Rotterdam Prostate Cancer Risk Calculator Research Articles

Performance of magnetic resonance imaging-based prostate cancer risk calculators and decision strategies in two large European medical centres.

To compare the performance of currently available biopsy decision support tools incorporating magnetic resonance imaging (MRI) findings in predicting clinically significant prostate cancer (csPCa). We retrospectively included men who underwent prostate MRI and subsequent targeted and/or systematic prostate biopsies in two large European centres. Available decision support tools were identified by a PubMed search. Performance was assessed by calibration, discrimination, decision curve analysis (DCA) and numbers of biopsies avoided vs csPCa cases missed, before and after recalibration, at risk thresholds of 5%-20%. A total of 940 men were included, 507 (54%) had csPCa. The median (interquartile range) age, prostate-specific antigen (PSA) level, and PSA density (PSAD) were 68 (63-72) years, 9 (7-15) ng/mL, and 0.20 (0.13-0.32) ng/mL2 , respectively. In all, 18 multivariable risk calculators (MRI-RCs) and dichotomous biopsy decision strategies based on MRI findings and PSAD thresholds were assessed. The Van Leeuwen model and the Rotterdam Prostate Cancer Risk Calculator (RPCRC) had the best discriminative ability (area under the receiver operating characteristic curve 0.86) of the MRI-RCs that could be assessed in the whole cohort. DCA showed the highest clinical utility for the Van Leeuwen model, followed by the RPCRC. At the 10% threshold the Van Leeuwen model would avoid 22% of biopsies, missing 1.8% of csPCa, whilst the RPCRC would avoid 20% of biopsies, missing 2.6% of csPCas. These multivariable models outperformed all dichotomous decision strategies based only on MRI-findings and PSAD. Even in this high-risk cohort, biopsy decision support tools would avoid many prostate biopsies, whilst missing very few csPCa cases. The Van Leeuwen model had the highest clinical utility, followed by the RPCRC. These multivariable MRI-RCs outperformed and should be favoured over decision strategies based only on MRI and PSAD.

External validation of the Rotterdam Prostate Cancer Risk Calculator within a Dutch high-risk clinical cohort

SamenvattingHet positieve effect van de Rotterdam Prostate Cancer Risk Calculator (RPCRC)-3/4 en RPCRC-MRI is reeds bevestigd. Toch worden de prestaties en de toepasbaarheid ervan in de klinische praktijk in twijfel getrokken. Deze studie verricht een externe validatie van de RPCRC-3/4 en -MRI binnen een Nederlands klinisch hoogrisicocohort. Mannen (n = 1.575) die tussen 2018 en 2021 prostaatbiopten ondergingen in verband met een klinische verdenking op prostaatkanker (PCa) werden retrospectief geïncludeerd. Bij 996/1.575 (63,2 %) en 656/1.575 (41,7 %) mannen werd respectievelijk PCa en klinisch significant PCa (csPCa) gediagnosticeerd. Uit analyse bleek de RPCRC-3/4 het risico op csPCa te onderschatten: al zou RPCRC-3/4 37,3 % van alle MRI’s voorkomen, dan nog zou 18,3 % van de csPCa-diagnoses worden gemist. Herkalibratie en aanpassing van risicodrempels was om die reden dan ook geïndiceerd. De RPCRC-MRI presteerde daarentegen adequaat en herkalibratie was niet noodzakelijk.

Avoiding Prostate Biopsies in Patients at Low Risk for Prostate Cancer: A Prospective Evaluation of a PSA-Density-Based Safety Net

Introduction and Objectives: Decision-making to perform prostate biopsy should include individual risk assessment. Patients classified as low risk by the Rotterdam Prostate Cancer Risk Calculator are advised to forego biopsy (PBx). There is concern about missing clinically significant prostate cancer (csPCa). A clear pathway for follow-up is needed. Material and Methods: Data for 111 consecutive patients were collected. Patients were encouraged to adhere to a PSA-density-based safety net after PBx was omitted. Cut off values indicating a re-evaluation were PSA density >0.15 ng/mL/ccm in PBx-naïve patients and >0.2 ng/mL/ccm in men with past-PBx. Primary endpoint was whether men had their PSA taken regularly. Secondary endpoint was whether a new multiparametric MRI was performed when PSA-density increased. Tertiary endpoint was whether biopsy was performed when risk stratification revealed an increased risk. Results: Median follow-up was 12 months (IQR 9–15 months). The primary endpoint was reached by 97.2% (n = 106). The secondary endpoint was reached by 30% (n = 3). The tertiary endpoint was reached by 50% (n = 2). Histopathologic analyses revealed csPCa in none of these cases. Risk stratification did not change (p = 0.187) with the majority of patients (89.2%, n = 99). Conclusion: The concern of missing csPCa when omitting PBx in the risk-stratified pathway may be negated. Changes in risk stratification during follow-up should lead to subsequent PBx. We suggest implementing a safety net based on PSA density and digital rectal examination (DRE).

