Artificial Intelligence and Prostate Cancer: Diagnosis and Grading, mpMRI, and Active Surveillance

Across all aspects of daily life, artificial intelligence more than ever is harnessing the power of machine learning to automate and improve the efficiency of tasks. This is also true in medicine and, in particular, in the field of prostate cancer. The concept of artificial intelligence began in the 1950s with the prime objective of emulating the cognitive capabilities of human beings in machines. More specifically, artificial intelligence is the ability of a machine to independently replicate intellectual processes typical of human cognition. Machine learning comprises algorithms that parse data, learn from that data, and then apply what they have learned to make informed decisions. Deep learning is a form of machine learning that is inspired by the structure of the human brain and is particularly effective in feature detection:1

Written by: Zachary Klaassen, MD MSc & Rashid K. Sayyid, MD MSc
  1. George RS, Htoo A, Cheng M, et al. Artificial intelligence in prostate cancer: Definitions, current research, and future directions. Urol Oncol. 2022;40: 262-270.
  2. Marginean F, Arvidsson I, Simoulis A, et al. An Artificial Intelligence-based Support Tool for Automation and Standardisation of Gleason Grading in Prostate Biopsies. Eur Urol Focus. 2021;7: 995-1001.
  3. Huang W, Randhawa R, Jain P, et al. Development and Validation of an Artificial Intelligence-Powered Platform for Prostate Cancer Grading and Quantification. JAMA Netw Open. 2021;4: e2132554.
  4. Bulten W, Kartasalo K, Chen PC, et al. Artificial intelligence for diagnosis and Gleason grading of prostate cancer: the PANDA challenge. Nat Med. 2022;28: 154-163.
  5. Paulson N, Zeevi T, Papademetris M, et al. Prediction of Adverse Pathology at Radical Prostatectomy in Grade Group 2 and 3 Prostate Biopsies Using Machine Learning. JCO Clin Cancer Inform. 2022;6: e2200016.
  6. Kartasalo K, Bulten W, Delahunt B, et al. Artificial Intelligence for Diagnosis and Gleason Grading of Prostate Cancer in Biopsies-Current Status and Next Steps. Eur Urol Focus. 2021;7: 687-691.
  7. Jung M, Jin MS, Kim C, et al. Artificial intelligence system shows performance at the level of uropathologists for the detection and grading of prostate cancer in core needle biopsy: an independent external validation study. Mod Pathol. 2022;35: 1449-1457.
  8. Suarez-Ibarrola R, Sigle A, Eklund M, et al. Artificial Intelligence in Magnetic Resonance Imaging-based Prostate Cancer Diagnosis: Where Do We Stand in 2021? Eur Urol Focus. 2022;8: 409-417.
  9. Mehralivand S, Harmon SA, Shih JH, et al. Multicenter Multireader Evaluation of an Artificial Intelligence-Based Attention Mapping System for the Detection of Prostate Cancer With Multiparametric MRI. AJR Am J Roentgenol. 2020;215: 903-912.
  10. Hiremath A, Shiradkar R, Fu P, et al. An integrated nomogram combining deep learning, Prostate Imaging-Reporting and Data System (PI-RADS) scoring, and clinical variables for identification of clinically significant prostate cancer on biparametric MRI: a retrospective multicentre study. Lancet Digit Health. 2021;3: e445-e454.
  11. Hosseinzadeh M, Saha A, Brand P, Slootweg I, de Rooij M, Huisman H. Deep learning-assisted prostate cancer detection on bi-parametric MRI: minimum training data size requirements and effect of prior knowledge. Eur Radiol. 2022;32: 2224-2234.
  12. Lee C, Light A, Saveliev ES, van der Schaar M, Gnanapragasam VJ. Developing machine learning algorithms for dynamic estimation of progression during active surveillance for prostate cancer. NPJ Digit Med. 2022;5: 110.
  13. Nayan M, Salari K, Bozzo A, et al. A machine learning approach to predict progression on active surveillance for prostate cancer. Urol Oncol. 2022;40: 161 e161-161 e167.

