The European Association of Urology (EAU) guidelines state that there should be an individual strategy for risk adapted screening. A risk-adapted follow-up approach needs to be utilized, and multivariable risk-prediction tools should be implemented. Various calculators can be used to prolong risk adapted follow-up intervals up to 5-6 years in low PSA levels. However, risk calculators can overestimate clinical relevance in low PSA level of less than 3 ng/ml.
The next topic discussed was the various PSA cut-offs that should be used. With a PSA level of 0-1.9 ng/ml, most seldom will an aggressive prostate cancer be developed within 5-11 years. The Rotterdam calculator used in the ERSPC trial showed a cumulative incidence of 0.36% in 11 years in patients with a PSA below 1.9 ng/ml, while the PLCO trial showed a cumulative incidence of 0% in 5 years in patients with a PSA of less 1.9 ng/ml. According to some risk calculators, withholding a biopsy at a PSA of less 3 ng/ml, with a risk of <12 %, will spare approximately 30% of the biopsies, and this should be considered in the appropriate patients.
Dr. Recker moved on to discuss the proper way a prostate biopsy should be performed. First, it is important to take at least 10-12 cores and go as far posterior and lateral as possible. Additionally, it is important to sample suspicious areas found on digital rectal examination (DRE) or on transrectal ultrasound (TRUS). When performing the biopsy, it can either be done transrectally, or in a transperineal approach. Lastly, it is important to culture the results of prebiopsy rectal swabs to identify the most appropriate antibiotic to be given before the biopsy.
When PSA is 3 ng/ml or above, the risk calculation is improved by using the mpMRI in men scheduled to undergo a repeat biopsy. This strategy has been shown to spare about 50% of all re-biopsies.
In summary, according to the European perspective, screening should start at a young age of 45-50 to get baseline prognostic data. PSA is the gatekeeper, and we should use an individual strategy for organized PSA screening and use risk calculators with clinical follow-up in patients with low PSAs. All biopsies should entail 12 cores at minimum in addition to any suspected area palpated on DRE or seen in TRUS. mpMRI should be used at the minimum before doing a re-biopsy. There is no doubt that the role of mpMRI will grow in the future, and that it will become a major factor in the risk calculation business.
Presented by: Franz Recker, Cantonal Hospital Aarau, Switzerland
Written By: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre Twitter: @GoldbergHanan at the 38th Congress of the Society of International Urology - October 4- 7, 2018 - Seoul, South Korea
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