Patient Selection For Prostate Biopsy Research Articles

Prostate cancer risk assessment and avoidance of prostate biopsies using fully automatic deep learning in prostate MRI: comparison to PI-RADS and integration with clinical data in nomograms.

Risk calculators (RCs) improve patient selection for prostate biopsy with clinical/demographic information, recently with prostate MRI using the prostate imaging reporting and data system (PI-RADS). Fully-automated deep learning (DL) analyzes MRI data independently, and has been shown to be on par with clinical radiologists, but has yet to be incorporated into RCs. The goal of this study is to re-assess the diagnostic quality of RCs, the impact of replacing PI-RADS with DL predictions, and potential performance gains by adding DL besides PI-RADS. One thousand six hundred twenty-seven consecutive examinations from 2014 to 2021 were included in this retrospective single-center study, including 517 exams withheld for RC testing. Board-certified radiologists assessed PI-RADS during clinical routine, then systematic and MRI/Ultrasound-fusion biopsies provided histopathological ground truth for significant prostate cancer (sPC). nnUNet-based DL ensembles were trained on biparametric MRI predicting the presence of sPC lesions (UNet-probability) and a PI-RADS-analogous five-point scale (UNet-Likert). Previously published RCs were validated as is; with PI-RADS substituted by UNet-Likert (UNet-Likert-substituted RC); and with both UNet-probability and PI-RADS (UNet-probability-extended RC). Together with a newly fitted RC using clinical data, PI-RADS and UNet-probability, existing RCs were compared by receiver-operating characteristics, calibration, and decision-curve analysis. Diagnostic performance remained stable for UNet-Likert-substituted RCs. DL contained complementary diagnostic information to PI-RADS. The newly-fitted RC spared 49% [252/517] of biopsies while maintaining the negative predictive value (94%), compared to PI-RADS ≥ 4 cut-off which spared 37% [190/517] (p < 0.001). Incorporating DL as an independent diagnostic marker for RCs can improve patient stratification before biopsy, as there is complementary information in DL features and clinical PI-RADS assessment. For patients with positive prostate screening results, a comprehensive diagnostic workup, including prostate MRI, DL analysis, and individual classification using nomograms can identify patients with minimal prostate cancer risk, as they benefit less from the more invasive biopsy procedure. The current MRI-based nomograms result in many negative prostate biopsies. The addition of DL to nomograms with clinical data and PI-RADS improves patient stratification before biopsy. Fully automatic DL can be substituted for PI-RADS without sacrificing the quality of nomogram predictions. Prostate nomograms show cancer detection ability comparable to previous validation studies while being suitable for the addition of DL analysis.

Contemporary Diagnosis of Very Low-risk Prostate Cancer in a Multihospital Health Care System

The National Comprehensive Cancer Network (NCCN) very low risk (VLR) category for prostate cancer (PCa) represents clinically insignificant disease, and detection of VLR PCa contributes to overdiagnosis. Greater use of magnetic resonance imaging (MRI) and biomarkers before patient selection for prostate biopsy (PBx) reduces unnecessary biopsies and may reduce the diagnosis of clinically insignificant PCa. We tested a hypothesis that the proportion of VLR diagnoses has decreased with greater use of MRI-informed PBx using data from our 11-hospital system. From 2018 to 2023, 351/3197 (11%) men diagnosed with PCa met the NCCN VLR criteria. The proportion of VLR diagnoses did not change from 2018 to 2023 (p = 0.8) despite an increase in the use of MRI-informed PBx (from 49% to 82%; p < 0.001). Of patients who underwent combined systematic and targeted PBx and were diagnosed with VLR disease, cancer was found in systematic PBx regions in 79% of cases and in targeted PBx regions in 31% of cases. When performing both systematic and targeted PBx, prebiopsy MRI-based risk calculators could limit VLR diagnosis by 41% using a risk threshold of >5% for Gleason grade group ≥3 PCa to recommend biopsy; the reduction would be 77% if performing targeted PBx only. These findings suggest that VLR disease continues to account for a significant minority of PCa diagnoses and could be limited by targeted PBx and risk stratification calculators. Patient summaryWe looked at recent trends for the diagnosis of very low-risk (VLR) prostate cancer. We found that VLR cancer still seems to be frequently diagnosed despite the use of MRI (magnetic resonance imaging) scans before biopsy. The use of risk calculators to identify men who could avoid biopsy and/or biopsy only for lesions that are visible on MRI could reduce the overdiagnosis of VLR prostate cancer.

