2022 Canadian Urological Association recommendations on prostate cancer screening and early diagnosis Flashcards
What was the sample size of the PLCO trial in the 2017 update?
76,683
What is the age range for participants in the ERSPC trial (2014 update)?
55-69
How many European countries participated in the ERSPC trial?
8 European countries
How frequently was PSA screening done in the Goteborg trial (2014 update)?
Every 2 years
In the PLCO trial, how was a positive test defined?
PSA >4 ng/ml or an abnormal DRE
In the ERSPC trial, how was a positive test defined?
PSA >3.4 ng/ml
What was the rate ratio for CSS in the Goteborg trial (2014 update)?
0.58 (0.46-0.72)
Which trial reported a 42% relative risk reduction in favor of screening?
Goteborg (2014 update)
What does NNS stand for?
Number needed to screen
How many prostate cancer deaths were reported in the screened group of the ERSPC trial?
355
In the Goteborg trial, what was the NND?
1:13
Which trial had a median follow-up of 18 years?
Goteborg (2014 update)
What does CSS stand for?
Prostate cancer-specific survival
Which trial conducted the PSA screening annually for 6 years and had an annual DRE for 4 years?
PLCO (2017 update)
How many participants were in the ERSPC trial (2014 update)?
162,243
Which trial was conducted across 10 US centers?
PLCO (2017 update)
Where was the Goteborg trial (2014 update) conducted?
Goteborg, Sweden
In the Goteborg trial, how was a positive test defined from 1999-2004?
PSA >2.9 ng/ml
In the Goteborg trial, how was a positive test defined from 2005 onwards?
PSA >2.5 ng/ml
How many prostate cancer deaths were reported in the control group of the Goteborg trial?
122
What was the rate ratio for CSS in the ERSPC trial (2014 update)?
0.79 (0.69-0.91)
How many prostate cancer deaths were reported in the control group of the PLCO trial?
244
What was the NND for the ERSPC trial?
1:27
What is the age range for participants in the Goteborg trial (2014 update)?
50-64
Which trial showed a 21% relative risk reduction in favor of screening?
ERSPC (2014 update)
What was the NNS for the Goteborg trial?
1:139
Fig. 1. Prostate cancer screening pathway.
According to the 2017 recommendations by the United States Preventative Services Task Force (USPSTF), is PSA-based screening for prostate cancer recommended for men aged 55-69?
Yes. Clinicians should inform men about the potential benefits and harms, and the decision should be individual. There are no separate recommendations for high-risk populations.
What is the USPSTF’s stance on PSA-based screening for men aged 70 and above?
They recommend against it. The evidence indicates no mortality benefit for these men.
For the European Association of Urology (2016), when is PSA testing recommended for men?
For men >50, with an individualized, risk-adapted strategy for those with a life-expectancy of at least 10-15 years. For those >45 at elevated risk.
What is the European Association of Urology’s recommendation on follow-up based on initial PSA level?
Offer risk-adapted follow-up. If initially at risk, follow-up intervals of 2 years. If not at risk, postpone follow-up to 8 years.
What does the National Comprehensive Cancer Network (2016) recommend for prostate screening in men aged 45-75?
Yes, with a baseline evaluation that includes history and physical exam, race, and family history of BRCA1/2 mutations. Risk assessment should consider baseline PSA and DRE.
For the same organization (NCCN), what is the advised frequency based on PSA levels for men aged 45-75?
If PSA <1 ng/mL and DRE normal, 2-4-year intervals. If PSA 1-3 ng/mL and DRE normal, 1-2-year intervals. If PSA >3 ng/mL or suspicious DRE, consider biopsy.
According to the Canadian Task Force on Preventative Health (2014), is PSA screening recommended for men aged <55?
No, due to low prostate cancer incidence, lack of evidence of benefit, and evidence of harms.
What’s the stance of the American Urological Association (2013) on PSA screening for men aged 40-54?
It’s not routinely recommended for average-risk men. Decisions should be individualized for men <55 at higher risk. For those choosing screening, a 2-year interval or more may be preferred.
