AUA: Early Detection of Prostate Cancer (2023): Difference between revisions
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== Repeat biopsy == | == Repeat biopsy == | ||
· Clinicians should not discontinue prostate cancer screening based solely on a negative prostate biopsy. | * · Clinicians should communicate with patients following biopsy to review biopsy results, reassess risk of undetected or future development of GG2+ disease, and mutually decide whether to discontinue screening, continue screening, or perform adjunctive testing for early reassessment of risk. | ||
* · Clinicians should not discontinue prostate cancer screening based solely on a negative prostate biopsy. | |||
· After a negative biopsy, clinicians should not solely use a PSA threshold to decide whether to repeat the biopsy. | * · After a negative biopsy, clinicians should not solely use a PSA threshold to decide whether to repeat the biopsy. | ||
* · If the clinician and patient decide to continue screening after a negative biopsy, clinicians should re-evaluate the patient within the normal screening interval (two to four years) or sooner, depending on risk of clinically significant prostate cancer and life expectancy. | |||
· If the clinician and patient decide to continue screening after a negative biopsy, clinicians should re-evaluate the patient within the normal screening interval (two to four years) or sooner, depending on risk of clinically significant prostate cancer and life expectancy. | * · 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. | ||
* o PSA level alone should not be used to decide whether to repeat the prostate biopsy in patients with a previous negative biopsy. | |||
· 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. | * o 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 and guide further management. | ||
* · After a negative initial biopsy in patients with low probability for harboring GG2+ prostate cancer, clinicians should not reflexively perform biomarker testing. | |||
o PSA level alone should not be used to decide whether to repeat the prostate biopsy in patients with a previous negative biopsy. | * o In patients with a negative biopsy, with low probability for GG2+ disease, it is unlikely that additional biomarker tests will be informative. | ||
* · After a negative biopsy, clinicians may use blood, urine, or tissue-based biomarkers selectively for further risk stratification if results are likely to influence the decision regarding repeat biopsy or otherwise substantively change the patient’s management. | |||
o 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 and guide further management. | * o ConfirmMDx, the only tissue-based biomarker assessing epigenetic changes in GSTP1, APC, RASSF1 in negative biopsy tissue was developed in the MATLOC study221 and validated in the DOCUMENT222 study to detect any prostate cancer and not specifically for GG2+ disease. Moreover, how to integrate the use of these tests with mpMRI in prostate cancer early detection paradigms is yet to be studied comprehensively.192, 193, | ||
* o It is imperative clinicians are familiar with biomarkers, understand what information or data each test provides, and consider whether additional information will impact | |||
· After a negative initial biopsy in patients with low probability for harboring GG2+ prostate cancer, clinicians should not reflexively perform biomarker testing. | * o management decisions before ordering a test. | ||
* · In patients with focal (one core) HGPIN on biopsy, clinicians should not perform immediate repeat biopsy. | |||
o In patients with a negative biopsy, with low probability for GG2+ disease, it is unlikely that additional biomarker tests will be informative. | * o contemporary studies indicate a 20% to 30% risk of any cancer detected (not just high-grade) in subsequent biopsies,214, 226-232 which is the same risk following an initial benign biopsy. | ||
* · In patients with multifocal HGPIN, clinicians may proceed with additional risk evaluation, guided by PSA/DRE and mpMRI findings. | |||
· After a negative biopsy, clinicians may use blood, urine, or tissue-based biomarkers selectively for further risk stratification if results are likely to influence the decision regarding repeat biopsy or otherwise substantively change the patient’s management. | * o The risk of GG2+ detection in repeat biopsies of patients with multifocal HGPIN is approximately 30%, which is not higher than in those without this finding. | ||
* o A recommendation to repeat a prostate biopsy after 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. | |||
o ConfirmMDx, the only tissue-based biomarker assessing epigenetic changes in GSTP1, APC, RASSF1 in negative biopsy tissue was developed in the MATLOC study221 and validated in the DOCUMENT222 study to detect any prostate cancer and not specifically for GG2+ disease. Moreover, how to integrate the use of these tests with mpMRI in prostate cancer early detection paradigms is yet to be studied comprehensively.192, 193, | * · In patients with ASAP, clinicians should perform additional testing. | ||
* o An ASAP finding alone on needle biopsy is associated with a 30% to 50% risk of prostate cancer detection on repeat biopsy,214, 225, 229, 233, 236-243 with approximately 10% to 20% of these being GG2+. | |||
o It is imperative clinicians are familiar with biomarkers, understand what information or data each test provides, and consider whether additional information will impact | * o Following an ASAP diagnosis, which may include repeat systematic needle biopsy with consideration of mpMRI +/- targeted biopsy, PSA, as well as urine, or serum biomarkers | ||
* · In patients with AIP, clinicians should perform additional testing. | |||
o management decisions before ordering a test. | * o 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).244-248 AIP encompasses many of the lesions formerly designated cribriform HGPIN, exhibiting loose cribriform architecture with moderate cytologic atypia, but lacking marked pleomorphism or necrosis. | ||
* o 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 | |||
· In patients with focal (one core) HGPIN on biopsy, clinicians should not perform immediate repeat biopsy. | * · In patients undergoing repeat biopsy with no prior prostate MRI, clinicians should obtain a prostate MRI prior to biopsy. | ||
* · In patients with indications for a repeat biopsy who do not have a suspicious lesion on MRI, clinicians may proceed with a systematic biopsy. | |||
o contemporary studies indicate a 20% to 30% risk of any cancer detected (not just high-grade) in subsequent biopsies,214, 226-232 which is the same risk following an initial benign biopsy. | * o Factors that may identify patients likely to have clinically significant prostate cancer after a negative biopsy and a negative MRI include a PSA density > 0.15 ng/mL a PHI density value > 0.44 or a PSA velocity of 0.27 ng/mL/year or greater. | ||