MRI-measured adipose features as predictive factors for detection of prostate cancer in males undergoing systematic prostate biopsy: a retrospective study based on a Chinese population

ABSTRACT In this study, we retrospectively evaluated the data of 901 men undergoing ultrasonography-guided systematic prostate biopsy between March 2013 and May 2022. Adipose features, including periprostatic adipose tissue (PPAT) thickness and subcutaneous fat thickness, were measured using MRI before biopsy. Prediction models of all PCa and clinically significant PCa (csPCa) (Gleason score higher than 6) were established based on variables selected by multivariate logistic regression and prediction nomograms were constructed. Patients with PCa had higher PPAT thickness (4.64 [3.65–5.86] vs. 3.54 [2.49–4.51] mm, p < 0.001) and subcutaneous fat thickness (29.19 [23.05–35.95] vs. 27.90 [21.43–33.93] mm, p = 0.013) than those without PCa. Patients with csPCa had higher PPAT thickness (4.78 [3.80–5.88] vs. 4.52 [3.80–5.63] mm, p = 0.041) than those with non-csPCa. Adding adipose features to the prediction models significantly increased the area under the receiver operating characteristics curve for the prediction of all PCa (0.850 vs. 0.819, p < 0.001) and csPCa (0.827 vs. 0.798, p < 0.001). Based on MRI-measured adipose features and clinical parameters, we established two nomograms that were simple to use and could improve patient selection for prostate biopsy in Chinese population.

A review of optimal prostate biopsy: indications and techniques.

Prostate biopsy is the gold standard diagnostic technique for the detection of prostate cancer. Patient selection for prostate biopsy is complex and is influenced by emerging use of prebiopsy imaging. The introduction of the magnetic resonance imaging (MRI)–transrectal ultrasound (TRUS) fusion prostate biopsy has clear advantages over the historical standard of care. There are several biopsy techniques currently utilized with unique advantages and disadvantages. We review and summarize the current body of literature pertaining to when and how a prostate biopsy should be performed. We discuss current recommendations regarding patient selection for biopsy and discuss future directions regarding prebiopsy imaging. We offer a description of the MRI–TRUS fusion biopsy technique and a comparison of many of the currently available fusion software platforms. Articles pertaining to the title were obtained via PubMed index search with relevant keywords supplemented with personal collection of related publications. Prostate biopsy should be considered for patients with gross digital rectal exam (DRE) abnormality, patients with a prostate-specific antigen (PSA) greater than 4 ng/ml, and concomitant risk factors for prostate cancer or patients with lesions identified on multiparametric MRI (mpMRI) with Prostate Imaging Reporting and Data System 2 (PI-RADS2) score of 4 or 5. MRI–TRUS fusion biopsy has demonstrated advantages in cancer detection when compared with TRUS-guided biopsy. There are currently several fusion software platforms available with a variety of biopsy approaches. Future efforts should detail the role of prebiopsy imaging as a triage tool for prostate biopsy. Consensus should be sought regarding the preferred modality of fusion biopsy. Additional data describing each fusion software platform would enable a more rigorous comparison of platform sensitivities.

PD23-09 MULTIVARIABLE RISK-STRATIFICATION IN A PRIMARY HEALTHCARE SETTING: REFERRAL RATE AND BIOPSY RESULTS FROM A UROLOGY OUTPATIENT CENTER.

