Changing the Prostate Cancer Detection Paradigm: Clinical Application of European Association of Urology Guideline–recommended Magnetic Resonance Imaging–based Risk Stratification in Men with Suspected Prostate Cancer

• Published in: European urology focus 2021-09, Vol.7 (5), p.1011-1018
• Main Authors: Tully, Karl H., Bahlburg, Henning, Berg, Sebastian, Hanske, Julian, von Landenberg, Nicolas, Noldus, Joachim, Palisaar, Rein-Jüri, Roghmann, Florian, Brock, Marko
• Format: Article
• Language: English
• Subjects: Humans; Magnetic Resonance Imaging; Male; Multiparametric magnetic resonance imaging; Predictive Value of Tests; Prostate - diagnostic imaging; Prostate - pathology; Prostate biopsy; Prostate cancer; Prostatic Neoplasms - pathology; Risk Assessment; Risk calculator; Risk stratification; Urology
• ISSN: 2405-4569; 2405-4569
• DOI: 10.1016/j.euf.2020.09.014

Multiparametric magnetic resonance imaging using the Prostate Imaging Reporting and Data System version 2.1 allows for a personalized, risk-stratified approach to indicating prostate biopsies (PBx) in order to reduce PBx and concomitant complications in men with suspected prostate cancer (PCa). One way to achieve this goal is to implement the risk-stratified pathway (RSP) using the Rotterdam Prostate Cancer Risk Calculator. To describe the clinical implementation of the RSP and to examine its impact on the number of PBx and the resulting changes in the PCa detection pattern compared with men undergoing PBx in a detection-focused pathway (DFP) without prior risk assessment. An institutional dataset of 505 consecutive patients with suspected PCa between July 2019 and February 2020 was used. Chi-square test and Mann-Whitney U test were employed to examine differences in the number of PBx and the PCa detection pattern between the DFP (n = 195, 38.6%) and the RSP (n = 310, 61.4%). To minimize differences in risk stratification, inverse probability of treatment weighting was used. After implementing the RSP, the overall biopsy rate could be reduced by 11.2% (100% vs 88.8%, p < 0.001. Additionally, compared with the DFP, the number of biopsy cores per patient was reduced in the RSP (14 [interquartile range {IQR} 14–15] vs 14 [IQR 6–14], p < 0.001) and the detection of clinically significant PCa was increased (44.3% vs 57.7%, p = 0.038). Overdiagnosis of clinically insignificant disease was decreased in the RSP (22.8% vs 12.6%, p = 0.039). Implementation of the RSP in clinical practice reduced the number of PBx and brought forth a shift in the PCa detection pattern toward clinically significant disease, while reducing overdiagnosis of clinically insignificant disease. In this study, we examined the impact of risk stratification on the number of prostate biopsies (PBx) and the consecutive detection pattern in men with suspected prostate cancer (PCa). We found that the risk-stratified pathway reduced the number of PBx while simultaneously shifting the PCa detection pattern toward clinically significant PCa. The risk-stratified, magnetic resonance imaging–based pathway reduces the number of biopsies in patients with suspected prostate cancer, with only a minimal risk of missing clinically significant disease. Apart from changing detection patterns, it may also help reduce biopsy-associated complication rates.