Radiotherapy in Prostate Cancer: Utilization of Adjuvant and Salvage Radiotherapy


While external beam radiotherapy is a standard treatment option as first-line therapy for men with localized prostate cancer, it is also an important component of care for patients following radical prostatectomy. For approximately two-thirds of patients undergoing radical prostatectomy for prostate cancer, surgery is curative, and patients remain disease-free (without biochemical or radiographic evidence of recurrence).1 However, patients with adverse pathologic findings (defined as seminal vesicle invasion, extraprostatic extension, and positive surgical margins (residual tumor at the surgical site) experience up to a 60% risk of recurrence at 10 years.2
Written by: Rashid Sayyid, MD MSc, & Zachary Klaassen, MD MSc
  1. Bianco Jr FJ, Scardino PT, Eastham JA. Radical prostatectomy: long-term cancer control and recovery of sexual and urinary function ("trifecta"). Urology. 2005;66(5 Suppl):83-94.
  2. Thompson IM, Valicenti RK, Albertsen P, et al. Adjuvant and salvage radiotherapy after prostatectomy: AUA/ASTRO Guideline. J Urol. 2013;190(2):441-9.
  3. Parker CC, Clarke NW, Cook AD, et al. Timing of radiotherapy after radical prostatectomy (RADICALS-RT): a randomised, controlled phase 3 trial. Lancet. 2020;396(10260):1413-1421.
  4. Kneebone A, Fraser-Browne C, Duchesne GM, et al. Adjuvant radiotherapy versus early salvage radiotherapy following radical prostatectomy (TROG 08.03/ANZUP RAVES): a randomised, controlled, phase 3, non-inferiority trial. Lancet Oncol. 2020;21(10):1331-1340.
  5. Sargos P, Chabaud S, Latorzeff I, et al. Adjuvant radiotherapy versus early salvage radiotherapy plus short-term androgen deprivation therapy in men with localised prostate cancer after radical prostatectomy (GETUG-AFU 17): a randomised, phase 3 trial. Lancet Oncol. 2020;21(10):1341-1352.
  6. Vale CL, Fisher D, Kneebone A, et al. Adjuvant or early salvage radiotherapy for the treatment of localised and locally advanced prostate cancer: a prospectively planned systematic review and meta-analysis of aggregate data. Lancet. 2020;396(10260):1422-1431.
  7. Pollack A, Karrison TG, Balogh A, et al. The addition of androgen deprivation therapy and pelvic lymph node treatment to prostate bed salvage radiotherapy (NRG Oncology/RTOG 0534 SPPORT): an international, multicentre, randomised phase 3 trial. Lancet.2022;399(10338):1886-1901.
  8. Feng FY, Huang H, Spratt DE, et al. Validation of a 22-Gene Genomic Classifier in Patients With Recurrent Prostate Cancer: An Ancillary Study of the NRG/RTOG 9601 Randomized Clinical Trial. JAMA Oncol. 2021;7(4):544-552.
  9. Dal Pra A, Ghadjar P, Hayoz S, et al. Validation of the Decipher genomic classifier in patients receiving salvage radiotherapy without hormone therapy after radical prostatectomy - an ancillary study of the SAKK 09/10 randomized clinical trial. Ann Oncol. 2022;33(9):950-958.
  10. Jani AB, Schreibmann E, Goyal S, et al. 18F-fluciclovine-PET/CT imaging versus conventional imaging alone to guide postprostatectomy salvage radiotherapy for prostate cancer (EMPIRE-1): a single centre, open-label, phase 2/3 randomised controlled trial. 2021;397(10288):1895-1904.