* · In patients undergoing repeat biopsy and who have a suspicious lesion on MRI, clinicians should perform targeted biopsies of the suspicious lesion and may also perform a systematic template biopsy. | |||
· In patients with multifocal HGPIN, clinicians may proceed with additional risk evaluation, guided by PSA/DRE and mpMRI findings. | * o While these results suggest a combined biopsy with systematic and targeted cores optimizes cancer yield, such an approach entails obtaining a larger number of cores, which may increase patient discomfort and other biopsy-associated complications,263, | ||
* o Off-target biopsy samples may be influenced by the sampling error associated with software image registration at targeted biopsy.265 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. | |||
o The risk of GG2+ detection in repeat biopsies of patients with multifocal HGPIN is approximately 30%, which is not higher than in those without this finding. | |||
o A recommendation to repeat a prostate biopsy after 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. | |||
· In patients with ASAP, clinicians should perform additional testing. | |||
o An ASAP finding alone on needle biopsy is associated with a 30% to 50% risk of prostate cancer detection on repeat biopsy,214, 225, 229, 233, 236-243 with approximately 10% to 20% of these being GG2+. | |||
o Following an ASAP diagnosis, which may include repeat systematic needle biopsy with consideration of mpMRI +/- targeted biopsy, PSA, as well as urine, or serum biomarkers | |||
· In patients with AIP, clinicians should perform additional testing. | |||
o 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).244-248 AIP encompasses many of the lesions formerly designated cribriform HGPIN, exhibiting loose cribriform architecture with moderate cytologic atypia, but lacking marked pleomorphism or necrosis. | |||
o 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 | |||
· In patients undergoing repeat biopsy with no prior prostate MRI, clinicians should obtain a prostate MRI prior to biopsy. | |||
· In patients with indications for a repeat biopsy who do not have a suspicious lesion on MRI, clinicians may proceed with a systematic biopsy. | |||
o Factors that may identify patients likely to have clinically significant prostate cancer after a negative biopsy and a negative MRI include a PSA density > 0.15 ng/mL a PHI density value > 0.44 or a PSA velocity of 0.27 ng/mL/year or greater. | |||
· In patients undergoing repeat biopsy and who have a suspicious lesion on MRI, clinicians should perform targeted biopsies of the suspicious lesion and may also perform a systematic template biopsy. | |||
o While these results suggest a combined biopsy with systematic and targeted cores optimizes cancer yield, such an approach entails obtaining a larger number of cores, which may increase patient discomfort and other biopsy-associated complications,263, | |||
o Off-target biopsy samples may be influenced by the sampling error associated with software image registration at targeted biopsy.265 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. | |||
== Biopsy technique == | == Biopsy technique == | ||
o On the other hand, use of transrectal approach may be appropriate in certain situations (e.g., patient preference/comfort, patient cannot be placed into the lithotomy position, clinician training/experience or lack of appropriate equipment for the transperineal approach). | * · Clinicians may use software registration of MRI and ultrasound images during fusion biopsy, when available. | ||
* o 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. | |||
* o 1 RCT266 where software-based registration demonstrated better cancer detection rate (CDR) compared with cognitive registration (33.3% versus 19.0%; p=0.016), both approaches have been shown to have similar CDR in multiple studies,267-270 inclusive of an RCT showing no difference in CDR of software-based versus cognitive fusion or in-bore MRI targeted biopsy.271 | |||
* o There are drawbacks, however, to implementing softwarebased fusion biopsy program. There are technical issues (e.g., software bugs, system crashes), operator error, and unusual anatomy (e.g., large prostates, previous transurethral resections of the prostate). Thus, the ability to perform cognitive fusion techniques using anatomic fiducial markers such as intraprostatic cysts may augment software-based fusion approaches in some cases such as to minimize the risk of misregistration. Clinicians who adopt the cognitive fusion technique exclusively should undergo advanced training in MRI interpretation to optimize cancer detection. | |||
* · Clinicians should obtain at least two needle biopsy cores per target in patients with suspicious prostate lesion(s) on MRI. | |||
* o The optimal number of biopsy cores per MRI target may differ based on multiple factors including patient characteristics (e.g., age, PSA, biopsy naïve versus prior biopsy), target characteristics (e.g., size, location, PIRADS classification), and biopsy approach/technique (e.g., software fusion versus cognitive fusion, transrectal versus transperineal).272 | |||
* o the incremental value in cancer detection is diminished after obtaining more than three cores per target.273, 274 In patients with a suspicious prostate lesion(s) by MR imaging, at least two needle cores per target provides the most reproducible and accurate cancer detection rate. For prostate cancer risk group stratification, all cores from the same MRI target should be considered as a single core.275 | |||
* · Clinicians may use either a transrectal or transperineal biopsy route when performing a biopsy. | |||
* o CDRs associated with transrectal versus transperineal biopsy route are not significantly different.158, 276 There is some suggestion that transperineal biopsy may detect anterior and apical cancers at a higher rate; however prospective, randomized data are lacking and existing data are contradictory.277 Recent meta-analyses and retrospective reviews of single center data suggest a lower risk of infection with the transperineal approach; however, prospective, randomized data are lacking to make a definitive conclusion.277-280 Use of transperineal biopsies may have some value in patients who have experienced infectious complications with a prior biopsy, are at higher risk for biopsy-related infection, or have anterior lesions that may not be as easily accessible transrectally. | |||
* o On the other hand, use of transrectal approach may be appropriate in certain situations (e.g., patient preference/comfort, patient cannot be placed into the lithotomy position, clinician training/experience or lack of appropriate equipment for the transperineal approach). | |||
== References == | == References == | ||