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AUA: Early Detection of Prostate Cancer (2023): Difference between revisions

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*'''<span style="color:#ff0000">For biopsy-naïve patients with abnormal lesions on prostate MRI, perform targeted biopsies and may also perform a systematic template biopsy.</span>'''
*'''<span style="color:#ff0000">For biopsy-naïve patients with abnormal lesions on prostate MRI, perform targeted biopsies and may also perform a systematic template biopsy.</span>'''
** Adding a systematic biopsy to the target only approach
** Adding a systematic biopsy to the target only approach
***Advantage: potentially finding more GG2+ cancer
***Advantage:  
***Disadvantages: potentially finding more GG1 cancer and risks of additional biopsy cores.
****Optimizes cancer yield, potentially finding more GG2+ cancer
*****Incremental yield of off-target biopsy samples may be influenced by the sampling error associated with software image registration at targeted biopsy
***Disadvantages:  
****Potentially finding more GG1 cancer
****May increase patient discomfort and other biopsy-associated complications due to larger number of cores
*'''Software registration of MRI and ultrasound images during fusion biopsy may be used, when available.'''
*'''Software registration of MRI and ultrasound images during fusion biopsy may be used, when available.'''
** Targeted prostate biopsy of a visible lesion on mpMRI can be performed using software-based registration of mpMRI images and real-time ultrasound or cognitive registration.
** Targeted prostate biopsy of a visible lesion on mpMRI can be performed using software-based registration of mpMRI images and real-time ultrasound or cognitive registration.
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== Repeat biopsy ==
== Repeat biopsy ==
*'''<span style="color:#ff0000">If prostate biopsy demonstrates</span>'''
*'''<span style="color:#ff0000">If prostate biopsy demonstrates</span>'''
**'''<span style="color:#ff0000">Malignancy, discuss management of localized prostate cancer</span>''' (+/- staging studies, if applicable)
**'''<span style="color:#ff0000">Malignancy: discuss management of localized prostate cancer</span>''' (+/- staging studies, if applicable)
**'''<span style="color:#ff0000">High-grade Prostatic Intraepithelial Neoplasia</span>'''
**'''<span style="color:#ff0000">High-grade Prostatic Intraepithelial Neoplasia</span>'''
***'''<span style="color:#ff0000">If focal (one core): should not perform immediate repeat biopsy.</span>'''
***'''<span style="color:#ff0000">If focal (one core): should not perform immediate repeat biopsy.</span>'''
**** Contemporary studies indicate a 20-30% risk of any cancer detected (not just high-grade) in subsequent biopsies, which is the same risk following an initial benign biopsy.
**** Risk of any cancer detected (not just high-grade) in subsequent biopsies is 20-30%, which is the same risk following an initial benign biopsy.
*** '''<span style="color:#ff0000">Multifocal: may proceed with additional risk evaluation, guided by PSA/DRE and mpMRI findings.</span>'''
*** '''<span style="color:#ff0000">Multifocal: may proceed with additional risk evaluation.</span>'''
**** The risk of GG2+ detection in repeat biopsies of patients with multifocal HGPIN is ≈30%, which is not higher than in those without this finding.
**** Risk of GG2+ detection in repeat biopsies of patients with multifocal HGPIN is ≈30%, which is not higher than in those without this finding.
**** Repeat biopsy after HGPIN should be based on PSA and DRE evolution, and mpMRI findings.
**** Repeat biopsy after multifocal HGPIN should be based on PSA and DRE evolution, and mpMRI findings.
*****Due to a lack of data stating otherwise, repeat prostate biopsy should not be recommended solely because of a previous diagnosis of HGPIN, even if multifocal.
** '''<span style="color:#ff0000">Atypia</span>'''
** '''<span style="color:#ff0000">Atypia</span>'''
***'''<span style="color:#ff0000">Atypical small acinar proliferation (ASAP): should perform additional testing.</span>'''
***'''<span style="color:#ff0000">Atypical small acinar proliferation (ASAP): should perform additional testing.</span>'''
**** An ASAP finding alone on needle biopsy is associated with a 30-50% risk of prostate cancer detection on repeat biopsy, with ≈10-20% of these being GG2+.
**** ASAP alone on needle biopsy is associated with a 30-50% risk of prostate cancer detection on repeat biopsy, with ≈10-20% of these being GG2+.
**** Additional testing may include repeat systematic needle biopsy with consideration of mpMRI +/- targeted biopsy, PSA, as well as urine, or serum biomarkers
**** Additional testing may include repeat systematic needle biopsy with consideration of mpMRI +/- targeted biopsy, PSA, and biomarkers (serum- or urine-based)
*** '''<span style="color:#ff0000">Atypical intraductal proliferation (AIP): should perform additional testing.</span>'''
*** '''<span style="color:#ff0000">Atypical intraductal proliferation (AIP): should perform additional testing.</span>'''
**** AIP describes lesions with greater architectural complexity and/or cytologic atypia than would be expected in HGPIN but lacking definitive criteria for the diagnosis of intraductal carcinoma (IDC-P). AIP encompasses many of the lesions formerly designated cribriform HGPIN, exhibiting loose cribriform architecture with moderate cytologic atypia, but lacking marked pleomorphism or necrosis.
**** AIP describes lesions with greater architectural complexity and/or cytologic atypia than would be expected in HGPIN but lacking definitive criteria for the diagnosis of intraductal carcinoma (IDC-P). AIP encompasses many of the lesions formerly designated cribriform HGPIN, exhibiting loose cribriform architecture with moderate cytologic atypia, but lacking marked pleomorphism or necrosis.