You have accessJournal of UrologyProstate Cancer: Detection & Screening II1 Apr 2018PD23-09 MULTIVARIABLE RISK-STRATIFICATION IN A PRIMARY HEALTHCARE SETTING: REFERRAL RATE AND BIOPSY RESULTS FROM A UROLOGY OUTPATIENT CENTER. Daniël Osses, Arnout Alberts, Gonny Bausch, and Monique Roobol Daniël OssesDaniël Osses More articles by this author , Arnout AlbertsArnout Alberts More articles by this author , Gonny BauschGonny Bausch More articles by this author , and Monique RoobolMonique Roobol More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.1190AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The use of multivariable risk-stratification in primary care could optimize the diagnostic pathway by reducing unnecessary referrals to specialist care. Dutch primary care physicians (PCPs) refer men with prostate-specific antigen (PSA) level ≥3.0 ng/ml to the urologist for risk-based patient selection for prostate biopsy using the Rotterdam Prostate Cancer Risk Calculator (RPCRC). Here, we calculated the risk and assessed the rate of men referred to the urologist with PSA level ≥3.0 ng/ml by implementing the RPCRC in a primary care setting. METHODS PCPs were given the possibility to refer men with a suspicion of prostate cancer (PCa) or screening wish to a primary care clinic (STAR-SHL) where further assessment including next to PSA, digital rectal examination and transrectal ultrasound with prostate volume measurement was performed by specially trained personnel. Risk-based advice on referral to the urologist was given to the PCP on the basis of the RPCRC results (lower part Table 1). If requested, advice on treatment of lower urinary tract symptoms (LUTS) was given. All men signed informed consent. RESULTS Between January 2014 and September 2017 a total of 243 men, median age 64 yr (range 39-91) were referred by their PCP for a consultation at the primary care clinic. Of 108 men with PSA level ≥3.0 ng/ml and a referral related to PCa, PCPs were advised to refer 58 men to the urologist (54%) (Table 1). Of the men with available follow-up (FU) (N=187, median FU 16 months; range 1-37) 54 men (8 men PSA <3.0 and 46 men PSA ≥3.0) were considered high-risk. Of these men 51 (94%) men were actually referred to specialist care by their PCP and so far 38 men underwent biopsy. PCa was detected in 30 men (47% had Gleason score [GS] ≥3+4 PCa), translating into an overall positive predictive value of 79%. Within the available FU time 2 of 38 (5%) men with PSA level ≥3.0 ng/ml considered low-risk have been diagnosed with GS 3+3 PCa. CONCLUSIONS Use of the RPCRC in a primary healthcare setting could prevent almost half of referrals of men with PSA level ≥3.0 ng/ml to the urologist. In more than three-quarter of men referred for prostate biopsy, the suspicion of PCa was confirmed. These data show huge potential for multivariable risk-stratification in primary care. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e483 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Daniël Osses More articles by this author Arnout Alberts More articles by this author Gonny Bausch More articles by this author Monique Roobol More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Multivariable risk-based patient selection for prostate biopsy in a primary health care setting: referral rate and biopsy results from a urology outpatient clinic.

BackgroundAccording to their guidelines, Dutch general practitioners (GPs) refer men with prostate-specific antigen (PSA) level ≥3.0 ng/mL to the urologist for risk-based patient selection for prostate biopsy using the Rotterdam Prostate Cancer Risk Calculator (RPCRC). Use of the RPCRC in primary care could optimize the diagnostic pathway even further by reducing unnecessary referrals. To investigate this, we calculated the risk and assessed the rate of men referred to the urologist with PSA level ≥3.0 ng/mL by implementing the RPCRC in a primary health care setting.MethodsIn January 2014, an exploratory study was initiated in collaboration with the primary health care facility of the GP laboratory in Rotterdam. GPs were given the possibility to refer men with a suspicion of prostate cancer (PCa) or a screening wish to this primary care facility (STAR-SHL) where further assessment was performed by specially trained personnel. Risk-based advice on referral to the urologist was given to the GP on the basis of the RPCRC results. If requested, advice on the treatment of lower urinary tract symptoms (LUTS) was provided. All men signed informed consent.ResultsBetween January 2014 and September 2017, a total of 243 men, median age 64 [interquartile range (IQR), 57–70] years were referred for a consultation at the primary care facility. Of the 108 men with PSA level ≥3.0 ng/mL and a referral related to PCa, GPs were advised to refer 58 men to the urologist (54%). Of the men with available follow-up (FU) data [n=187, median FU, 16 (IQR, 9–25) months] 54 men were considered high-risk (i.e., had an elevated risk of PCa as calculated by the RPCRC). Of these men, 51 (94%) were actually referred to secondary care by their GP, and so far 38 men underwent biopsy. PCa was detected in 30 men [47% had Gleason score (GS) ≥3+4 PCa], translating to an overall positive predictive value (PPV) of 79%. Within the available FU time, 2 out of 38 (5%) men with PSA level ≥3.0 ng/mL which were considered low-risk have been diagnosed with GS 3+3 PCa.ConclusionsRisk-stratification with the RPCRC in a primary health care setting could prevent almost half of referrals of men with PSA level ≥3.0 ng/mL to the urologist. In more than three-quarters of men referred for prostate biopsy, the suspicion of PCa was confirmed and almost half of men had clinically significant PCa (GS ≥3+4 PCa). These data show a huge potential for multivariable risk-stratification in primary care.

