequency with a small mortality benefit. Younger women's screening decisions, therefore, may be complex. Shared decision-making (SDM) is recommended for women under 50 and may support women under 55 for whom guidelines vary. How women with limited health literacy (LHL) approach breast cancer screening decision-making is less understood, and most SDM tools are not designed with their input. This phenomenological study sought to characterize mammography counseling experiences among women with LHL and primary care providers (PCPs). Women ages 40-54 with LHL who had no history of breast cancer or mammogram within 9 months were approached before a primary care visit at a safety-net hospital. PCPs at this site were invited to participate. Qualitative interviews explored mammography counseling experiences. Patients also reviewed sample information materials. A constant comparison technique generated four themes salient to 25 patients and 20 PCPs: addressing family history versus comprehensive risk assessment; potential mammography harms discussions; information delivery preferences; and integrating pre-visit information tools. Findings suggest that current counseling techniques may not be responsive to patient-identified needs. Opportunities exist to improve how mammography information is shared and increase accessibility across the health literacy spectrum.

Dealing with the Lack of Time for Detailed Shared Decision-making in Primary Care: Everyday Shared Decision-making

Policymakers and researchers are strongly encouraging clinicians to support patient autonomy through shared decision-making (SDM). In setting policies for clinical care, decision-makers need to understand that current models of SDM have tended to focus on major decisions (e.g., surgeries and chemotherapy) and focused less on everyday primary care decisions. Most decisions in primary care are substantive everyday decisions: intermediate-stakes decisions that occur dozens of times every day, yet are non-trivial for patients, such as whether routine mammography should start at age 40, 45, or 50. Expectations that busy clinicians use current models of SDM (here referred to as "detailed" SDM) for these decisions can feel overwhelming to clinicians. Evidence indicates that detailed SDM is simply not realistic for most of these decisions and without a feasible alternative, clinicians usually default to a decision-making approach with little to no personalization. We propose, for discussion and refinement, a compromise approach to personalizing these decisions (everyday SDM). Everyday SDM is based on a feasible process for supporting patient autonomy that also allows clinicians to continue being respectful health advocates for their patients. We propose that alternatives to detailed SDM are needed to make progress toward more patient-centered care.

3-T Multiparametric MRI Followed by In-Bore MR-Guided Biopsy for Detecting Clinically Significant Prostate Cancer After Prior Negative Transrectal Ultrasound-Guided Biopsy

OBJECTIVE. The purpose of this study was to evaluate the rate of detection of clinically significant prostate cancer (csPCa), as assessed on the basis of Prostate Imaging Reporting and Data System version 2.1 (PI-RADSv2.1) guidelines, using 3-T in-bore MR-guided biopsy (MRGB) for a cohort of patients suspected of having csPCa despite having a history of recent negative transrectal ultrasound-guided biopsy results. MATERIALS AND METHODS. The cohort in this retrospective, single-center study was derived from a database of 330 patients who underwent multiparametric MRI (mpMRI) followed by in-bore transrectal 3-T MRGB. Seventy-nine patients (mean [± SD] age, 64.1 ± 8.6 years) with prior negative transrectal ultrasound-guided biopsy results and positive pre-MRGB mpMRI results (PI-RADS score ≥ 3) composed the final cohort. The rate of detection of PCa and csPCa (the latter of which was defined by a Gleason score of 3 + 4 or higher) was stratified according to updated PI-RADSv2.1 assessment. RESULTS. MRGB detected PCa in 36 patients (45.6%), 30 (83.3%) of whom had csPCa. The PI-RADSv2.1 score was a strong predictor (odds ratio, 3.97; 95% CI, 1.93-7.47) of csPCa detection. We found two benign transition zone target lesions that were downgraded from PI-RADSv2 category 3 to PI-RADSv2.1 category 2. PCa was detected in 18.4% (7/38), 65.2% (15/23), and 87.5% (14/16) of individuals with PI-RADSv2.1 category 3, 4, and 5 lesions, respectively, with 85.7% (6/7), 86.7% (13/15), and 78.6% (11/14) of these cases found to be csPCa, respectively. Of the seven PI-RADSv2.1 category 3 csPCa lesions, six had prostate-specific antigen density greater than 0.10 ng/mL/cc. CONCLUSION. With the use of 3-T in-bore MRGB, csPCa was detected in 38% of individuals with prior negative transrectal ultrasound-guided biopsy results. PI-RADSv2.1 was a strong predictor of csPCa detection. On the basis of our results, patients with PI-RADSv2.1 category 4 or 5 lesions and patients with PI-RADSv2.1 category 3 lesions and a prostate-specific antigen density greater than or equal to 0.10 ng/mL/cc may benefit from in-bore MRGB.

