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Risk stratification of prostate cancer with MRI and prostate-specific antigen density-based tool for personalized decision making.

Published version
Peer-reviewed

Repository DOI


Type

Article

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Authors

Rajendran, Ishwariya 
Lee, Kang-Lung 
Thavaraja, Liness 

Abstract

OBJECTIVES: MRI is now established for initial prostate cancer diagnosis; however, there is no standardized pathway to avoid unnecessary biopsy in low-risk patients. Our study aimed to test previously proposed MRI-focussed and risk-adapted biopsy decision models on a real-world dataset. METHODS: Single-centre retrospective study performed on 2055 biopsy naïve patients undergoing MRI. Diagnostic pathways included "biopsy all", "MRI-focussed" and two risk-based MRI-directed pathways. Risk thresholds were based on prostate-specific antigen (PSA) density as low (<0.10 ng mL-2), intermediate (0.10-0.15 ng mL-2), high (0.15-0.20 ng mL-2), or very high-risk (>0.20 ng mL-2). The outcome measures included rates of biopsy avoidance, detection of clinically significant prostate cancer (csPCa), missed csPCa, and overdiagnosis of insignificant prostate cancer (iPCa). RESULTS: Overall cancer rate was 39.9% (819/2055), with csPCa (Grade-Group ≥2) detection of 30.3% (623/2055). In men with a negative MRI (Prostate Imaging-Reporting and Data System, PI-RADS 1-2), the risk of cancer was 1.2%, 2.6%, 9.0%, and 12.9% in the low, intermediate, high, and very high groups, respectively; for PI-RADS score 3 lesions, the rates were 10.5%, 14.3%, 25.0%, and 33.3%, respectively. MRI-guided pathway and risk-based pathway with a low threshold missed only 1.6% csPCa with a biopsy-avoidance rate of 54.4%, and the risk-based pathway with a higher threshold avoided 62.9% (1292/2055) of biopsies with 2.9% (61/2055) missed csPCa detection. Decision curve analysis found that the "risk-based low threshold" pathway has the highest net benefit for probability thresholds between 3.6% and 13.9%. CONCLUSION: Combined MRI and PSA-density risk-based pathways can be a helpful decision-making tool enabling high csPCa detection rates with the benefit of biopsy avoidance and reduced iPCa detection. ADVANCES IN KNOWLEDGE: This real-world dataset from a large UK-based cohort confirms that combining MRI scoring with PSA density for risk stratification enables safe biopsy avoidance and limits the over-diagnosis of insignificant cancers.

Description

Keywords

MRI, prostate cancer, risk assessment, Humans, Male, Decision Making, Magnetic Resonance Imaging, Prostate-Specific Antigen, Prostatic Neoplasms, Retrospective Studies, Risk Assessment

Journal Title

Br J Radiol

Conference Name

Journal ISSN

0007-1285
1748-880X

Volume Title

Publisher

Oxford University Press (OUP)
Sponsorship
Cancer Research Uk (None)
This research was supported by the NIHR Cambridge Biomedical Research Centre (NIHR203312). The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care. The authors also acknowledge support from Cancer Research UK (Cambridge Imaging Centre grant number C197/A16465), the Engineering and Physical Sciences Research Council Imaging Centre in Cambridge and Manchester, and the Cambridge Experimental Cancer Medicine Centre.

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2024-04-16 11:28:09
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