Prostate cancer risk assessment by the primary care physician and urologist: transabdominal- versus transrectal ultrasound prostate volume-based use of the Rotterdam Prostate Cancer Risk Calculator.

Our objective was to assess the accuracy of transabdominal ultrasound (TAUS) measured prostate volume in the primary care setting with transrectal ultrasound (TRUS) measured prostate volume by the urologist as the reference test. Furthermore, our objective was to assess whether risk-stratification using TAUS prostate volume by the primary care physician could reduce unnecessary referrals to the urologist. Men in two Dutch primary care offices with a prostate cancer (PCa) screening request received a digital rectal examination (DRE), prostate specific-antigen (PSA), and TAUS prostate volume measurement by the general practitioner, followed by Rotterdam Prostate Cancer Risk Calculator (RPCRC) risk assessment. The examination was repeated by a urologist using TRUS. A prostate biopsy was performed in case of a RPCRC positive biopsy advice. A non-inferiority analysis was performed comparing TAUS and TRUS prostate volume differences. A risk-based referral strategy using TAUS and the RPCRC in the primary care setting was compared with the standard referral strategy based on PSA (≥3 ng/mL) and DRE. A total of 105 men were included with a median PSA of 1.9 ng/mL. The mean prostate volumes measured by TAUS and TRUS were 55 and 45 mL, respectively. The mean overestimation of the prostate volume by TAUS as compared to the reference test was 9.9 mL (95% CI: 5.9-13.8). According to Dutch standard practice, 41 out of 105 (39%) men would have been referred to the urologist. Stratification in primary care based on the RPCRC using TAUS prostate volume would have avoided 29 out of the 41 (71%) referrals, at the expense of non-referral of 5 out of 11 (45%) men with a biopsy indication, according to the urologist. RPCRC-based risk stratification in primary care using TAUS prostate volume measurement is feasible and may prevent unnecessary referrals to the urologist and reduce costs. The accuracy of the risk assessment with TAUS might be improved by sufficient training and centralization to achieve a higher volume of consultations in primary care facilities.

External validation of the Rotterdam Prostate Cancer Risk Calculator (RPCRC) and comparison to Stockholm3 for prostate cancer diagnosis in a Swedish population-based screening cohort

External validation of the Rotterdam Prostate Cancer Risk Calculator (RPCRC) and comparison to Stockholm3 for prostate cancer diagnosis in a Swedish population-based screening cohort

External Validation of the Rotterdam Prostate Cancer Risk Calculator and Comparison with Stockholm3 for Prostate Cancer Diagnosis in a Swedish Population-based Screening Cohort

BackgroundThe Rotterdam Prostate Cancer Risk Calculator (RPCRC) and Stockholm3 can be used to aid urologists in their decision to refer men to magnetic resonance imaging (MRI) or biopsy for early detection of prostate cancer. ObjectiveTo assess the external validity of the RPCRC and compare it with using PSA and Stockholm3 to detect clinically significant prostate cancer. Design, setting, and participantsUsing data from the prospective, population-based, randomised STHLM3-MRI screening trial, we included participants with prostate-specific antigen (PSA) ≥3 ng/ml or Stockholm3 risk threshold ≥11% in the standard group who underwent systematic prostate biopsies. Outcome measurements and statistical analysisProbabilities for clinically significant prostate cancer (csPC, International Society of Urological Pathology grade ≥2) were calculated for each participant using the RPCRC and Stockholm3 with and without prostate volume. Performance of the risk calculators was assessed by discrimination, calibration, and clinical benefits. Results and limitationsIn total, 666 men with a median age of 67 yr (interquartile range [IQR]: 61–71) and PSA of 3.4 ng/ml (2.5–5.0) were included, of whom 154 (23%) had csPC. Risk distribution of the RPCRC was narrow: median risks of 2% (IQR 1–4%) compared with 14% (IQR: 9.5–23%) for Stockholm3. Using RPCRC’s recommended risk threshold of ≥4% for finding csPC, 54% of all csPC cases would be detected versus 94% using Stockholm3 with a threshold of ≥11%. Calibration of Stockholm3 was adequate while RPCRC underestimated the risk of csPC. The Stockholm3 test showed positive net benefits at clinically relevant thresholds, while the RPCRC showed negative net benefits. Compared with PSA, the RPCRC was associated with lower detection of csPC (84 vs 103; 0.82 [0.71–0.93]), while Stockholm3 was associated with higher detection of csPC (143 vs 103; 1.40 [1.23–1.57]). The main limitation was that Stockholm3 was evaluated in a similar population to where it was developed. ConclusionsThe performance of the RPCRC in a Swedish population-based cohort is suboptimal with a considerable underestimation of prostate cancer risk, while the Stockholm3 test showed superior performance and a positive clinical benefit. Patient summaryThe use of the Rotterdam Prostate Cancer Risk Calculator available online to predict the risk of prostate cancer in a Swedish cohort was found to be clinically harmful as it underpredicted the risk of clinically significant prostate cancer, while the Stockholm3 test performed well showing clinical benefits.

