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      Reducing Biopsies and Magnetic Resonance Imaging Scans During the Diagnostic Pathway of Prostate Cancer: Applying the Rotterdam Prostate Cancer Risk Calculator to the PRECISION Trial Data


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          Take Home Message

          Risk stratification can be used to reduce the numbers of systematic prostate biopsy procedures, magnetic resonance imaging scans, and targeted prostate biopsies, but clinicians should be aware of the a priori risk of their patient cohort to realize the full benefit of this powerful approach.



          Risk stratification in the diagnostic pathway of prostate cancer (PCa) can be used to reduce biopsies and magnetic resonance imaging (MRI) scans, while maintaining the detection of clinically significant PCa (csPCa). The use of highly discriminating and well-calibrated models will generate better clinical outcomes if context-dependent thresholds are used.


          To retrospectively assess the effect of the upfront use of the Rotterdam Prostate Cancer Risk Calculator (RPCRC) developed in a screening cohort and the RPCRC-MRI developed in a clinical cohort while exploring the need to adapt thresholds in biopsy-naïve men in the PRECISION (Prostate Evaluation for Clinically Important Disease: Sampling Using Image Guidance or Not?) trial.

          Design, setting, and participants

          In the transrectal ultrasonography arm, we evaluated 188 men; in the MRI arm, we evaluated 206 (for the reduction of MRI scans) and 137 (for the reduction of targeted biopsies) men.

          Outcome measurements and statistical analysis

          Performance was assessed by discrimination, calibration, and clinical utility.

          Results and limitations

          The performance of the RPCRC was good. However, intercept adjustment was warranted. Net benefit was observed from a recalibrated probability of 32% for any PCa and 10% for csPCa. After recalibration and applying a threshold of 20% for any PCa or 10% for csPCa, 28% of all biopsies could have been reduced, missing five cases of csPCa. The uncalibrated RPCRC could reduce 35% of all MRI scans, with a threshold of 20% for any PCa or 4% for csPCa. In the MRI arm, performance was good without stressing recalibration. Net benefit was observed from a probability of 22% for any PCa and 7% for csPCa. With a threshold of 20% for any PCa or 4% for csPCa, 9% of all targeted biopsies could be reduced, missing one grade group 2 PCa.


          The performance of the RPCRC and RPCRC-MRI in men included in the PRECISION trial was good, but recalibration and adaptation of the risk threshold of the RPCRC are indicated to reach optimal performance.

          Patient summary

          In this report, we show that risk stratification with the Rotterdam Prostate Cancer Risk Calculator has added value in reducing harm, but adjustment to reflect the characteristics of the patient cohort is indicated.

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          Most cited references25

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          Is Open Access

          Diagnostic accuracy of multi-parametric MRI and TRUS biopsy in prostate cancer (PROMIS): a paired validating confirmatory study

          Men with high serum prostate specific antigen usually undergo transrectal ultrasound-guided prostate biopsy (TRUS-biopsy). TRUS-biopsy can cause side-effects including bleeding, pain, and infection. Multi-parametric magnetic resonance imaging (MP-MRI) used as a triage test might allow men to avoid unnecessary TRUS-biopsy and improve diagnostic accuracy.
            • Record: found
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            MRI-Targeted or Standard Biopsy for Prostate-Cancer Diagnosis

            Multiparametric magnetic resonance imaging (MRI), with or without targeted biopsy, is an alternative to standard transrectal ultrasonography-guided biopsy for prostate-cancer detection in men with a raised prostate-specific antigen level who have not undergone biopsy. However, comparative evidence is limited.
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              Use of prostate systematic and targeted biopsy on the basis of multiparametric MRI in biopsy-naive patients (MRI-FIRST): a prospective, multicentre, paired diagnostic study

              Whether multiparametric MRI improves the detection of clinically significant prostate cancer and avoids the need for systematic biopsy in biopsy-naive patients remains controversial. We aimed to investigate whether using this approach before biopsy would improve detection of clinically significant prostate cancer in biopsy-naive patients.

                Author and article information

                Eur Urol Open Sci
                Eur Urol Open Sci
                European Urology Open Science
                15 December 2021
                February 2022
                15 December 2021
                : 36
                : 1-8
                [a ]Department of Urology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
                [b ]Division of Surgery and Interventional Science, University College London, London, UK
                Author notes
                [* ]Corresponding author. Department of Urology, Erasmus University Medical Center, P.O. Box 2040, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands. Tel. +31 10 703 2239; Fax: +31 10 703 5315. s.remmers@ 123456erasmusmc.nl

                ERSPC Rotterdam Study Group: W.J. Kirkels, J.B.W. Rietbergen, I.W. van der Cruijsen, R. Raaijmakers, S.H. de Vries, S. Roemeling, C. Gosselaar, T. Wolters, R.C.N. van den Bergh, P.J. van Leeuwen, M. Bul, X. Zhu, H.A. van Vugt, L.P. Bokhorst, A.R. Alberts, F.-J. Drost, J.F.M. Verbeek, D.F. Osses, H. Luiting, S. Remmers, R. Hogenhout, J.W. Salman, L.D.F. Venderbos, G. Yurdakul, A. Boeken-Kruger, C. Wijburg, M. Forouzanfor, M. de Boer, R. Postma, A.N. Vis, R. Hoedemaeker, G.J.L.H. van Leenders, B. Blijenberg, P.J. van der Maas, S. Otto, G. Draisma, P. Beemsterboer, M. Essink-Bot, I. Korfage, R. Boer, M. Wildhagen, W. Merkelbach, W. Hoekstra, J. Blom, R.A.M. Damhuis, A. Reedijk, R. Kranse, D.W. Roobol, W. Roobol, E. van den Berg, G-J de Zwart, C.G.A.M. Franken-Raab, M. van Slooten-Midderig, A. Smit, V. van der Drift, E. de Bilde, L. Mani, M. Visser-van Dongen, H. Versteeg-Leenheer, B. Zoutendijk, N. Vink, H. van Meurs, A.E. de Bruijn, F.H. Schröder.


                PRECISION Investigators’ Group: Antti S. Rannikko, Marcelo Borghi, Valeria Panebianco, Lance A. Mynderse, Markku H. Vaarala, Alberto Briganti, Lars Budäus, Giles Hellawell, Richard G. Hindley, Scott Eggener, Maneesh Ghei, Arnauld Villers, Franck Bladou, Geert M. Villeirs, Jaspal Virdi, Silvan Boxler, Grégoire Robert, Paras B. Singh, Wulphert Venderink, Boris A. Hadaschik, Alain Ruffion, Jim C. Hu, Daniel Margolis, Sébastien Crouzet, Laurence Klotz, Samir S. Taneja, Peter Pinto, Inderbir Gill, Clare Allen, Francesco Giganti, Alex Freeman, Stephen Morris, Shonit Punwani, Norman R. Williams, Chris Brew-Graves, Jonathan Deeks, Yemisi Takwoingi, Mark Emberton.

                © 2021 The Author(s)

                This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

                Prostate Cancer

                clinical decision-making,magnetic resonance imaging,nomograms,probability,prostatic neoplasms,risk stratification


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