Quality of decision aids developed for women at average risk of breast cancer eligible for mammographic screening: Systematic review and assessment according to the International Patient Decision Aid Standards instrument

Mammographic screening contributes to a reduction in specific mortality, but it has disadvantages. Decision aids are tools designed to support people's decisions. Because these aids influence patient choice, their quality is crucial. The objective of the current study was to conduct a systematic review of decision aids developed for women eligible for mammographic screening who have an average breast cancer risk and to assess the quality of these aids. The systematic review included articles published between January 1, 1997, and August 1, 2019, in the PubMed, Embase, Cochrane, and PsycInfo databases. The studies were reviewed independently by 2 reviewers. Any study containing a decision aid for women eligible for mammographic screening with an average breast cancer risk was included. Two double-blind reviewers assessed the quality of the selected decision aids using the International Patient Decision Aid Standards instrument, version 3 (IPDASi). Twenty-three decision aids were extracted. Classification of decision aid quality using the IPDASi demonstrated large variations among the decision aids (maximum IPDASi score, 188; mean ± SD score, 132.6 ± 23.8; range, 85-172). Three decision aids had high overall scores. The 3 best-rated dimensions were disclosure (maximum score, 8; mean score, 6.8), focusing on transparency; information (maximum score, 32; mean score, 26.1), focusing on the provision of sufficient details; and probabilities (maximum score, 32; mean score 25), focusing on the presentation of probabilities. The 3 lowest-rated dimensions were decision support technology evaluation (maximum score, 8; mean score, 4.3), focusing on the effectiveness of the decision aid; development (maximum score, 24; mean score, 12.6), evaluating the development process; and plain language (maximum score, 4; mean score, 1.9), assessing appropriateness for patients with low literacy. The results of this review identified 3 high-quality decision aids for breast cancer screening.

Focal therapy for localized prostate cancer in the era of routine multi-parametric MRI

BACKGROUND

Prostate cancer focal therapy aims to minimize the side-effects of whole gland treatments, such as radical prostatectomy and radiotherapy without compromising oncological efficacy. However, concerns exist regarding the multifocal nature of prostate cancer and the lack of long-term oncological data for this form of treatment. In recent years, the routine adoption of multi-parametric magnetic resonance imaging (mpMRI) of the prostate has improved our ability to select candidates for focal therapy and to accurately deliver this form of prostate cancer treatment.

METHODS

We performed a review of the literature to provide a summary of the oncological and functional outcomes of men receiving primary prostate focal therapy. Furthermore, we discuss the impact of the routine implementation of mpMRI as part of the initial prostate cancer diagnostic pathway on the selection of candidates and delivery of focal therapy. Finally, we summarize knowledge gaps in the field and highlight active clinical trials in this arena.

RESULTS

Primary focal therapy involves the application of one of a number of energies that ablate tissue, such as cryotherapy and high intensity focused ultrasound (HIFU). Success is principally dependent on highly accurate patient selection and disease localization underpinned in large part by the routine integration of pre-biopsy mpMRI. Prospective medium-term follow-up data for primary HIFU and cryotherapy for men with intermediate-risk disease have shown acceptable cancer control with low risk of side effects and complications. Additional research is needed to clearly define an appropriate follow-up approach and to guide the management of in- and out-of-field recurrences. Multiple comparative trials with randomization against standard care are currently underway in men with intermediate- and high-risk prostate cancer.