PD40-10 EFFECTS OF THE 2012 USPSTF PSA SCREENING RECOMMENDATIONS ON PROSTATE BIOPSY PRACTICES IN AN INNER CITY HOSPITAL WITH A HIGH RISK PATIENT POPULATION

You have accessJournal of UrologyProstate Cancer: Detection & Screening V1 Apr 2017PD40-10 EFFECTS OF THE 2012 USPSTF PSA SCREENING RECOMMENDATIONS ON PROSTATE BIOPSY PRACTICES IN AN INNER CITY HOSPITAL WITH A HIGH RISK PATIENT POPULATION Johnathan A. Khusid, Igor Inoyatov, Adan Beccera, Llewellyn Hyacinthe, Brian K. McNeil, and Andrew G. Winer Johnathan A. KhusidJohnathan A. Khusid More articles by this author , Igor InoyatovIgor Inoyatov More articles by this author , Adan BecceraAdan Beccera More articles by this author , Llewellyn HyacintheLlewellyn Hyacinthe More articles by this author , Brian K. McNeilBrian K. McNeil More articles by this author , and Andrew G. WinerAndrew G. Winer More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1750AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES In the 2012 US Preventative Services Task Force (USPSTF) recommendation against prostate specific antigen (PSA) screening, it was acknowledged that African American men represented a disproportionately small minority of the population analyzed. We sought to describe the prostate biopsy practice patterns before and after the recommendation in an inner city hospital that serves a high risk patient population of predominantly Afro Caribbean descent. METHODS A retrospective chart review of patients who underwent prostate biopsy from 10/27/2008 to 12/15/2015 was performed. Patients were grouped into those who underwent biopsy prior to, and after the new USPSTF guidelines (5/22/2012). Patient and clinical characteristics were compared between the two time periods. Bivariate analyses included two sample t tests, chi square tests, and the Mann Whitney U tests. RESULTS Our analysis revealed no significant differences in the age, percent of positive biopsies, or type of physician initiating screening. There was a significant difference in median PSA (p= 0.05) and a trend toward significance in the difference in racial distribution between the two groups (p=0.06). Among those with positive biopsies, patients biopsied after the recommendation had significantly greater core positivity, and a borderline significantly higher incidence of clinically significant disease defined by D Amico criteria (p=0.24) CONCLUSIONS In a high risk patient population, we found that men biopsied after the USPSTF recommendation were more likely to have a higher PSA level, more likely to be African American, had greater core positivity, and a higher incidence of clinically significant disease. These results suggest that high risk patients in an inner city setting are also being negatively affected by the implementation of the task force recommendations. Further research is required to determine whether the practice pattern change occurred at the level of PSA screening or rather at patient selection for prostate biopsy. Such research will allow clinicians to provide more granular counseling with regards to PSA screening and prostate biopsies for high risk patients. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e753-e754 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Johnathan A. Khusid More articles by this author Igor Inoyatov More articles by this author Adan Beccera More articles by this author Llewellyn Hyacinthe More articles by this author Brian K. McNeil More articles by this author Andrew G. Winer More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Risk of hospitalization and death following prostate biopsy in Scotland

ObjectiveTo investigate the risk of hospitalization and death following prostate biopsy. Study designRetrospective cohort study. MethodsOur study population comprised 10,285 patients with a record of first ever prostate biopsy between 2009 and 2013 on computerized acute hospital discharge or outpatient records covering Scotland. Using the general population as a comparison group, expected numbers of admissions/deaths were derived by applying age-, sex-, deprivation category-, and calendar year-specific rates of hospital admissions/deaths to the study population. Indirectly standardized hospital admission ratios (SHRs) and mortality ratios (SMRs) were calculated by dividing the observed numbers of admissions/deaths by expected numbers. ResultsCompared with background rates, patients were more likely to be admitted to hospital within 30 days (SHR 2.7; 95% confidence interval 2.4, 2.9) and 120 days (SHR 4.0; 3.8, 4.1) of biopsy. Patients with prior co-morbidity had higher SHRs. The risk of death within 30 days of biopsy was not increased significantly (SMR 1.6; 0.9, 2.7), but within 120 days, the risk of death was significantly higher than expected (SMR 1.9; 1.5, 2.4). The risk of death increased with age and tended to be higher among patients with prior co-morbidity. Overall risks of hospitalization and of death up to 120 days were increased both in men diagnosed and those not diagnosed with prostate cancer. ConclusionsHigher rates of adverse events in older patients and patients with prior co-morbidity emphasizes the need for careful patient selection for prostate biopsy and justifies ongoing efforts to minimize the risk of complications.