External validation of the Rotterdam prostate cancer risk calculator within a high-risk Dutch clinical cohort.

This study aims to externally validate the Rotterdam Prostate Cancer Risk Calculator (RPCRC)-3/4 and RPCRC-MRI within a Dutch clinical cohort. Men subjected to prostate biopsies, between 2018 and 2021, due to a clinical suspicion of prostate cancer (PCa) were retrospectively included. The performance of the RPCRC-3/4 and RPCRC-MRI was analyzed in terms of discrimination, calibration and net benefit. In addition, the need for recalibration and adjustment of risk thresholds for referral was investigated. Clinically significant (cs) PCa was defined as Gleason score ≥ 3 + 4. A total of 1575 men were included in the analysis. PCa was diagnosed in 63.2% (996/1575) of men and csPCa in 41.7% (656/1575) of men. Use of the RPCRC-3/4 could have prevented 37.3% (587/1575) of all MRIs within this cohort, thereby missing 18.3% (120/656) of csPCa diagnoses. After recalibration and adjustment of risk thresholds to 20% for PCa and 10% for csPCa, use of the recalibrated RPCRC-3/4 could have prevented 15.1% (238/1575) of all MRIs, resulting in 5.3% (35/656) of csPCa diagnoses being missed. The performance of the RPCRC-MRI was good; use of this risk calculator could have prevented 10.7% (169/1575) of all biopsies, resulting in 1.2% (8/656) of csPCa diagnoses being missed. The RPCRC-3/4 underestimates the probability of having csPCa within this Dutch clinical cohort, resulting in significant numbers of csPCa diagnoses being missed. For optimal performance of a risk calculator in a specific cohort, evaluation of its performance within the population under study is essential.

External Validation of the Prostate Biopsy Collaborative Group Risk Calculator and the Rotterdam Prostate Cancer Risk Calculator in a Swedish Population-based Screening Cohort

BackgroundExternal validation of risk calculators (RCs) is necessary to determine their clinical applicability beyond the setting in which these were developed. ObjectiveTo assess the performance of the Rotterdam Prostate Cancer RC (RPCRC) and the Prostate Biopsy Collaborative Group RC (PBCG-RC). Design, setting, and participantsWe used data from the prospective, population-based STHLM3 screening study, performed in 2012–2015. Participants with prostate-specific antigen ≥3 ng/ml who underwent systematic prostate biopsies were included. Outcome measurements and statistical analysisProbabilities for clinically significant prostate cancer (csPCa), defined as International Society of Urological Pathology grade ≥2, were calculated for each participant. External validity was assessed by calibration, discrimination, and clinical usefulness for both original and recalibrated models. Results and limitationsOut of 5841 men, 1054 (18%) had csPCa. Distribution of risk predictions differed between RCs; median risks for csPCa using the RPCRC and PBCG-RC were 3.3% (interquartile range [IQR] 2.1–7.1%) and 20% (IQR 15–28%), respectively. The correlation between RC risk estimates on individual level was moderate (Spearman’s r = 0.55). Using the RPCRC’s recommended risk threshold of ≥4% for finding csPCa, 36% of participants would get concordant biopsy recommendations. At 10% risk cut-off, RCs agreed in 23% of cases. Both RCs showed good discrimination, with areas under the curves for the RPCRC of 0.74 (95% confidence interval [CI] 0.72–0.76) and the PBCG-RC of 0.70 (95% CI 0.68–0.72). Calibration was adequate using the PBCG-RC (calibration slope: 1.13 [95% CI 1.03–1.23]), but the RPCRC underestimated the risk of csPCa (calibration slope: 0.73 [0.68–0.79]). The PBCG-RC showed a net benefit in a decision curve analysis, whereas the RPCRC showed no net benefit at clinically relevant risk threshold levels. Recalibration improved clinical benefit, and differences between RCs decreased. ConclusionsAssessment of calibration is essential to ensure the clinical value of risk prediction tools. The PBCG-RC provided clinical benefit in its current version online. On the contrary, the RPCRC cannot be recommended in this setting. Patient summaryPredicting the probability of finding prostate cancer on biopsy differed between two assessed risk calculators. After recalibration, the agreement of the models improved, and both were shown to be clinically useful.

