The Capio Prostate Cancer Center Model for Prostate Cancer Diagnostics-Real-world Evidence from 2018 to 2022

Background

The Capio Prostate Cancer Center (Capio PCC) in Stockholm, Sweden, adopts a comprehensive diagnostic approach, utilizing prostate-specific antigen (PSA), Stockholm3, and magnetic resonance imaging (MRI) for prostate cancer risk assessment, followed by targeted and systematic biopsies for high-risk cases.

Objective

This study aims to elucidate the clinical process and real-world outcomes of the Capio PCC model for prostate cancer diagnosis at Capio S:t Göran Hospital.

Design setting and participants

Between 2018 and 2022, a cohort of 12 406 men aged 45-75 yr underwent prostate cancer testing, adhering to Capio PCC's structured diagnostic protocol.

Outcome measurements and statistical analysis

We provide a comprehensive description of the Capio PCC model and present results from its implementation, including assessments of PSA, Stockholm3, MRI scans, and biopsies. A comparative analysis is conducted between the diagnostic outcomes obtained at Capio PCC and those obtained at other regions in Sweden.

Results and limitations

The median participant age was 61 yr (interquartile range [IQR]: 55-67), with PSA levels at 1.6 ng/ml (IQR: 0.8-3.3) and Stockholm3 scores at 4 (IQR: 3-11). Among 1064 men (8.6%) undergoing biopsies, 611 (57% of biopsied) were diagnosed with International Society of Urological Pathology grade ≥ 2 cancer. Notably, employing a Stockholm3 ≥ 15 cutoff for biopsy, in lieu of PSA ≥ 3 ng/ml, reduced biopsy recommendations by 43%. For men with PSA levels between 1.5 and 2.9 ng/ml, 360 (12%) exhibited Stockholm3 scores of ≥ 15, with 72 (56% of biopsied) diagnosed with clinically significant prostate cancer. A comparative analysis with national Swedish prostate cancer detection data indicated that the Capio PCC model (vs Sweden) revealed a distribution of 14% (vs 25%) low-risk, 59% (vs 42%) intermediate-risk, and 26% (vs 30%) high-risk and advanced cancers.

Conclusions

This study underscores the effectiveness of the protocol-driven diagnostic process at Capio PCC, enabling earlier detection of intermediate-risk prostate cancer and reducing the need for MRI assessments compared with standard prostate cancer care in Sweden.

Patient summary

At the Capio Prostate Cancer Center, a novel diagnostic approach incorporating prostate-specific antigen, Stockholm3, magnetic resonance imaging, and targeted biopsies has been implemented to enhance prostate cancer testing and diagnosis in Stockholm, Sweden.

Association of 5α-Reductase Inhibitors With Prostate Cancer Mortality

Importance

There is evidence that 5α-reductase inhibitors (5-ARIs), a standard treatment of benign prostate hyperplasia, are associated with a decrease in the incidence of prostate cancer (PCa). However, studies to date have had conflicting results regarding the association with prostate cancer mortality (PCM).

Objective

To evaluate the association of treatment with 5-ARIs with PCM in men without a prior diagnosis of PCa.

Design, Setting, and Participants

This population-based cohort study was conducted in Stockholm, Sweden, between January 1, 2007, and December 31, 2018, and included 429 977 men with a prostate-specific antigen (PSA) test within the study period. Study entry was set to 1 year after the first PSA test. Data were analyzed from September 2021 to December 2021.

Exposures

After their initial PSA test, men with 2 or more newly dispensed prescriptions of 5-ARI, finasteride, or dutasteride were considered 5-ARI users (n = 26 190).

Main Outcomes and Measures

Primary outcome was PCM. Cox proportional hazards regression models were used to calculate multivariable-adjusted hazard ratios (HRs) and 95% CIs for all-cause mortality and PCM.