Understanding the Use of Prostate Biopsy Among Men with Limited Life Expectancy in a Statewide Quality Improvement Collaborative

BackgroundThe potential harms of a prostate cancer (PCa) diagnosis may outweigh its benefits in elderly men. ObjectiveTo assess the use of prostate biopsy in men with limited life expectancy (LE) within the practices comprising the Michigan Urological Surgery Improvement Collaborative (MUSIC). Design, setting, and participantsMUSIC is a consortium of 42 practices and nearly 85% of the urologists in Michigan. From July 2013 to October 2014, clinical data were collected prospectively for all men undergoing prostate biopsy. Outcome measurements and statistical analysisWe calculated comorbidity-adjusted LE in men aged ≥66 yr and identified men with <10 yr LE (limited LE) undergoing a first biopsy. Our LE calculator was not designed for men aged <66 yr; thus these men were excluded. Multivariable models estimated the proportion of all biopsies performed for men with limited LE in each MUSIC practice, adjusting for differences in patient characteristics. We also evaluated what treatments, if any, these patients received. Results and limitationsAmong 3035 men aged ≥66 yr undergoing initial prostate biopsy, 60% had none of the measured comorbidities. Overall, 547 men (18%) had limited LE. Compared with men with a longer LE, these men had significantly higher prostate-specific antigen levels and abnormal digital rectal examination findings. The adjusted proportion of biopsies performed for men with limited LE ranged from 3.8% to 39% across MUSIC practices (p < 0.001). PCa was diagnosed in 69% of men with limited LE; among this group, 74% received any active treatment. Of these men, 46% had high-grade cancer (Gleason score 8–10). ConclusionsAmong a large and diverse group of urology practices, nearly 20% of prostate biopsies are performed in men with limited LE. These data provide useful context for quality improvement efforts aimed at optimizing patient selection for prostate biopsy. Patient summaryIn this report, nearly 2 of every 10 men undergoing prostate biopsy had a life expectancy (LE) <10 yr. Implementing LE calculators in clinical practice may help refine patient selection for prostate biopsy.