How does the American College of Physicians (2013) view PSA screening for men aged <50 and ≥70?
They recommend against screening for both age groups.
For men aged 50-69, what does the American College of Physicians (2013) suggest regarding PSA screening?
They recommend informing men about the limited benefits and substantial harms. The decision should be based on risk, discussion of benefits and harms, patient’s health and life expectancy, and preferences.
What is the ranking of prostate cancer among malignancies in Canadian men excluding skin cancers?
Prostate cancer is the most commonly diagnosed noncutaneous malignancy among Canadian men.
Where does prostate cancer rank in terms of causes of cancer-related death among Canadian men?
It is the third leading cause of cancer-related death.
Approximately how many Canadian men were diagnosed with prostate cancer in 2016? And how many died from it?
An estimated 21,600 men were diagnosed, and 4,000 men died from the disease.
How is the clinical course of prostate cancer described?
Prostate cancer is a heterogeneous disease with a clinical course that can range from indolent to life-threatening.
What is the significant challenge in managing prostate cancer?
Identifying and treating men with clinically significant prostate cancer while avoiding the over-diagnosis and over-treatment of indolent disease.
What has caused conflicting recommendations in prostate cancer screening and early diagnosis guidelines?
Various professional associations have developed different guidelines, leading to conflicting recommendations.
What recent updates prompted the CUA to develop new recommendations?
Recent updates from several large, randomized, prospective trials and the emergence of several new diagnostic tests.
What is the primary aim of the CUA’s recommendations on prostate cancer screening and early diagnosis?
To provide guidance on current best prostate cancer screening and early diagnosis practices and to inform on new and emerging diagnostic modalities.
What were the five main questions guiding the literature searches and evidence synthesis on prostate cancer screening and diagnosis?
Should Canadian men undergo prostate cancer screening?
At what age should prostate cancer screening begin?
When can prostate cancer screening be stopped?
How frequently should prostate cancer screening be performed?
What diagnostic tests, besides PSA, are available for early prostate cancer diagnosis?
What was the purpose of answering the first four questions about prostate cancer screening?
To provide guidance on prostate cancer screening in general.
What was the aim of the fifth question about prostate cancer screening?
To provide information on additional available diagnostic tests beyond PSA.
Describe the two-step approach used to synthesize evidence for the first four questions.
Back:
Complete bibliographic review of existing guidelines on prostate cancer screening and diagnosis.
Search of the literature using MEDLINE for articles related to prostate cancer screening and diagnosis published between January 1, 2016, and February 2, 2017. Additional search on PubMed without MEDLINE filters.
How was the search conducted for the fifth question related to additional diagnostic tests?
A systematic search was performed similarly but without date restrictions for tests not covered by existing guidelines.
Which types of articles were excluded from the literature search?
Case series, case reports, non-systematic reviews, editorials, and letters to the editor.
What is the CUA’s stance on offering PSA screening?
PSA screening should be offered to men with a life expectancy greater than 10 years. The decision should be based on shared decision-making after discussing potential benefits and harms. (Level of evidence: 1; Grade of recommendation: B).
Why is prostate cancer screening considered controversial?
There are varying recommendations on PSA screening and no consensus among several professional and government organizations.
Name the three major randomized, controlled trials that provide credible Level 1 evidence concerning prostate cancer screening.
Prostate, Lung, Colon, and Ovarian screening trial (PLCO)
European Randomized Study of Screening for Prostate Cancer (ERSPC)
Goteborg randomized trial of PSA screening.
What was the result of the PCLO trial concerning prostate cancer-specific mortality?
There was no difference in prostate cancer-specific mortality between the intervention (screening) and control arms. However, a high contamination rate may have biased this result.
What significant outcomes were observed in the ERSPC and Goteborg trials?
The ERSPC showed a 21% relative risk reduction in prostate cancer mortality. The Goteborg study showed a relative risk reduction of 42% in prostate cancer mortality.
How has prostate cancer mortality changed since the introduction of PSA screening in North America?
Prostate cancer mortality has declined. Modeling studies suggest the largest contribution to this reduction is from screening.