The Impact of Surgeon Experience and Volume on Patient Outcomes in Radical Prostatectomy Patients


The last decade has seen an increased uptake of the robotic-assisted laparoscopic approach for radical prostatectomies. Despite the negative results of the only published phase III randomized clinical trial comparing robotic-assisted laparoscopic to open radical prostatectomy, which demonstrated no significant differences in short- and medium-term functional outcomes between the two approaches,1 it is currently estimated that more than 70% of radical prostatectomy surgeries performed since 2012 in the United States have been with robotic assistance.2 In 2018, it was estimated that 92.6% of all radical prostatectomies in England were performed using this minimally invasive technique.3
Written by: Rashid K. Sayyid, MD MSc and Zachary Klaassen, MD,MSc
  1. Coughlin GD, Yaxley JW, Chambers SK, et al. Robot-assisted laparoscopic prostatectomy versus open radical retropubic prostatectomy: 24-month outcomes from a randomised controlled study. Lancet Oncol 2018;19(8):1051-1060.
  2. Schroeck FR, Jacobs BL, Bhayani  SB, et al.  J.  Cost of new technologies in prostate cancer treatment: systematic review of costs and cost effectiveness of robotic-assisted laparoscopic prostatectomy, intensity-modulated radiotherapy, and proton beam therapy. Eur Urol 2017;72(5):712-735.
  3. Gray WK, Day J, Briggs TWR, Harrison S. An observational study of volume–outcome effects for robot-assisted radical prostatectomy in England. BJU International 2021;12(1):93-103.
  4. Begg CB, Riedel ER, Bach PB, et al. Variations in Morbidity after Radical Prostatectomy. N Engl J Med 2002;346:1138-1144.
  5. Hu JC, Gold KF, Pashos CL, et al. Role of surgeon volume in radical prostatectomy outcomes. J Clin Oncol 2003;21(3):401-405.
  6. Almatar A, Wallis CJD, Hrrschorn S, et al. Effect of radical prostatectomy surgeon volume on complication rates from a large population-based cohort. Can Urol Assoc J 2016;10(1-2):45-49.
  7. Godtman RA, Persson E, Cazzaniga W, et al. Association of surgeon and hospital volume with short-term outcomes after robot-assisted radical prostatectomy: Nationwide, population-based study. PLoS One 2021;16(6):e0253081.
  8. Gray WK, Day J, Briggs TWR, Harrison S. An observational study of volume–outcome effects for robot-assisted radical prostatectomy in England. BJU International 2021;129(1):93-103.
  9. Van den Broeck T, Oprea-Lager D, Moris L, et al. A Systematic Review of the Impact of Surgeon and Hospital Caseload Volume on Oncological and Nononcological Outcomes After Radical Prostatectomy for Nonmetastatic Prostate Cancer. Eur Urol 2021;80(5):531-545.
  10. Porcaro AB, Tafuri A, Sebben M, et al. Linear extent of positive surgical margin impacts biochemical recurrence after robotassisted radical prostatectomy in a high-volume centre. J Robot Surg 2020;14:663–675.
  11. Steinsvik EAS, Axcrona K, Angelsen A, et al. Does a surgeon’s annual radical prostatectomy volume predict the risk of positive surgical margins and urinary incontinence at one-year follow-up?—Findings from a prospective national study. Scand J Urol 2013;47:92–100.
  12. Williams SB, Gu X, Lipsitz SR, Nguyen PL, Choueiri TK, Hu JC. Utilization and expense of adjuvant cancer therapies following radical prostatectomy. Cancer 2011;117:4846–54.
  13. Hu JC, Wang Q, Pashos CL, Lipsitz SR, Keating NL. Utilization and outcomes of minimally invasive radical prostatectomy. J Clin Oncol 2008;26:2278–84.
  14. Bolton DM, Papa N, Ta AD, et al. Predictors of prostate cancer specific mortality after radical prostatectomy: 10 year oncologic outcomes from the Victorian Radical Prostatectomy Registry. BJU Int 2015;116:66–72.
  15. Schmitges J, Trinh QD, Sun M, et al. Annual prostatectomy volume is related to rectal laceration rate after radical prostatectomy. Urology 2012;79:796–803.