MP67-06 VARIATION IN PROSTATE CANCER DETECTION RATES IN A STATEWIDE QUALITY IMPROVEMENT COLLABORATIVE

You have accessJournal of UrologyProstate Cancer: Detection & Screening IV1 Apr 2014MP67-06 VARIATION IN PROSTATE CANCER DETECTION RATES IN A STATEWIDE QUALITY IMPROVEMENT COLLABORATIVE Christopher B. Riedinger, Susan Linsell, Jun Ye, Rodney Dunn, James E. Montie, David C. Miller, and Brian R. Lane Christopher B. RiedingerChristopher B. Riedinger More articles by this author , Susan LinsellSusan Linsell More articles by this author , Jun YeJun Ye More articles by this author , Rodney DunnRodney Dunn More articles by this author , James E. MontieJames E. Montie More articles by this author , David C. MillerDavid C. Miller More articles by this author , and Brian R. LaneBrian R. Lane More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.2073AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES There remains significant controversy around the optimal criteria for recommending prostate biopsy. To examine this issue further, urologists in the Michigan Urological Surgery Improvement Collaborative (MUSIC) assessed statewide prostate biopsy practice patterns and variation in prostate cancer (PC) detection. METHODS MUSIC is a statewide physician-led collaborative designed to improve prostate cancer care. From 3/2012 through 6/2013, 17 MUSIC practices collected standardized clinical and pathological data for 3015 men undergoing first-time prostate biopsy. We examined pathologic biopsy outcomes across practices, stratifying men by age and PSA level. RESULTS The overall cancer detection rate was 52%, with significant variability across MUSIC practices (range: 43% to 70%, p<0.0001). 27% of all patients biopsied were > 69 years, ranging from 19% to 36% at individual practices. Men with a PSA < 4 ng/ml were 26% of our study population (range: 10% to 37%). Detection rates in patients > 69 years ranged from 42% to 86% for individual practices (p=0.0008). For patients with PSA < 4 (n=793), cancer detection rates ranged from 22% to 58% across individual practices (p=0.0065). The predicted probability of cancer detection varied significantly across MUSIC practices (p<0.0001) after adjusting for patient age, PSA, prostate size, family history and DRE findings. Prostate size 30 – 60 cc and > 60 cc were less likely to predict prostate cancer detection than size < 30 cc (odds ratio [OR] 0.53, 95% confidence interval [CI] 0.44-0.64 and OR 0.23, 95% CI 0.18-0.29, respectively). CONCLUSIONS Cancer detection rates are higher than previously reported. Practice patterns and cancer yield for prostate biopsy vary widely across urology practices in Michigan. These data serve as a foundation for our efforts to understand and improve patient selection for prostate biopsy. Percentage(%) of biopsies positive for PCa No. Overall Lowest Rate Among 17 Practices Highest Rate Among 17 Practices P Value All patients 3015 52 43 70 < 0.0001 Age < 55 years 434 45 18 73 0.1313 55 - 69 years 1766 50 32 67 0.0001 > 69 years 814 59 42 86 0.0008 PSA values < 4 793 38 22 58 0.0065 4 - 10 1853 54 47 63 0.2354 > 10 362 71 44 83 0.0526 Median prostate size < 30 596 62 49 100 0.0022 30 - 60 1641 52 33 75 < 0.0001 > 60 736 39 14 50 0.9222 Family history Negative 2339 50 41 71 < 0.0001 Positive 676 58 42 82 0.2604 DRE findings Negative 2085 49 40 66 < 0.0001 Positive 755 59 36 90 0.0005 © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e750-e751 Peer Review Report Advertisement Copyright & Permissions© 2014MetricsAuthor Information Christopher B. Riedinger More articles by this author Susan Linsell More articles by this author Jun Ye More articles by this author Rodney Dunn More articles by this author James E. Montie More articles by this author David C. Miller More articles by this author Brian R. Lane More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

MP67-07 TRANS-RECTAL ULTRASOUND VISIBILITY OF PROSTATE LESIONS INCREASES ACCURACY OF MR-TRUS IMAGE-FUSION GUIDED BIOPSIES.

patients > 69 years ranged from 42% to 86% for individual practices (p1⁄40.0008). For patients with PSA 60 cc were less likely to predict prostate cancer detection than size < 30 cc (odds ratio [OR] 0.53, 95% confidence interval [CI] 0.440.64 and OR 0.23, 95% CI 0.18-0.29, respectively). CONCLUSIONS: Cancer detection rates are higher than previously reported. Practice patterns and cancer yield for prostate biopsy vary widely across urology practices in Michigan. These data serve as a foundation for our efforts to understand and improve patient selection for prostate biopsy.

Variation in Prostate Cancer Detection Rates in a Statewide Quality Improvement Collaborative

There remains significant controversy surrounding the optimal criteria for recommending prostate biopsy. To examine this issue further urologists in MUSIC assessed statewide prostate biopsy practice patterns and variation in prostate cancer detection. MUSIC is a statewide, physician led collaborative designed to improve prostate cancer care. From March 2012 through June 2013 at 17 MUSIC practices standardized clinical and pathological data were collected on a total of 3,015 men undergoing first-time prostate biopsy. We examined pathological biopsy outcomes according to patient characteristics and across MUSIC practices. The average cancer detection rate was 52% with significant variability across MUSIC practices (range 43% to 70%, p<0.0001). Of all patients biopsied 27% were older than 69 years, ranging from 19% to 36% at individual practices. Men with prostate specific antigen less than 4 ng/ml comprised an average of 26% of the study population (range 10% to 37%). The detection rate in patients older than 69 years ranged from 42% to 86% at individual practices (p=0.0008). In the 793 patients with prostate specific antigen less than 4 ng/ml the cancer detection rate ranged from 22% to 58% across individual practices (p=0.0065). The predicted probability of cancer detection varied significantly across MUSIC practices even after adjusting for patient age, prostate specific antigen, prostate size, family history and digital rectal examination findings (p<0.0001). While overall detection rates are higher than previously reported, the cancer yield of prostate biopsy varies widely across urology practices in Michigan. These data serve as a foundation for our efforts to understand and improve patient selection for prostate biopsy.