A Prospective Multicenter Comparison Study of Risk-adapted Ultrasound-directed and Magnetic Resonance Imaging–directed Diagnostic Pathways for Suspected Prostate Cancer in Biopsy-naïve Men

BackgroundEuropean Association of Urology guidelines recommend a risk-adjusted biopsy strategy for early detection of prostate cancer in biopsy-naïve men. It remains unclear which strategy is most effective. Therefore, we evaluated two risk assessment pathways commonly used in clinical practice. ObjectiveTo compare the diagnostic performance of a risk-based ultrasound (US)-directed pathway (Rotterdam Prostate Cancer Risk Calculator [RPCRC] #3; US volume assessment) and a magnetic resonance imaging (MRI)-directed pathway. Design, setting, and participantsThis was a prospective multicenter study (MR-PROPER) with 1:1 allocation among 21 centers (US arm in 11 centers, MRI arm in ten). Biopsy-naïve men with suspicion of prostate cancer (age ≥50 yr, prostate-specific antigen 3.0–50 ng/ml, ± abnormal digital rectal examination) were included. InterventionBiopsy-naïve men with elevated risk of prostate cancer, determined using RPCRC#3 in the US arm and Prostate Imaging Reporting and Data System scores of 3–5 in the MRI arm, underwent systematic biopsies (US arm) or targeted biopsies (MRI arm). Outcome measurements and statistical analysisThe primary outcome was the proportion of men with grade group (GG) ≥2 cancer. Secondary outcomes were the proportions of biopsies avoided and GG 1 cancers detected. Categorical (nonparametric) data were assessed using the Mann-Whitney U test and χ2 tests. Results and limitationsA total of 1965 men were included in the intention-to-treat population (US arm n = 950, MRI arm n = 1015). The US and MRI pathways detected GG ≥2 cancers equally well (235/950, 25% vs 239/1015, 24%; difference 1.2%, 95% confidence interval [CI] −2.6% to 5.0%; p = 0.5). The US pathway detected more GG 1 cancers than the MRI pathway (121/950, 13% vs 84/1015, 8.3%; difference 4.5%, 95% CI 1.8–7.2%; p < 0.01). The US pathway avoided fewer biopsies than the MRI pathway (403/950, 42% vs 559/1015, 55%; difference −13%, 95% CI −17% to −8.3%; p < 0.01). Among men with elevated risk, more GG ≥2 cancers were detected in the MRI group than in the US group (52% vs 43%; difference 9.2%, 95% CI 3.0–15%; p < 0.01). ConclusionsRisk-adapted US-directed and MRI-directed pathways detected GG ≥2 cancers equally well. The risk-adapted US-directed pathway performs well for prostate cancer diagnosis if prostate MRI capacity and expertise are not available. If prostate MRI availability is sufficient, risk assessment should preferably be performed using MRI, as this avoids more biopsies and detects fewer cases of GG 1 cancer. Patient summaryAmong men with suspected prostate cancer, relevant cancers were equally well detected by risk-based pathways using either ultrasound or magnetic resonance imaging (MRI) to guide biopsy of the prostate. If prostate MRI availability is sufficient, risk assessment should be performed with MRI to reduce unnecessary biopsies and detect fewer irrelevant cancers.