**** Given these associations, a diagnosis of AIP as either the sole finding or together with GG1 cancer only warrants additional testing, which may include early repeat systematic needle biopsy or MRI +/- targeted biopsy. The timing of additional testing should be based on reassessment of risk
**** AIP, as either the sole finding or together with GG1 cancer only, warrants additional testing, which may include early repeat systematic needle biopsy or MRI +/- targeted biopsy. The timing of additional testing should be based on reassessment of risk
**'''<span style="color:#ff0000">Negative, reassess risk of undetected or future development of GG2+ disease</span>'''
**'''<span style="color:#ff0000">Negative: reassess risk of undetected or future development of GG2+ disease</span>'''
***'''<span style="color:#ff0000">At the time of re-evaluation after negative biopsy, clinicians should use a risk assessment tool that incorporates the protective effect of prior negative biopsy.</span>'''
***'''<span style="color:#ff0000">At the time of re-evaluation after negative biopsy, clinicians should use a risk assessment tool that incorporates the protective effect of prior negative biopsy.</span>'''
****The guideline recommends utilizing validated risk calculators, particularly calculators that incorporate previous negative biopsy and mpMRI use in the repeat biopsy setting.
****The guideline recommends utilizing validated risk calculators, particularly calculators that incorporate previous negative biopsy and mpMRI use in the repeat biopsy setting.
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*****If continuing screening after a negative biopsy, patient should be re-evaluated within the normal screening interval (2-4 years) or sooner, depending on risk of clinically significant prostate cancer and life expectancy.
*****If continuing screening after a negative biopsy, patient should be re-evaluated within the normal screening interval (2-4 years) or sooner, depending on risk of clinically significant prostate cancer and life expectancy.
****'''<span style="color:#ff0000">Perform adjunctive testing for early reassessment of risk.</span>'''
****'''<span style="color:#ff0000">Perform adjunctive testing for early reassessment of risk.</span>'''
***** If concern remains elevated for GG2+ based on PSA density, previous MRI findings, or other factors, the clinician and patient may consider adjunctive testing (blood, urine, or tissue tests), or MRI (if not previously performed) to further risk stratify the patient if results are likely to influence the decision regarding repeat biopsy or otherwise substantively change the patient’s management.
***** If concern remains elevated for GG2+ based on PSA density, previous MRI findings, or other factors, consider adjunctive testing (blood, urine, or tissue tests), or MRI (if not previously performed) to further risk stratify the patient if results are likely to influence the decision regarding repeat biopsy or otherwise substantively change the patient’s management.
******'''Biomarker testing'''
******'''Biomarker testing'''
*******After a negative initial biopsy in patients with low probability for harboring GG2+ prostate cancer, clinicians should not reflexively perform biomarker testing.
*******After a negative initial biopsy in patients with low probability for harboring GG2+ prostate cancer, clinicians should not reflexively perform biomarker testing.
********In patients with a negative biopsy, with low probability for GG2+ disease, it is unlikely that additional biomarker tests will be informative.
********In patients with a negative biopsy, with low probability for GG2+ disease, it is unlikely that additional biomarker tests will be informative.
*******ConfirmMDx, the only tissue-based biomarker assessing epigenetic changes in GSTP1, APC, RASSF1 in negative biopsy tissue was developed in the MATLOC study and validated in the DOCUMENT study to detect any prostate cancer and not specifically for GG2+ disease.  
*******ConfirmMDx
********How to integrate the use of these tests with mpMRI in prostate cancer early detection paradigms is yet to be studied comprehensively.
********The only tissue-based biomarker assessing epigenetic changes in GSTP1, APC, RASSF1 in negative biopsy tissue  
********Developed in the MATLOC study and validated in the DOCUMENT study to detect any prostate cancer and not specifically for GG2+ disease.
*******Unclear how to integrate the use of these tests with mpMRI in prostate cancer early detection.
*******It is imperative clinicians are familiar with biomarkers, understand what information or data each test provides, and consider whether additional information will impact  management decisions before ordering a test.
*******It is imperative clinicians are familiar with biomarkers, understand what information or data each test provides, and consider whether additional information will impact  management decisions before ordering a test.
******'''<span style="color:#ff0000">MRI prior to repeat biopsy</span>'''
******'''<span style="color:#ff0000">MRI prior to repeat biopsy</span>'''
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**********PSA velocity of ≥0.27 ng/mL/year
**********PSA velocity of ≥0.27 ng/mL/year
********'''<span style="color:#ff0000">Have a suspicious lesion on MRI, should perform targeted biopsies of the suspicious lesion and may also perform a systematic template biopsy.</span>'''
********'''<span style="color:#ff0000">Have a suspicious lesion on MRI, should perform targeted biopsies of the suspicious lesion and may also perform a systematic template biopsy.</span>'''
*********Combined biopsy with systematic and targeted cores
**********Advantage: optimizes cancer yield
***********Incremental yield of off-target biopsy samples may be influenced by the sampling error associated with software image registration at targeted biopsy
**********Disadvantage: may increase patient discomfort and other biopsy-associated complications due to larger number of cores
*********Ultimately, the decision to perform systematic sampling in addition to target sampling should be based on an integrated evaluation of MRI factors such as quality and confidence in target presence and clinical factors such as PSA, technique of initial biopsy, and time since prior systematic biopsy.
*********Ultimately, the decision to perform systematic sampling in addition to target sampling should be based on an integrated evaluation of MRI factors such as quality and confidence in target presence and clinical factors such as PSA, technique of initial biopsy, and time since prior systematic biopsy.


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