What concerns are associated with PSA screening?
Over-diagnosis and over-treatment. Up to 67% of men diagnosed via screening might have clinically insignificant prostate cancer, leading to unnecessary exposure to potential harms of biopsy, treatment, and psychological effects.
How has the practice of active surveillance impacted prostate cancer treatment in Canada?
Active surveillance for low-risk prostate cancer has reduced the over-treatment of prostate cancer. However, it doesn’t eliminate the issue of over-diagnosis and has potential detriments to quality of life.
What does the CUA recommend regarding the decision-making process for PSA screening?
The CUA recommends engaging in a thorough discussion on the potential risks and benefits of PSA screening with patients. Shared decision-making should be performed, taking into account individualized decisions based on personal values.
What is the primary goal of prostate cancer screening according to the 2022 Canadian Urological Association’s recommendations?
The primary goal should be the early detection of clinically significant prostate cancer in healthy men while minimizing the detection and treatment of low-risk disease.
At what age does the CUA recommend starting PSA testing for most men?
The CUA suggests starting PSA testing at age 50 for most men.
Which men are recommended to start PSA testing at age 45?
Men at an increased risk of prostate cancer, particularly those with a family history of prostate cancer in a first- or second-degree relative.
What risk does a PSA >4 ng/ml in men aged 45-49 indicate?
A nearly 5% risk of developing lethal prostate cancer within 15 years.
How do men aged <50 with a family history of prostate cancer in a first-degree relative differ in risk compared to those with a second-degree relative?
Men aged <50 with a family history of prostate cancer in a first-degree relative have an approximately five-fold increased risk, while those with a second-degree relative have a two-fold increased risk of receiving a prostate cancer diagnosis.
Why is PSA testing not recommended for men less than age 45?
The potential benefits and harms have not been prospectively studied, and testing might lead to biopsies and diagnoses that are unlikely to provide benefit. Additionally, the potential delay in diagnosis in the small proportion of men at this age with significant prostate cancer is unlikely to lead to a missed opportunity for curative treatment.
Which men are the CUA’s recommendations not directed towards, and what is the suggested approach for them?
The recommendations are not directed towards men with known germ-line mutations associated with prostate cancer development (e.g., BRCA1, BRCA2, HOXB13). An individualized testing strategy after consultation with a clinical geneticist is most appropriate for these cases.
What is the recommended PSA testing interval for men with PSA <1 ng/ml according to the 2022 Canadian Urological Association?
Repeat PSA testing every four years. (Level of evidence: 3; Grade of recommendation: C)
What is the recommended PSA testing interval for men with PSA levels between 1–3 ng/ml?
Repeat PSA testing every two years. (Level of evidence: 3; Grade of recommendation: C)
How should men with PSA >3 ng/ml be approached regarding PSA testing intervals?
How should men with PSA >3 ng/ml be approached regarding PSA testing intervals?
Which trials provide the basis for the PSA testing intervals recommendations by the Canadian Urological Association in 2022?
The ERSPC trial and the Goteborg trial.
What’s the 10-year prostate cancer detection rate for men with a PSA <1 ng/ml?
3.4%, with 90% considered low-risk.
Why are longer intervals between PSA testing appropriate for men with PSA <1 ng/ml?
Because the risk of developing metastatic disease within 15 years for these men is very low, reducing the risk of over-detection due to lead-time bias or natural fluctuations in PSA levels.
As baseline PSA levels rise above 1 ng/ml, what happens to the risk related to prostate cancer?
The intermediate-term risk of developing both any prostate cancer and clinically significant prostate cancer increases substantially.
In the ERSPC trial, what PSA level was considered a positive test?
A PSA level of 3 ng/ml.
In the Goteborg trial, what PSA level range was considered a positive test?
Between 2.5 and 3.4 ng/ml (depending on the year of study).
For men with PSA >3 ng/ml, what adjunctive strategy might be considered?
Testing strategies that estimate the risk of clinically significant disease, which can be helpful for biopsy decision-making.
