SAN DIEGO, CA USA (UroToday.com) - The prostate cancer screening session at the AUA 2013 in San Diego included several main themes: (1) change in practice patterns following release of the USPSTF’s PSA screening recommendations, (2) improvement of biopsy techniques by integrating MRI technology, and (3) rising rates of complications following repeat prostate biopsy.
Several studies assessed PSA utilization across health care systems following the changes to the USPSTF screening guidelines. Encompassing 41 411 patients, these studies identified a significant decrease in PSA screening, with one study showing a 5% decrease in overall PSA tests performed, 28% decrease in elevated PSA referrals, and a 64% decrease in number of biopsies performed since the final USPSTF recommendation was released in May 2012.
In search of new and improved prostate cancer detection tools, two studies examined the use of advance imaging to improve upon TRUS-guided prostate biopsy in men with benign findings on initial biopsy or for those on active surveillance. For men with benign findings on initial biopsy, MRI/TRUS fusion transperineal biopsy had a higher overall cancer detection rate and a higher proportion of clinically significant high-grade prostate cancer detection compared to transrectal and transperineal biopsy techniques, without MRI guidance.
Examining the risk of misclassification of patients eligible for AS in patients undergoing pre-biopsy multiparametric resonance imaging and 12 transrectal ultrasound-guided systematic biopsies plus two targeted biopsies at any MRI area suspicious for malignancy, the authors found the risk of misclassification of patients eligible for AS can be reduced by 14% with pre-biopsy mp-MRI and targeted biopsies at any MRI area suspicious for malignancy.
Beyond improved detection, urologists must also attempt to reduce the harms of biopsy by reducing complications, and defining the scope of the problem is the first step. Two posters examined complications following repeat biopsies. Looking at 433 men who underwent repeat biopsy while being managed on active surveillance for prostate cancer at Memorial Sloan Kettering Cancer Center (poster 1244). The authors evaluated the impact of other risk factors including history of BPH, previous infectious complications, and antibiotic regimen on the risk of infectious complications. Only the number of previous prostate biopsies (OR 1.34, 95% CI 1.02-1.76) was significantly associated with an increased risk of infection (p=0.036) with each previous biopsy increasing the odds of an infection 1.3 times. Bacteria with flouroquinolone resistance and resistance to broad-spectrum antibiotics were the most commonly identified organisms in this population. Similarly, another study examined 41 425 men using SEER-Medicare linked data, showing that the risk of incurring endocarditis, sepsis, and/or shock ≤ 30 days after each PBx was by 17% for each additional PBx (P < 0.001) on multivariate analysis. These findings are important to consider when counseling men on active surveillance as they should be aware of the increasing risks associated with each serial prostate biopsy. As such, urologists can use these data to explore ways to reduce complications in men undergoing repeat biopsy.
Summarizing this session on prostate cancer screening, the changes in the USPSTF screening guidelines have resulted in a decrease in PSA screening, PSA-related referrals, and the number of biopsies being performed. Perhaps in response, urologists are trying to identify ways to improve safety and yield of biopsies; however, much work remains to be done.
Posters discussed were presented in the Prostate Cancer Detection and Screening I. session.
Presented at the American Urological Association (AUA) Annual Meeting - May 4 - 8, 2013 - San Diego Convention Center - San Diego, California USA
Reported for UroToday.com by Anthony T. Corcoran, MD