CONCLUSION

The widespread adoption of prostate mpMRI has led to improved disease localization, enabling the performance of focal therapy as a viable treatment strategy for men with low volume intermediate-risk prostate cancer.

Impact of peri-prostatic fat measurements using MRI on the prediction of prostate cancer with transrectal ultrasound-guided biopsy

OBJECTIVES

To estimate the impact of peri-prostatic fat (PPF) measurements using preoperative magnetic resonance imaging on the prediction of prostate cancer (PCa) with transrectal ultrasound-guided biopsy.

PATIENTS AND METHODS

We performed a retrospective 2-center study on 660 consecutive patients receiving transrectal ultrasound-guided biopsy-biopsy from June 2016 to October 2018. Pathologic and immunohistochemical characteristics were collected. PPF measurements including PPF area (PPFA) and PPFA to prostate area (PA) ratio (PPFA/PA) were assessed by preoperative staging magnetic resonance imaging. Clinical variables were correlated with Gleason score by using Spearman (ρ) correlation coefficients. Multivariable analysis was performed to identify independent predictors of PCa. The diagnostic performance was estimated using ROC curves.

RESULTS

The Gleason score was significantly correlated with age (ρ = 0.114, P = 0.035), prostate-specific antigen (PSA) (ρ = 0.482, P < 0.001), PIRADS scoring (ρ = 0.403, P < 0.001) and PPFA/PA (ρ = 0.238, P < 0.001). Multivariate analysis revealed that PPFA/PA, age, digital rectal examination, family history of PCa, PSA, and PIRADS scoring were independently predictive of PCa. The ROC AUC to detect PCa or clinically significant PCa (CS-PCa; Gleason Score 3 + 4 or greater) improved with the addition of PPFA/PA (PCa: 0.93 vs. 0.89; CS-PCa: 0.92 vs. 0.90).

CONCLUSION

PPFA/PA is an independent predictor for PCa along with age, digital rectal examination, family history of PCa, PSA, and PIRADS scoring. PPF measurements especially PPFA/PA may help detect PCa or CS-PCa, thus helping improve PCa risk stratification and screening to avoid unnecessary biopsies.

A meta-analysis of zinc levels in breast cancer

BACKGROUND

Breast cancer is the most commonly occurring neoplasm in females, comprising 16% of all female cancers worldwide. Various studies indicate some discrepancies regarding zinc (Zn) levels in various samples of breast cancer patients.

OBJECTIVE

The present study evaluated by meta-analysed the published data for Zn levels analyzed in breast tissue, plasma, serum, and hair samples and its relationship with breast cancer.

METHODS

The present meta-analysis included 36 studies, all of which were published in the years between 1984 to 2017 and selected by searching the databases MEDLINE, EMBASE, Cochrane Library, PubMed, Scopus, and the ISI Web of Knowledge. The articles were analyzed, and I² statistics were used to examine heterogeneity. The objective analysis was performed on data from the 36 studies, with total 1699 study subjects and 2009 controls.

RESULTS

Significant statistical differences overall were observed, based on a random effects model (SMD (95 % CI), -0.78[-1.40, -0.16], P = 0.014). Data from 19 of these studies indicated significant statistical differences between cancerous patients and controls with regard to serum and plasma Zn concentration (SMD [(95 %CI): -1.61(-2.43, -0.79)]. There was a significant statistical difference between the breast tissue and hair as regards Zn status (SMD (95%CI): 2.32(1.42, 3.21)) and (SMD (95v%CI): -1.80(-3.41, -0.20), respectively. Zn concentration levels typically decreased in blood and hair samples of patients with breast cancer, whereas it was elevated in tumor tissues.