Results

The study cohort included 349 152 men. The median (IQR) age for those with 2 or more filled prescriptions of 5-ARI was 66 (61-73) years and 57 (50-64) years for those without. The median follow-up time was 8.2 (IQR, 4.9-10) years with 2 257 619 person-years for the unexposed group and 124 008 person-years for the exposed group. The median exposure to treatment with 5-ARI was 4.5 (IQR, 2.1-7.4) years. During follow-up, 35 767 men (8.3%) died, with 852 deaths associated with PCa. The adjusted multivariable survival analysis showed a lower risk of PCM in the 5-ARI group with longer exposure times (0.1-2.0 years: adjusted HR, 0.89; 95% CI, 0.64-1.25; >8 years: adjusted HR, 0.44; 95% CI, 0.27-0.74). No statistically significant differences were seen in all-cause mortality between the exposed and unexposed group. Men treated with 5-ARIs underwent more PSA tests and biopsies per year than the unexposed group (median of 0.63 vs 0.33 and 0.22 vs 0.12, respectively).

Conclusions and Relevance

The results of this cohort study suggest that there was no association between treatment with 5-ARI and increased PCM in a large population-based cohort of men without a previous PCa diagnosis. Additionally, a time-dependent association was seen with decreased risk of PCM with longer 5-ARI treatment. Further research is needed to determine whether the differences are because of intrinsic drug effects or PCa testing differences.

Survival in mantle cell lymphoma after frontline treatment with Rbendamustine, R-CHOP and the Nordic MCL2 regimen - a real world study on patients diagnosed in Sweden 2007-2017

Not available.

Identifying Prostate Cancer Among Men with Lower Urinary Tract Symptoms

Background

In men aged above 50 yr, lower urinary tract symptoms (LUTS), benign prostate hyperplasia, and prostate cancer are common urological conditions. Current guidelines for general practitioners frequently recommend prostate-specific antigen (PSA) testing in patients with LUTS for the detection of prostate cancer.

Objective

To assess the performance of PSA, PSA density, and the Stockholm3 blood test for identification of prostate cancer among men with LUTS.

Design, setting, and participants

In this post hoc analysis of a population-based diagnostic trial (STHLM3, n = 58 588), 4588 men aged 50–69 yr, without previous prostate cancer, with International Prostate Symptom Score (IPSS) data, and having PSA ≥ 3 ng/mL were identified. Men with at least moderate LUTS, defined as an IPSS score of ≥8, were included. PSA density and Stockholm3 scores were calculated.

Intervention

Participants underwent 10–12-core systematic prostate biopsies.

Outcome measurements and statistical analysis

The primary outcome was significant prostate cancer (sPCa) defined as International Society of Urological Pathology (ISUP) grade ≥2. Logistic regression analysis adjusted for age and previous biopsy status was performed. The area under the receiver operating characteristic curve (AUC) was calculated, and decision curve analysis was performed.

Results and limitations

Out of 4588 men, 1544 (34%) reported at least moderate LUTS. The median age was 64 yr, and 11% had undergone a previous prostate biopsy. The Stockholm3 test showed superior discrimination for sPCa to PSA density, which in turn showed superior discrimination to PSA (AUC 0.77 vs 0.70 vs 0.61, p <  0.02). Calibration of the Stockholm3 test was adequate. Performing biopsy only in men with PSA ≥5 ng/mL saved 64% of biopsies, but resulted in missing 52% of detectable sPCa. Recommending biopsy for men with PSA density ≥0.07 resulted in sparing 26% of biopsy procedures and delaying the diagnosis of 12% of sPCa cases, with a 6.1% risk of sPCa among unbiopsied men. Recommending men with Stockholm3 ≥ 0.11 for biopsy resulted in sparing 53% of biopsy procedures and delaying the diagnosis of 20% of sPCa cases, with a 5.1% risk of finding sPCa in unbiopsied men.

Conclusions

PSA density and the Stockholm3 blood test were superior to PSA for the identification of prostate cancer among men with LUTS.

Patient summary

In this analysis of a large Swedish study, we find that the use of prostate-specific antigen (PSA) density or the Stockholm3 blood test instead of only PSA might improve the detection of prostate cancer among men with lower urinary tract symptoms.