Does genotyping of risk‐associated single nucleotide polymorphisms improve patient selection for prostate biopsy when combined with a prostate cancer risk calculator?

Genome-wide association studies have identified single nucleotide polymorphisms (SNPs) associated with higher risk of prostate cancer (PCa). This study aimed to evaluate whether published SNPs improve the performance of a clinical risk-calculator in predicting prostate biopsy result. Three hundred forty-six patients with a previous prostate biopsy (191 positive, 155 negative) were enrolled. After literature search, nine SNPs were selected for their statistically significant association with increased PCa risk. Allelic odds ratios were computed and a new logistic regression model was built integrating the clinical risk score (i.e., prior biopsy results, PSA level, prostate volume, transrectal ultrasound, and digital rectal examination) and a multilocus genetic risk score (MGRS). Areas under the receiver operating characteristic (ROC) curves (AUC) of the clinical score alone versus the integrated clinic-genetic model were compared. The added value of the MGRS was assessed using the Integrated Discrimination Improvement (IDI) and Net Reclassification Improvement (NRI) statistics. Predictive performance of the integrated clinico-genetic model (AUC = 0.781) was slightly higher than predictive performance of the clinical score alone (AUC = 0.770). The prediction of PCa was significantly improved with an IDI of 0.015 (P-value = 0.035) and a continuous NRI of 0.403 (P-value < 0.001). The predictive performance of the clinical model was only slightly improved by adding MGRS questioning the real clinical added value with regards to the cost of genetic testing and performance of current inexpensive clinical risk-calculators.

Patient Selection for Prostate Biopsy: Risk-based or PSA-based?

Aim: The AUA Best Practice Statement on PSA advocates a risk-based approach to selecting men for biopsy, based not on a PSA threshold, but on the risk of finding cancer on biopsy. We have therefore studied the association between candidate risk factors and prostate biopsy results. Method: All patients who underwent a prostate biopsy within the Epsom and St Helier NHS Trust between July 2005 and July 2007 were identified. Those with a serum PSA value of &lt;15.0ng/ml were selected for inclusion. Univariate and multivariate logistic regression analysis was done to analyse risk factors for the presence of cancer, and of significant cancer, on biopsy. Significant prostate cancer on biopsy was arbitrarily defined as either a Gleason score of 7 or more, or the presence of cancer in 50% or more of the cores. Results: Of 400 cases, 153 (38%) were found to have prostate cancer on biopsy, of which 93 were classed as significant. On multivariate analysis, smaller prostate volume, abnormal DRE, PSA level and absence of previous negative biopsy were independent predictors of significant prostate cancer. The multivariate logistic regression results were used to create a predictive nomogram for significant cancer. Conclusion: The PSA level is merely one of several factors that predict biopsy results. A risk-based, rather than a PSA-based, approach to selecting men for prostate biopsy has the potential to both reduce the number of men undergoing biopsy, and increase the detection of significant cancers.

Complications After Prostate Biopsy: Data From SEER-Medicare

More than 1 million prostate biopsies are performed annually among Medicare beneficiaries. We determined the risk of serious complications requiring hospitalization. We hypothesized that with emerging multidrug resistant organisms there may be an increasing risk of infectious complications. In a 5% random sample of Medicare participants in SEER (Surveillance, Epidemiology and End Results) regions from 1991 to 2007 we compared 30-day hospitalization rates and ICD-9 primary diagnosis codes for admissions between 17,472 men who underwent prostate biopsy and a random sample of 134,977 controls. Multivariate logistic and Poisson regression were used to examine the risk and predictors of serious infectious and noninfectious complications with time. The 30-day hospitalization rate was 6.9% within 30 days of prostate biopsy, which was substantially higher than the 2.7% in the control population. After adjusting for age, race, SEER region, year and comorbidities prostate biopsy was associated with a 2.65-fold (95% CI 2.47-2.84) increased risk of hospitalization within 30 days compared to the control population (p <0.0001). The risk of infectious complications requiring hospitalization after biopsy was significantly greater in more recent years (p(trend) = 0.001). Among men undergoing biopsy, later year, nonwhite race and higher comorbidity scores were significantly associated with an increased risk of infectious complications. The risk of hospitalization within 30 days of prostate biopsy was significantly higher than in a control population. Infectious complications after prostate biopsy have increased in recent years while the rate of serious noninfectious complications is relatively stable. Careful patient selection for prostate biopsy is essential to minimize the potential harms.