CONCLUSIONS

There is a significant relationship between lowered serum Zn concentrations and risk of breast cancer onset or recurrences in women, but because of high heterogeneity, we recommend other primary studies.

Effect of financial incentives on breast, cervical and colorectal cancer screening delivery rates: Results from a systematic literature review

Preventive care, such as screening, is important for reducing the risk of cancer, a leading cause of death worldwide. Indeed, some type of cancers are detected through screening programs, which in most countries run for colorectal, breast, and cervical cancers. In this context, general practitioners play a key role in increasing the participation rate in cancer screening programs. To improve cancer screening delivery rates, performance incentives have increasingly been implemented in primary care by healthcare payers and organizations in different countries. The effects of these tools are still not clear. We conducted a systematic literature review in order to answer the following research question: What is the evidence in the literature for the effects of financial incentives on the delivery rates of breast, cervical and colorectal cancer screening in general practice? We performed a literature search in Web of Science, PubMed, Cochrane Library and Google Scholar, according to the PRISMA guidelines. 18 studies were selected, classified and discussed according to the health preventive services investigated. Most of studies showed partial or no effects of financial incentives on breast and cervical cancer screening delivery rates. Few positive or partial effects were found regarding colorectal cancer screening. Ongoing monitoring of incentive programs is critical to determining the effectiveness of financial incentives and their effects on the improvement of cancer screening delivery rates.

Feasibility of prostatectomy without prostate biopsy in the era of new imaging technology and minimally invasive techniques

BACKGROUND

Routinely, after receiving prostate specific antigen (PSA) testing and digital rectum examination, patients with suspected prostate cancer are required to undergo prostate biopsy. However, the ability of ultrasound-guided prostate biopsy to detect prostate cancer is limited. Nowadays, a variety of diagnostic methods and more sensitive diagnostic methods, such as multi-parameter prostate magnetic resonance imaging (mpMRI) and prostate-specific membrane antigen positron emission tomography/computed tomography (PSMA PET/CT) can be applied clinically. Furthermore, laparoscopic/robot-assisted prostatectomy is also a safe and effective procedure for the treatment of benign prostatic hyperplasia. So maybe it is time to reconsider the necessary to perform prostate biopsy before radical prostatectomy.

AIM

To explore the feasibility of radical prostatectomy without prostate biopsy in the era of new imaging technology and minimally invasive techniques.

METHODS

From June 2014 to November 2018, 11 cases of laparoscopic radical prostatectomy without prostate biopsy were performed at the three tertiary medical centers involved in this study. All patients received prostate magnetic resonance imaging and prostate cancer was suspected, including six patients with positive ⁶⁸Ga-PSMA PET/CT results. Laparoscopic radical prostatectomy and pelvic lymph node dissection were performed for all patients.

RESULTS

All surgeries were accomplished successfully. The mean age was 69 ± 7.7 year, the mean body mass index was 24.7 ± 1.6 kg/m², the range of serum PSA was 4.3 to >1000 ng/mL, and the mean prostate volume was 40.9 ± 18.3 mL. The mean operative time was 96 ± 23.3 min, the mean estimated blood loss was 90 ± 90.9 mL, and the median duration of catheter placement was 14 d. The final pathology confirmed that all specimens were prostate cancer except one case of benign prostatic hyperplasia. No major complications occurred in 90 d postoperatively.

CONCLUSION

The current practice of mandating a prostatic biopsy before prostatectomy should be reconsidered in the era of new imaging technology and minimally invasive techniques. Radical prostatectomy could be carried out without the evidence of malignancy. Large-sample randomized controlled trials are definitely required to confirm the feasibility of this new concept.

Clinically significant prostate cancer detection on MRI: A radiomic shape features study

PURPOSE

Prostate multiparametric MRI (mpMRI) is the imaging modality of choice for detecting clinically significant prostate cancer (csPCa). Among various parameters, lesion maximum diameter and volume are currently considered of value to increase diagnostic accuracy. Quantitative radiomics allows for the extraction of more advanced shape features. Our aim was to assess which shape features derived from MRI index lesions correlate with csPCa presence.