Biomarker discrimination and calibration with MRI-targeted biopsies: an analysis with the Stockholm3 test

BACKGROUND

The validated Stockholm3 test is used to improve PC detection. Stockholm3, however, was developed using systematic biopsies. We aimed to assess Stockholm3 operating performance when using MRI-targeted biopsies for PC detection.

METHODS

A prospective cohort of 532 men was considered for prostate biopsy during 2016-2017. All men underwent Stockholm3 testing and MRI before biopsy. All PIRADs ≥3 lesion underwent targeted biopsy; all men underwent systematic biopsy. The primary outcome was ISUP Grade Group ≥2 (GG ≥ 2) PC. Detection strategies included: (1) systematic biopsies alone, (2) targeted biopsies alone, (3) targeted with associated systematic biopsies for MRI+, and (4) all biopsies in all men. For each strategy, the Stockholm3 operating characteristics were assessed with discrimination, calibration, and decision curve analysis (DCA).

RESULTS

Median age was 65 years, median PSA was 6.2 ng/mL, median Stockholm3 score was 16.5%, and overall detection of GG ≥ 2 PC was 36% (193/532). Stockholm3 showed accurate discrimination for separating GG ≥ 2 cancer from benign and GG1, with an area under the curve of 0.84-0.86 depending on the biopsy strategy. Calibration analysis showed that Stockholm3 underestimated risks for GG ≥ 2 PC risk using MRI-targeted biopsies: there was a net benefit over biopsies in all men for Stockholm3 at risk thresholds varying from >3% in systematic biopsies to >15% in targeted with systematic biopsies in MRI+ men. When using a Stockholm3 score of >10% cutoff, a range of 32-38% of biopsies could be avoided while missing 5-11% of GG ≥ 2 PC and 0-3% of GG ≥ 3 PC.

CONCLUSIONS

Stockholm3 shows high discriminatory performance in an MRI-targeted biopsy setting, however risks are underpredicted due to MRI-targeted biopsies being more sensitive than the systematic biopsies for which Stockholm3 was developed. Stockholm3, along with any risk prediction model developed for systematic prostate biopsy decisions, will need recalibration for optimal use in an MRI-driven biopsy setting.

Head-to-head Comparison of Conventional, and Image- and Biomarker-based Prostate Cancer Risk Calculators

BACKGROUND

A new generation of risk calculators (RCs) for prostate cancer (PCa) incorporating magnetic resonance imaging (MRI) data have been introduced. However, these have not been validated externally, and their clinical benefit compared with alternative approaches remains unclear.

OBJECTIVE

To assess previously published PCa RCs incorporating MRI data, and compare their performance with traditional RCs (European Randomized Study of Screening for Prostate Cancer [ERSPC] 3/4 and Prostate Biopsy Collaborative Group [PBCG]) and the blood-based Stockholm3 test.

DESIGN, SETTING, AND PARTICIPANTS

RCs were tested in a prospective multicenter cohort including 532 men aged 45-74 yr participating in the Stockholm3-MRI study between 2016 and 2017.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The probabilities of detection of clinically significant PCa (csPCa) defined as Gleason score ≥3 + 4 were calculated for each patient. For each RC and the Stockholm3 test, discrimination was assessed by area under the curve (AUC), calibration by numerical and graphical summaries, and clinical usefulness by decision curve analysis (DCA).

RESULTS AND LIMITATIONS

The discriminative ability of MRI RCs 1-4 for the detection of csPCa was superior (AUC 0.81-0.87) to the traditional RCs (AUC 0.76-0.80). The observed prevalence of csPCa in the cohort was 37%, but calibration-in-the-large predictions varied from 14% to 63% across models. DCA identified only one model including MRI data as clinically useful at a threshold probability of 10%. The Stockholm3 test achieved equivalent performance for discrimination (AUC 0.86) and DCA, but was underpredicting the actual risk.

CONCLUSIONS

Although MRI RCs discriminated csPCa better than traditional RCs, their predicted probabilities were variable in accuracy, and DCA identified only one model as clinically useful.

PATIENT SUMMARY

Novel risk calculators (RCs) incorporating imaging improved the ability to discriminate clinically significant prostate cancer compared with traditional tools. However, all but one predicted divergent compared with actual risks, suggesting that regional modifications be implemented before usage. The Stockholm3 test achieved performance comparable with the best MRI RC without utilization of imaging.