PSA Velocity: A Criterion for Prostate Biopsy?

Patient selection for prostate biopsy is typically based on several factors including age, race, prostate-specific antigen (PSA) values (both free and

Serum human glandular kallikrein (hK2) and insulin-like growth factor 1 (IGF-1) improve the discrimination between prostate cancer and benign prostatic hyperplasia in combination with total and %free PSA.

There is growing evidence describing an association of hK2 and IGFs with cancer. The aim of this study is to investigate the differences in serum levels of hK2 and IGFs in a large group of patients with benign prostatic hyperplasia (BPH) or prostatic carcinoma (CaP) and to examine the value of these variables, as well as their various combinations with PSA, for discriminating between these two clinical entities. Human glandular kallikrein 2 (hK2), insulin-like growth factor-1 (IGF-1), free and total PSA concentrations were measured with non-competitive immunological procedures. Receiver operating characteristic (ROC) analysis as well as univariate and multivariate logistic regression analysis were performed to investigate the potential utility of the various markers and their combinations for discriminating between BPH and CaP. hK2 and IGF-1 concentrations were increased in CaP patients, in comparison to BPH patients. hK2/free PSA and free/total PSA ratios (area under the curve, AUC = 0.70) were stronger predictors of prostate cancer than the IGF-1/total PSA ratio (AUC = 0.56) in the group of patients with total PSA <4 microg/L. The hK2/free PSA ratio (AUC = 0.74) was found to have significant discriminatory value in patients with total PSA within the "gray zone" (4-10 microg/L). Multivariate logistic regression models confirmed the observed relationships and identified IGF-1/free PSA and hK2/free PSA as independent predictors of CaP. hK2/free PSA and IGF-1/free PSA ratios may be useful adjuncts in improving patient selection for prostate biopsy.

Serum human glandular kallikrein-2 protease levels predict the presence of prostate cancer among men with elevated prostate-specific antigen.

We hypothesize that serum human glandular kallikrein-2 (hK2) levels predict the presence of prostate cancer among men prescreened by prostate-specific antigen (PSA). We conducted a cross-sectional study of 324 men who had no history of prostate cancer and who were referred for prostate biopsy. PSA and hK2 levels were measured using specific nonisotopic immunometric techniques. Cases were patients who were diagnosed with adenocarcinoma of the prostate from biopsy, and controls were patients who had no evidence of cancer from biopsy. The odds ratio for detection of prostate cancer was determined for hK2 measurements, controlling for age, total-PSA level, digital rectal examination, and symptoms of urinary obstruction. Of 324 men, 159 (49.1%) had cancer. Mean hK2 levels and hK2:free-PSA ratios were significantly higher in cases than in controls (1.18 v 0.53 ng/mL, respectively, for hK2, P =.0001; 1.17 v 0.62 for hK2:free-PSA ratio, P =.0001). The crude odds ratio for prostate cancer detection for patients in the highest quartile of hK2 level was 5.83 (95% confidence interval [CI], 2.8 to 12.1; P =.0001) compared with patients in the lowest quartile. The adjusted odds ratio was 6.72 (95% CI, 2.9 to 15.6; P =.0001). Similarly, the crude and adjusted odds ratios for prostate cancer detection using the hK2:free-PSA ratio were 7.36 (95% CI, 3.6 to 15.1; P =.0001) and 8.06 (95% CI, 3. 7 to 17.4; P =.0001), respectively. These odds ratios were higher than that observed for prostate cancer detection by total-PSA level (2.73; P =.03). Among men prescreened with PSA for prostate cancer, patients with high hK2 measurements have a five- to eight-fold increase in risk for prostate cancer, adjusting for PSA level and other established risk factors. hK2 measurements may be a useful adjunct to PSA in improving patient selection for prostate biopsy.