Reducing Biopsies and Magnetic Resonance Imaging Scans During the Diagnostic Pathway of Prostate Cancer: Applying the Rotterdam Prostate Cancer Risk Calculator to the PRECISION Trial Data

BackgroundRisk stratification in the diagnostic pathway of prostate cancer (PCa) can be used to reduce biopsies and magnetic resonance imaging (MRI) scans, while maintaining the detection of clinically significant PCa (csPCa). The use of highly discriminating and well-calibrated models will generate better clinical outcomes if context-dependent thresholds are used. ObjectiveTo retrospectively assess the effect of the upfront use of the Rotterdam Prostate Cancer Risk Calculator (RPCRC) developed in a screening cohort and the RPCRC-MRI developed in a clinical cohort while exploring the need to adapt thresholds in biopsy-naïve men in the PRECISION (Prostate Evaluation for Clinically Important Disease: Sampling Using Image Guidance or Not?) trial. Design, setting, and participantsIn the transrectal ultrasonography arm, we evaluated 188 men; in the MRI arm, we evaluated 206 (for the reduction of MRI scans) and 137 (for the reduction of targeted biopsies) men. Outcome measurements and statistical analysisPerformance was assessed by discrimination, calibration, and clinical utility. Results and limitationsThe performance of the RPCRC was good. However, intercept adjustment was warranted. Net benefit was observed from a recalibrated probability of 32% for any PCa and 10% for csPCa. After recalibration and applying a threshold of 20% for any PCa or 10% for csPCa, 28% of all biopsies could have been reduced, missing five cases of csPCa. The uncalibrated RPCRC could reduce 35% of all MRI scans, with a threshold of 20% for any PCa or 4% for csPCa. In the MRI arm, performance was good without stressing recalibration. Net benefit was observed from a probability of 22% for any PCa and 7% for csPCa. With a threshold of 20% for any PCa or 4% for csPCa, 9% of all targeted biopsies could be reduced, missing one grade group 2 PCa. ConclusionsThe performance of the RPCRC and RPCRC-MRI in men included in the PRECISION trial was good, but recalibration and adaptation of the risk threshold of the RPCRC are indicated to reach optimal performance. Patient summaryIn this report, we show that risk stratification with the Rotterdam Prostate Cancer Risk Calculator has added value in reducing harm, but adjustment to reflect the characteristics of the patient cohort is indicated.

P011 - External validation of the Rotterdam Prostate Cancer Risk Calculator and the Prostate Biopsy Collaborative Group Risk Calculator in a Swedish population-based screening cohort

P011 - External validation of the Rotterdam Prostate Cancer Risk Calculator and the Prostate Biopsy Collaborative Group Risk Calculator in a Swedish population-based screening cohort

P1008 - Reducing biopsies and mris in the diagnostic pathway of prostate cancer: Applying the Rotterdam Prostate Cancer Risk Calculator to the PRECISION trial data

P1008 - Reducing biopsies and mris in the diagnostic pathway of prostate cancer: Applying the Rotterdam Prostate Cancer Risk Calculator to the PRECISION trial data

Rotterdam mobile phone app including MRI data for the prediction of prostate cancer: A multicenter external validation

ObjectivesThe Rotterdam Prostate Cancer Risk calculator (RPCRC) has been validated in the past years. Recently a new version including multiparametric magnetic resonance imaging (mpMRI) data has been released. The aim of our study was to analyze the performance of the mpMRI RPCRC app. MethodsA series of men undergoing prostate biopsies were enrolled in eleven Italian centers. Indications for prostate biopsy included: abnormal Prostate specific antigen levels (PSA>4 ng/ml), abnormal DRE and abnormal mpMRI. Patients’ characteristics were recorded. Prostate cancer (PCa) risk and high-grade PCa risk were assessed using the RPCRC app. The performance of the mpMRI RPCRC in the prediction of cancer and high-grade PCa was evaluated using receiver operator characteristics, calibration plots and decision curve analysis. ResultsOverall, 580 patients were enrolled: 404/580 (70%) presented PCa and out of them 224/404 (55%) presented high-grade PCa. In the prediction of cancer, the RC presented good discrimination (AUC = 0.74), poor calibration (p = 0.01) and a clinical net benefit in the range of probabilities between 50 and 90% for the prediction of PCa (Fig. 1). In the prediction of high-grade PCa, the RC presented good discrimination (AUC = 0.79), good calibration (p = 0.48) and a clinical net benefit in the range of probabilities between 20 and 80% (Fig. 1). ConclusionsThe Rotterdam prostate cancer risk App accurately predicts the risk of PCa and particularly high-grade cancer. The clinical net benefit is wide for high-grade cancer and therefore its implementation in clinical practice should be encouraged. Further studies should assess its definitive role in clinical practice.

