Characteristics of Prostate Cancer Found at Fifth Screening in the European Randomized Study of Screening for Prostate Cancer Rotterdam: Can We Selectively Detect High-grade Prostate Cancer with Upfront Multivariable Risk Stratification and Magnetic Resonance Imaging?

• Published in: European urology 2018-03, Vol.73 (3), p.343-350
• Main Authors: Alberts, Arnout R, Schoots, Ivo G, Bokhorst, Leonard P, Drost, Frank-Jan H, van Leenders, Geert J, Krestin, Gabriel P, Dwarkasing, Roy S, Barentsz, Jelle O, Schröder, Fritz H, Bangma, Chris H, Roobol, Monique J
• Format: Article
• Language: English
• Subjects: Biopsy; MRI; Multivariable risk stratification; Prostate cancer; Risk calculator; Screening; Urology
• ISSN: 0302-2838; 1873-7560
• DOI: 10.1016/j.eururo.2017.06.019

Abstract Background The harm of screening (unnecessary biopsies and overdiagnosis) generally outweighs the benefit of reducing prostate cancer (PCa) mortality in men aged ≥70 yr. Patient selection for biopsy using risk stratification and magnetic resonance imaging (MRI) may improve this benefit-to-harm ratio. Objective To assess the potential of a risk-based strategy including MRI to selectively identify men aged ≥70 yr with high-grade PCa. Design, setting, and participants Three hundred and thirty-seven men with prostate-specific antigen ≥3.0 ng/ml at a fifth screening (71–75 yr) in the European Randomized study of Screening for Prostate Cancer Rotterdam were biopsied. One hundred and seventy-nine men received six-core transrectal ultrasound biopsy (TRUS-Bx), while 158 men received MRI, 12-core TRUS-Bx, and fusion TBx in case of Prostate Imaging Reporting and Data System ≥3 lesions. Outcome measurements and statistical analysis The primary outcome was the overall, low-grade (Gleason Score 3 + 3) and high-grade (Gleason Score ≥ 3 + 4) PCa rate. Secondary outcome was the low- and high-grade PCa rate detected by six-core TRUS-Bx, 12-core TRUS-Bx, and MRI ± TBx. Tertiary outcome was the reduction of biopsies and low-grade PCa detection by upfront risk stratification with the Rotterdam Prostate Cancer Risk Calculator 4. Results and limitations Fifty-five percent of men were previously biopsied. The overall, low-grade, and high-grade PCa rates in biopsy naïve men were 48%, 27%, and 22%, respectively. In previously biopsied men these PCa rates were 25%, 20%, and 5%. Sextant TRUS-Bx, 12-core TRUS-Bx, and MRI ± TBx had a similar high-grade PCa rate (11%, 12%, and 11%) but a significantly different low-grade PCa rate (17%, 28%, and 7%). Rotterdam Prostate Cancer Risk Calculator 4-based stratification combined with 12-core TRUS-Bx ± MRI-TBx would have avoided 65% of biopsies and 68% of low-grade PCa while detecting an equal percentage of high-grade PCa (83%) compared with a TRUS-Bx all men approach (79%). Conclusions After four repeated screens and ≥1 previous biopsies in half of men, a significant proportion of men aged ≥70 yr still harbor high-grade PCa. Upfront risk stratification and the combination of MRI and TRUS-Bx would have avoided two-thirds of biopsies and low-grade PCa diagnoses in our cohort, while maintaining the high-grade PCa detection of a TRUS-Bx all men approach. Further studies are needed to verify these results. Patient summary Prostate cancer s