  16. Sharma V, Meeks JJ. Open conversion during minimally invasive radical prostatectomy: impact on perioperative complications and predictors from national data. J Urol 2014;192:1657–1662.
  17. Begg CB, Riedel ER, Bach PB, et al. Variations in morbidity after radical prostatectomy. N Engl J Med 2002;346:1138–1144.
  18. Leow JJ, Leong EK, Serrell EC, et al. Systematic Review of the Volume-Outcome Relationship for Radical Prostatectomy. Eur Urol Focus 2018;4(6):775-89.
  19. Bravi CA, Tin A, Vertosick E, et al. The Impact of Experience on the Risk of Surgical Margins and Biochemical Recurrence after Robot-Assisted Radical Prostatectomy: A Learning Curve Study. J Urol 2019;202(1):108-113.
  20. Klein EA, Bianco FJ, Serio AM, et al. Surgeon Experience is Strongly Associated with Biochemical Recurrence after Radical Prostatectomy for all Preoperative Risk Categories. J Urol 2008;179(6):2212-2216.
  21. Alemozaffar M, Duclos A, Hevelone ND, et al. Technical Refinement and Learning Curve for Attenuating Neurapraxia During Robotic-Assisted Radical Prostatectomy to Improve Sexual Function. Eur Urol 2012;61(6):1222-12228.
  22. Ju IE, Trieu D, Chang SB, et al. Surgeon Experience and Erectile Function After Radical Prostatectomy: A Systematic Review. Sex Med Rev 2021;9(4):650-658.
  23. Fossati N, Di Trapani E, Gandaglia G, et al. Assessing the Impact of Surgeon Experience on Urinary Continence Recovery After Robot-Assisted Radical Prostatectomy: Results of Four High-Volume Surgeons. J Endourol 2017;31(9):872-877.
  24. Matulewicz RS, Tosoian JT, Stimson CJ, et al. Implementation of a Surgeon-Level Comparative Quality Performance Review to Improve Positive Surgical Margin Rates during Radical Prostatectomy. J Urol 2017;197(5):1245-1250.
  25. Kumar RV, Fergusson DA, Lavallee, et al. Performance Feedback May Not Improve Radical Prostatectomy Outcomes: The Surgical Report Card (SuRep) Study. J Urol 2021;206(2):346-353.

The Importance of a Prostate Cancer Survivorship Program: A Multi-Disciplinary Approach

Despite prostate cancer being the second most common cause of cancer mortality among American men,1 there are over 3 million men in the United States living with prostate cancer. As such, there are many “prostate cancer survivors” that are either on active surveillance/watchful waiting or have undergone treatment for localized (ie. radiation therapy, radical prostatectomy, focal therapy, etc) or advanced disease (ie. androgen deprivation therapy, chemotherapy, novel hormonal therapy, immunotherapy, etc).
Written by: Zachary Klaassen, MD, MSc & Sherita A. King, MD
  1. Siegel RL, Miller KD, Jemal A. Cancer statistics, 2019. CA Cancer J Clin. 2019;69(1):7-34.
  2. Hamdy FC, Donovan JL, Lane JA, et al. 10-Year Outcomes after Monitoring, Surgery, or Radiotherapy for Localized Prostate Cancer. N Engl J Med. 2016;375(15):1415-1424.
  3. Donovan JL, Hamdy FC, Lane JA, et al. Patient-Reported Outcomes after Monitoring, Surgery, or Radiotherapy for Prostate Cancer. N Engl J Med. 2016;375(15):1425-1437.
  4. Albkri A, Girier D, Mestre A, Costa P, Droupy S, Chevrot A. Urinary Incontinence, Patient Satisfaction, and Decisional Regret after Prostate Cancer Treatment: A French National Study. Urol Int. 2018;100(1):50-56.
  5. Pinkawa M, Berneking V, Schlenter M, Krenkel B, Eble MJ. Quality of Life After Radiation Therapy for Prostate Cancer With a Hydrogel Spacer: 5-Year Results. Int J Radiat Oncol Biol Phys. 2017;99(2):374-377.
