EAU 2024: Risk Adapted Screening for Prostate Cancer in Europe: PSA + Risk Calculators + MRI (The EAU Screening Algorithm)

(UroToday.com) The 2024 European Association of Urology (EAU) annual meeting featured a plenary session highlighting risk adapted screening for prostate cancer in Europe and a presentation by Dr. Katharina Beyer discussing the EAU screening algorithm using PSA + risk calculators + MRI. Dr. Beyer notes that PSA is easy to use, accessible, non-invasive, and not expensive.


However, if used without a step-by-step approach, PSA leads to overdiagnosis and overtreatment, hence a risk-adapted approach is needed. Ideally, a risk adapted approach would reduce unnecessary diagnostic procedures, reduce overdiagnosis, and increase detection of clinically significant prostate cancer detection, leading to a reduction in metastatic disease and mortality. Although long term outcomes are not yet available, we can build on the lessons learned from the traditional screening trials and the short-term outcomes of the current trials.

Risk calculators give an individualized assessment of the potential risk of biopsy detectable clinically significant prostate cancer. These calculators typically incorporate common variables such as PSA, DRE, age, %free PSA, and transrectal ultrasound. Risk calculators are easy to use, accessible, and non-invasive.

MRI reduces biopsies and also increases detection rate; however, it is costly, and availability and wait times vary between countries. Additionally, there are also concerns for interrater reliability. Dr. Beyer then walked through several risk-adapted examples:

Example 1 is: PSA ⇒ risk calculator ⇒ MRI ⇒ biopsy. The pros of this approach are improved sampling and reduction of unnecessary MRIs, whereas the cons are that there may be unnecessary biopsies in PI-RADS 3 lesions, and potentially missing clinically significant prostate cancer in MRI negative men. Examples of this approach include ProScreen and STHLM3-MRI.

Example 2 is: PSA ⇒ MRI ⇒ risk calculator ⇒ biopsy. The pros of this approach are improved biopsy sampling, no unnecessary biopsies in PI-RADS 3 lesions, and less missed clinically significant prostate cancer among MRI negative men, whereas the main con is unnecessary MRIs. Examples of this approach include OPT (PSA density) and RPCRC-MRI.

Example 3 is: PSA ⇒ risk calculator ⇒ MRI ⇒ risk calculator   biopsy. The pros of this approach are that it is an efficient use of stratification tools and diagnostic tools, with better sampling, whereas the con is that it uses the most stratification tools. An example of this approach is the PRAISE-U study.

Another approach similar to example 3 is PSA ⇒ risk calculator or PSA density ⇒ MRI ⇒ risk calculator ⇒ biopsy. Dr. Beyer notes that this algorithm is applied in the pilot studies in Lithuania, Spain (Galicia), Spain (Manresa), Poland, and Ireland.

Dr. Beyer concluded her presentation discussing the EAU screening algorithm using PSA + risk calculators + MRI with the following conclusions:

  • The current evidence points towards a risk-based strategy
  • Example 3 is the most used in the PRAISE-U project
  • Which algorithm variation suits best is based on the health care capacities within a country
  • Until now there has been no one-size-fits-all approach
  • PRAISE-U and the current ongoing trials will help to further define the use of the algorithms

Presented by: Katharina Beyer, King’s College London, London, UK

Written by: Zachary Klaassen, MD, MSc - Urologic Oncologist, Associate Professor of Urology, Georgia Cancer Center, WellStar MCG Health, @zklaassen_md on Twitter during the 2024 European Association of Urology (EAU) annual congress, Paris, France, April 5th - April 8th, 2024