Prostate Cancer Risk Calculator Apps in a Taiwanese Population Cohort: Validation Study.

BackgroundMobile health apps have emerged as useful tools for patients and clinicians alike, sharing health information or assisting in clinical decision-making. Prostate cancer (PCa) risk calculator mobile apps have been introduced to assess risks of PCa and high-grade PCa (Gleason score ≥7). The Rotterdam Prostate Cancer Risk Calculator and Coral–Prostate Cancer Nomogram Calculator apps were developed from the 2 most-studied PCa risk calculators, the European Randomized Study of Screening for Prostate Cancer (ERSPC) and the North American Prostate Cancer Prevention Trial (PCPT) risk calculators, respectively. A systematic review has indicated that the Rotterdam and Coral apps perform best during the prebiopsy stage. However, the epidemiology of PCa varies among different populations, and therefore, the applicability of these apps in a Taiwanese population needs to be evaluated. This study is the first to validate the PCa risk calculator apps with both biopsy and prostatectomy cohorts in Taiwan.ObjectiveThe study’s objective is to validate the PCa risk calculator apps using a Taiwanese cohort of patients. Additionally, we aim to utilize postprostatectomy pathology outcomes to assess the accuracy of both apps with regard to high-grade PCa.MethodsAll male patients who had undergone transrectal ultrasound prostate biopsies in a single Taiwanese tertiary medical center from 2012 to 2018 were identified retrospectively. The probabilities of PCa and high-grade PCa were calculated utilizing the Rotterdam and Coral apps, and compared with biopsy and prostatectomy results. Calibration was graphically evaluated with the Hosmer-Lemeshow goodness-of-fit test. Discrimination was analyzed utilizing the area under the receiver operating characteristic curve (AUC). Decision curve analysis was performed for clinical utility.ResultsOf 1134 patients, 246 (21.7%) were diagnosed with PCa; of these 246 patients, 155 (63%) had high-grade PCa, according to the biopsy results. After confirmation with prostatectomy pathological outcomes, 47.2% (25/53) of patients were upgraded to high-grade PCa, and 1.2% (1/84) of patients were downgraded to low-grade PCa. Only the Rotterdam app demonstrated good calibration for detecting high-grade PCa in the biopsy cohort. The discriminative ability for both PCa (AUC: 0.779 vs 0.687; DeLong’s method: P<.001) and high-grade PCa (AUC: 0.862 vs 0.758; P<.001) was significantly better for the Rotterdam app. In the prostatectomy cohort, there was no significant difference between both apps (AUC: 0.857 vs 0.777; P=.128).ConclusionsThe Rotterdam and Coral apps can be applied to the Taiwanese cohort with accuracy. The Rotterdam app outperformed the Coral app in the prediction of PCa and high-grade PCa. Despite the small size of the prostatectomy cohort, both apps, to some extent, demonstrated the predictive capacity for true high-grade PCa, confirmed by the whole prostate specimen. Following our external validation, the Rotterdam app might be a good alternative to help detect PCa and high-grade PCa for Taiwanese men.

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

BackgroundMultiparametric 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. ObjectiveTo 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. Design, setting, and participantsAn institutional dataset of 505 consecutive patients with suspected PCa between July 2019 and February 2020 was used. Outcome measurements and statistical analysisChi-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. Results and limitationsAfter 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). ConclusionsImplementation 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. Patient summaryIn 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.

Reducing unnecessary biopsies while detecting clinically significant prostate cancer including cribriform growth with the ERSPC Rotterdam risk calculator and 4Kscore