  6. Wallis CJ, Mahar AL, Satkunasivam R, et al. Cardiovascular and Skeletal-related Events Following Localized Prostate Cancer Treatment: Role of Surgery, Radiotherapy, and Androgen Deprivation. Urology. 2016;97:145-152.
  7. Ravi P, Karakiewicz PI, Roghmann F, et al. Mental health outcomes in elderly men with prostate cancer. Urol Oncol. 2014;32(8):1333-1340.
  8. Watts S, Leydon G, Birch B, et al. Depression and anxiety in prostate cancer: a systematic review and meta-analysis of prevalence rates. BMJ Open. 2014;4(3):e003901.
  9. Marzouk K, Assel M, Ehdaie B, Vickers A. Long-Term Cancer Specific Anxiety in Men Undergoing Active Surveillance of Prostate Cancer: Findings from a Large Prospective Cohort. J Urol. 2018;200(6):1250-1255.
  10. Dinh KT, Reznor G, Muralidhar V, et al. Association of Androgen Deprivation Therapy With Depression in Localized Prostate Cancer. J Clin Oncol. 2016;34(16):1905-1912.
  11. Nead KT, Sinha S, Yang DD, Nguyen PL. Association of androgen deprivation therapy and depression in the treatment of prostate cancer: A systematic review and meta-analysis. Urol Oncol. 2017;35(11):664 e661-664 e669.
  12. Klaassen Z, Jen RP, DiBianco JM, et al. Factors associated with suicide in patients with genitourinary malignancies. Cancer. 2015;121(11):1864-1872.
  13. 13.Dalela D, Krishna N, Okwara J, et al. Suicide and accidental deaths among patients with non-metastatic prostate cancer. BJU Int. 2016;118(2):286-297.
  14. Guo Z, Gan S, Li Y, et al. Incidence and risk factors of suicide after a prostate cancer diagnosis: a meta-analysis of observational studies. Prostate Cancer Prostatic Dis. 2018;21(4):499-508.
  15. Klaassen Z, Wallis CJ, Goldberg H, et al. Utilization of Psychiatric Resources Prior to Genitourinary (GU) Cancer Diagnosis: Implications for Survival Outcomes. AUA 2019. 2019.
  16. Fashoyin-Aje LA, Martinez KA, Dy SM. New patient-centered care standards from the commission on cancer: opportunities and challenges. J Support Oncol. 2012;10(3):107-111.
  17. Skolarus TA, Wolf AM, Erb NL, et al. American Cancer Society prostate cancer survivorship care guidelines. CA Cancer J Clin. 2014;64(4):225-249.
  18. Resnick MJ, Lacchetti C, Bergman J, et al. Prostate cancer survivorship care guideline: American Society of Clinical Oncology Clinical Practice Guideline endorsement. J Clin Oncol. 2015;33(9):1078-1085.
  19. Sharpley CF, Bitsika V, Christie DR, Hunter MS. Measuring depression in prostate cancer patients: does the scale used make a difference? Eur J Cancer Care (Engl). 2017;26(1).
  20. National Comprehensive Cancer N. Distress management. Clinical practice guidelines. J Natl Compr Canc Netw. 2003;1(3):344-374.
  21. Klaassen Z, Arora K, Wilson SN, et al. Decreasing suicide risk among patients with prostate cancer: Implications for depression, erectile dysfunction, and suicidal ideation screening. Urol Oncol. 2018;36(2):60-66.
  22. Recklitis CJ, Zhou ES, Zwemer EK, Hu JC, Kantoff PW. Suicidal ideation in prostate cancer survivors: understanding the role of physical and psychological health outcomes. Cancer. 2014;120(21):3393-3400.
  23. Wittmann D, Varlamos C, Rodriguez-Galano N, et al. Developing a Patient-Centered Model of Prostate Cancer Care: Patient Satisfaction With a Survivorship Program Embedded in Urologic-Oncologic Care. Urology. 2022;160:161-167.