Lower urinary tract symptoms (LUTS) are not associated with an increased risk of prostate cancer in men 50-69 years with PSA ≥3 ng/ml

Background: There is conflicting evidence about the association between prostate cancer and Lower Urinary Tract Symptoms (LUTS). We aimed to describe the prevalence of LUTS and its association with prostate cancer risk.Methods: We studied the association between International Prostate Symptom Score (IPSS) and prostate cancer in a population-based sample of men (n = 45,595) aged 50-69 years from the Stockholm3 study. Men with PSA ≥3 ng/ml (n = 4579) underwent systematic prostate biopsies. We used the International Society of Urological Pathology Gleason Grading (ISUP grade) and performed regression analysis for risk of any cancer (n = 1797), ISUP grade ≥2 (n = 840) and advanced cancer, defined as ISUP grade ≥3 or cT ≥3 (n = 353).Results: 74.6% of all men had no or mild LUTS (IPSS ≤7) and 3.2% had severe LUTS (IPSS >19). Men with any, ISUP grade ≥2 or advanced cancer had lower median IPSS compared to men with benign biopsy (any cancer: 4 (IQR 2-9); ISUP grade ≥2: 4 (2-8); advanced cancer: 4 (2-8); benign biopsy: 6 (3-11); p < 0.05). IPSS was not associated with increased risk of cancer in multivariate analyses (OR (any cancer) 0.97; 95% CI 0.96-0.98; OR (ISUP grade ≥2) 0.97; 95% CI 0.96-0.99; OR (advanced cancer) 0.99; 95% CI 0.99-1.01).Conclusions: Three-quarters of men aged 50-69 years report no or mild LUTS. Our data do not support any clinically meaningful association between LUTS and prostate cancer. Specifically, men with advanced prostate cancer did not exhibit more urinary symptoms than men without cancer.

The impact of different prostate-specific antigen (PSA) testing intervals on Gleason score at diagnosis and the risk of experiencing false-positive biopsy recommendations: a population-based cohort study

OBJECTIVE

Given a man's current prostate- specific antigen (PSA) level, age and family history of prostate cancer, what are the benefits (decreased risk of higher Gleason score [GS] cancer at diagnosis) and harms (increased risk of false-positive biopsy recommendation) of waiting 1, 2, 3, 4 or 5-8 years until the next PSA test?

DESIGN

Prospective cohort.

SETTING

All PSA tested men in Stockholm, Sweden, between 2003 and 2015.

PARTICIPANTS

Men aged 50-74 years with at least two PSA tests between 2003 and 2015 (n=174 636).

MAIN OUTCOME MEASURES

Log-binomial regression to calculate the risk ratio (RR) of GS ≥7 and GS 6 versus benign outcome at prostate biopsy and 12-year cumulative probability of experiencing a false-positive biopsy by testing interval, age, PSA level and first-degree family history.

RESULTS

Men with PSA ≤1 ng/mL had low risk of GS ≥7 prostate cancer irrespective of testing interval; <3% had a PSA >3 at the next testing occasion, and of the 663 men biopsied after the next PSA test only 32 (5%) had GS ≥7 cancer. Men with PSA >1 ng/mL had increased risk of being diagnosed with GS ≥7 prostate cancer when screened with longer than annual intervals (RRs ranged from 1.4 to 3.2 depending on PSA level and testing interval). The results were consistent across age groups and family history status. This benefit needs to be balanced against the increased risk for false-positive biopsy recommendation with shorter testing intervals (twofold for annual vs biennial and threefold for annual vs triennial).

CONCLUSIONS

Men aged 50-74 years with PSA ≤1 ng/mL can wait 3-4 years before having a new PSA test. For men with PSA >1 ng/mL, we observed an increased risk of being diagnosed with GS ≥7 prostate cancer with longer than annual testing intervals. This benefit needs to be balanced against the markedly increased risks for false-positive biopsy recommendations with shorter testing intervals recommendations.