MATERIALS AND METHODS

We retrospectively enrolled 75 consecutive subjects, who underwent mpMRI on a 3 T scanner, divided based on MRI index lesion Gleason Score in a csPCa group (GS > 3 + 4, n = 41) and a non-csPCa one (n = 34). Ten shape features were extracted both from axial T2-weighted and ADC maps images, after lesion tridimensional segmentation. Univariable and multivariable logistic analysis were used to evaluate the relationship between shape features and csPCa. Diagnostic performance was assessed measuring the area under the curve of the receiver operating characteristic (ROC) analysis. Diagnostic accuracy, sensitivity, and specificity were determined using the best cut-off on each ROC. A P value < 0.05 was considered statistically significant.

RESULTS

Univariable analysis demonstrated that almost every shape feature was statistically significant between csPCa e non-csPCa groups. However, multivariable analysis revealed that the parameter defined as surface area to volume ratio (SAVR), especially when extracted from ADC maps is the strongest independent predictor of csPCa among tested shape features.

CONCLUSION

The radiomic shape feature SAVR, extracted from ADC maps after index lesion segmentation, appears as a promising tool for csPCa detection.

What benefits and harms are important for a decision about cervical screening? A study of the perspective of different subgroups of women

Background: In cervical screening programs, women typically receive information leaflets to support their decision about participation. However, these leaflets are often based on what experts consider important benefits and harms of screening and not what women themselves consider important to know. Objective: To identify which benefits and harms women consider important for making a decision about cervical screening. Design: Cross-sectional study. Setting and participants: Women from the Dutch target group of cervical screening (N=248; 30-60 years), recruited through an online access panel. Main variables studied: Perceived importance of different benefits and harms of cervical screening, assessed through two rating items ("How important is the information about [this harm/benefit] for your decision?" and "For me it is a [benefit/harm] that participating in the screening program leads to [the benefit/harm]"), and one ranking item ("Rank the information according to their importance for your own choice"). Results: Women overall considered the benefits of cervical screening more important than the harms or disadvantages. The most important harm according to women was the chance of false positive results (M=4.88; SD=1.75). Differences between those with lower and higher numeracy/health literacy were found regarding several aspects, e.g. for the chance of false positive results, the chance of false negative results, the chance of overtreatment. Discussion and conclusion: The results suggest that leaflets could include more explicit information about false positive results.

The value of MR textural analysis in prostate cancer

Current diagnosis and treatment stratification of patients with suspected prostate cancer relies on a combination of histological and magnetic resonance imaging (MRI) findings. The aim of this article is to provide a brief overview of prostate pathological grading as well as the relevant aspects of multiparametric (MRI) mpMRI, before indicating the potential that magnetic resonance textural analysis (MRTA) offers within prostate cancer. A review of the evidence base on MRTA in prostate cancer will enable discussion of the utility of this field while also indicating recommendations to future research. Radiomic textural analysis allows the assessment of spatial inter-relationships between pixels within an image by use of mathematical methods. First-order textural analysis is better understood and may have more clinical validity than higher-order textural features. Textural features extracted from apparent diffusion coefficient maps have shown the most potential for clinical utility in MRTA of prostate cancers. Future studies should aim to integrate machine learning techniques to better represent the role of MRTA in prostate cancer clinical practice. Nomenclature should be used to reduce misidentification between first-order and second-order energy and entropy. Automated methods of segmentation should be encouraged in order to reduce problems associated with inclusion of normal tissue within regions of interest. The retrospective and small-scale nature of most published studies, make it difficult to draw meaningful conclusions. Future larger prospective studies are required to validate the textural features indicated to have potential in characterisation and/or diagnosis of prostate cancer before translation into routine clinical practice.