A European Model for an Organised Risk-stratified Early Detection Programme for Prostate Cancer

Abstract

Context: Overdiagnosis as the argument to stop pr.ostate cancer (PCa) screening is less valid since the introduction of new technologies such as risk calculators (RCs) and magnetic resonance imaging (MRI). These new technologies result in fewer unnecessary biopsy procedures and fewer cases of both overdiagnosis and underdetection. Therefore, we can now adequately respond to the growing and urgent need for a structured risk assessment to detect PCa early. Objective: To provide expert discussion on the existing evidence for a previously published risk-stratified strategy regarding an organised population-based early detection programme for PCa. Evidence acquisition: The proposed algorithm for early detection of PCa emerged from expert consensus by the authors based on available evidence derived from a nonsystematic review of the current literature using Medline/PubMed, Cochrane Library database, ClinicalTrials.gov, ISRCTN Registry, and the European Association of Urology guidelines on PCa. Evidence synthesis: Although not confirmed by the highest level of evidence, current literature and guidelines point towards an algorithm for early detection of PCa that starts with risk-based prostate-specific antigen (PSA) testing, followed by multivariable risk stratification with RCs. All men who are classified to be at intermediate and high risk are then offered prostate MRI. The combined data from RCs and MRI results can be used to select men for prostate biopsy. Low-risk men return to a risk-based safety net that includes individualised PSA-interval tests and, if necessary, repeated MRI. Depending on local availability, the use of the different risk stratification tools may be adapted. Conclusions: We present a risk-stratified algorithm for an organised populationbased early detection programme for clinically significant PCa. Although the proposed strategy has not yet been analysed prospectively, it exploits and may y These authors contributed equally. z These authors contributed equally.

Volatilomics: An Emerging and Promising Avenue for the Detection of Potential Prostate Cancer Biomarkers

“…Hopefully, the progressive increase in studies involving the VOMs composition of PCa patients will help to unveil biomarkers suitable for its diagnosis, as a complementary tool to the current methods [ 15 ]. Recent studies have shown that the conjugation of PSA screening with other methodologies, such as risk calculators, biomarkers, and imaging tests, e.g., magnetic resonance imaging (MRI) or fusion biopsies, can attenuate overdiagnosis and under-detection issues [ 96 ]. This means that the combination of volatilomics with other methodologies could be extremely valuable for the classification and screening of cancer, being beneficial in the active surveillance of patients [ 7 ].…”

Comparative Analysis of PSA Density and an MRI-Based Predictive Model to Improve the Selection of Candidates for Prostate Biopsy

“…The classic approach of PCa detection based on systematic biopsies after PCa suspicion, has been disapproved due to the high rates of unnecessary biopsies and the over detection of insignificant tumours (iPCa) [2][3][4][5]. While PCa suspicion continues to be based on serum prostate-specific antigen (PSA) elevation or abnormal digital rectal examination (DRE), the detection of csPCa has improved since the introduction of multiparametric magnetic resonance imaging (mpMRI) and guided biopsies [6,7]. Nevertheless, there remain uncertain scenarios in which a high rate of unnecessary biopsies and over detection of iPCa occur [8,9].…”

“…PI-RADS 3 remains the most uncertain scenario, in which csPCa usually does not reach 20% and in which more than 50% of the biopsied lesions reflect iPCa [9,15]. Prostate-specific antigen density (PSAD), MRI-based predictive models (MRI-PM), and modern markers are currently recommended for improving the selection of candidates for prostate biopsy [6,7,16].…”

Multiparametric Magnetic Resonance Imaging Grades the Aggressiveness of Prostate Cancer

“…This new diagnostic approach takes advantage of the high negative predictive value of mpMRI [ 4 ] and the increased csPCa sensitivity of guided biopsies [ 5 ]. The current decision-making with prostate biopsies is based on the Prostate Imaging-Report and Data System (PI-RADS) [ 6 ], and clinicians usually avoid prostate biopsies when the PI-RADS score is <3 due to the high negative predictive value of mpMRI for csPCa, reaching up to 95% [ 4 ]. In contrast, prostate biopsies are always recommended in men with PI-RADS > 3, due to the risk of csPCa higher than 50% in men with PI-RADS 4 and around 90% in those with PI-RADS 5 [ 7 ].…”