IntroductionThe use of risk calculators predicting clinically significant prostate cancer (csCaP) on biopsy reduces unnecessary biopsies and overdiagnosis of indolent disease compared to a Prostate Specific Antigen (PSA) strategy. Updating these tools using more specific outcome measures and contemporary predictors could potentially lead to further reductions. Our objective was to assess clinical impact of the 4 kallikrein (4K) score, the Rotterdam Prostate Cancer Risk Calculator (RPCRC), and the combination of both for predicting csCaP based on the latest International Society of Urological Pathology grading system and cribriform growth pattern. Materials and methodsOur prospective cohort consisted of 2,872 men from the first screening round in the European Randomized Study of Screening for Prostate Cancer Rotterdam; biopsy indication PSA ≥ 3.0. The predictive performance of the 4Kscore, RPCRC, and the combination of RPCRC with 4Kscore were assessed with area under the receiver operator characteristic curve (AUC) and calibration plots. Decision curve analysis was used to evaluate the reduction of unnecessary biopsy and indolent CaP. ResultsThe csCaP was present in 242 (8%) men, and indolent CaP in 578 (20%). The 4Kscore and RPCRC had similar high AUCs (0.88 vs. 0.87; P = 0.41). The 4Kscore-RPCRC combination improved AUC to 0.89 compared to 4Kscore (P < 0.01) and RPCRC (P < 0.01). The RPCRC and 4Kscore reduced the number of Bx with 42 and 44, respectively, per 100 men at risk compared to a ≥PSA 3.0 strategy without increasing missed csCaP. The RPCRC-4Kscore combination resulted in a slight additional net reduction of 3.3 biopsies per 100 men. ConclusionsThe RPCRC and 4Kscore had similar reductions of unnecessary biopsies and overdiagnosis of indolent disease. Combination of both models slightly reduced unnecessary biopsies further. Gain in net benefit must, however, be weighed against additional costs and availability of tests.

Prostate Cancer Risk Assessment in Biopsy-naïve Patients: The Rotterdam Prostate Cancer Risk Calculator in Multiparametric Magnetic Resonance Imaging-Transrectal Ultrasound (TRUS) Fusion Biopsy and Systematic TRUS Biopsy

BackgroundThe value of multiparametric magnetic resonance imaging (mpMRI) and targeted biopsy (TBx) remains controversial for biopsy-naïve men when compared to transrectal ultrasound (TRUS)-guided systematic biopsy (SBx). Risk-based patient selection could help to selectively identify men with significant prostate cancer (PCa) and thus reduce unnecessary mpMRI and biopsies. ObjectivesTo compare PCa detection rates for mpMRI TBx with SBx and to determine the rate of potentially avoided mpMRI and biopsies through risk-based selection using the Rotterdam Prostate Cancer Risk Calculator (RPCRC). Design, setting, and participantsTwo-hundred consecutive biopsy-naïve men in two centres underwent mpMRI scanning, 12-core SBx, and subsequent MRI-TRUS TBx in the case of suspicious lesion(s) (Prostate Imaging-Reporting and Data System v.2 score ≥3). Outcome measurements and statistical analysisWe measured the detection rate for high-grade (Gleason score ≥ 3+4) PCa for TBx and SBx. We carried out a retrospective stratification according to RPCRC biopsy advice to determine the rate of mpMRI and biopsies that could potentially be avoided by RPCRC-based patient selection in relation to the rate of high-grade PCa missed. Results and limitationsTBx yielded high-grade PCa in 51 men (26%) and low-grade PCa in 14 men (7%), while SBx yielded high-grade PCa in 63 men (32%) and low-grade PCa in 41 men (21%). Four out of 73 men (5%) with negative RPCRC advice and 63 out of 127 men (50%) with positive advice had high-grade PCa. Upfront RPCRC-based patient selection for mpMRI and TBx would have avoided 73 out of 200 (37%) mpMRI scans, missing two out of 51 (4%) high-grade PCas. Limitations include the RPCRC definition of high- and low-grade PCa and different mpMRI techniques. ConclusionsmpMRI with TBx detected PCa with high Gleason score and avoided biopsy in low-grade PCa, but failed to detect all high-grade PCa when compared to SBx among biopsy-naïve men. Risk-based patient selection using the RPCRC can avoid one-third of mpMRI scans and SBx in biopsy-naïve men. Patient summaryMen with a suspicion of prostate cancer are increasingly undergoing a magnetic resonance imaging (MRI) scan. Although promising, MRI-targeted biopsy is not accurate enough to safely replace systematic prostate biopsy for now. Individualised assessment of prostate cancer risk using the Rotterdam Prostate Cancer Risk Calculator could avoid one-third of MRI scans and systematic prostate biopsies.

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 ...

Prostate cancer risk-assessment for multiparametric MRI targeted and systematic biopsy: Balancing harms and benefit in biopsy naīve men using the Rotterdam Prostate Cancer Risk Calculator

Prostate cancer risk-assessment for multiparametric MRI targeted and systematic biopsy: Balancing harms and benefit in biopsy naīve men using the Rotterdam Prostate Cancer Risk Calculator

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.