When should men consider discontinuing PSA screening based on age and PSA levels?
Men aged 60 with a PSA <1 ng/ml
All other men at age 70.
What is the justification for discontinuing PSA screening for men aged 60 with a PSA <1 ng/ml?
The risk of developing or dying from metastatic prostate cancer is low. A large study found the 15-year cumulative incidence of metastatic prostate cancer was low in men with a PSA <1ng/ml at age 60 (0.4% and 0%, for screened and unscreened cohorts respectively).
What risk does a PSA >1 ng/ml at age 60 carry?
For men at age 60 with a PSA >1 ng/ml, the risk of developing potentially lethal prostate cancer increases substantially. Thus, screening can be continued.
Why is PSA screening likely not beneficial for men aged >70?
Highest incidence of prostate cancer over-diagnosis.
Several studies suggest no benefit.
High risk of over-diagnosis, especially > age 70.
ERSPC trial found no reduction in prostate cancer mortality when starting screening at >70.
Quality of life detriments may offset any potential benefit.
What should be considered for men in excellent health at age 70 regarding PSA testing?
PSA testing can be considered, but there’s a lack of empirical data. Continued PSA testing for these men is based on clinical judgment and personal preferences.
When should PSA screening be considered in relation to life expectancy?
For men with a life expectancy of less than 10 years, PSA screening should be discontinued.
Why is PSA testing not beneficial for men with a high risk of mortality from other causes?
PSA testing is unlikely to provide any benefit. If life expectancy is limited by other illnesses or comorbidities, PSA screening shouldn’t be initiated or should be stopped.
What has the past two decades seen in the realm of prostate cancer early diagnosis in addition to PSA?
The development or evaluation of several potential adjunctive measures to either increase benefits or reduce harms associated with screening. These include PSA kinetics, PSA density, percent free PSA, biomarker panels, prostate risk calculators, and the refinement of prostate mpMRI.
Why is prostate mpMRI gaining attention in recent years?
Several landmark studies have been published leading to updated recommendations by Cancer Care Ontario (CCO). The 2021 CCO recommendations significantly differ from the previous ones, now recommending mpMRI in many biopsy-naive men at risk of prostate cancer.
What is the stance of the Canadian Urological Association (CUA) on the 2021 CCO recommendations regarding mpMRI?
The CUA endorses the 2021 CCO recommendations on the use of mpMRI in biopsy-naive men at risk of prostate cancer, with some added practical considerations.
Where can one find a summary of the updated recommendations by Cancer Care Ontario (CCO) on prostate mpMRI?
A summary was published in the February 2022 issue of CUAJ.
In which patient group is mpMRI recommended prior to biopsy for prostate cancer early diagnosis?
Biopsy-naive patients at elevated risk of clinically significant prostate cancer (csPCa) who are candidates for curative management with suspected clinically localized prostate cancer.
If a patient’s mpMRI is positive, what biopsy methods should be performed?
Both mpMRI-targeted biopsy (TB) and TRUS-guided systematic biopsy (TRUS-SB) should be performed together to maximize detection of csPCa.
What is the recommended course of action if a patient’s mpMRI is negative?
Consider forgoing any biopsy after discussing the risks and benefits as part of shared decision-making with the patient and plan for ongoing follow-up.
What percentage range of patients with csPCa might be missed by a negative mpMRI?
Between 8% and 24%.
What should patients be informed about when their mpMRI result is negative?
They should be made aware of the risks and benefits of avoiding a biopsy.
Under what conditions should mpMRI only be performed?
Only if there is the availability of high-quality mpMRI interpretation and operators experienced in performing targeted biopsies.
When is mpMRI recommended given its limited availability?
Only for patients where there is an intent of curative management should the biopsy be positive for csPCa.
What is the recommended diagnostic step for patients with a prior negative TRUS-SB showing a high risk of csPCa and for whom curative management is being considered?
An mpMRI should be performed.
What percentage of patients with csPCa might be missed by a negative mpMRI?
Between 8% and 24%.
Why should patients be informed about the risks and benefits of biopsy avoidance when an mpMRI is negative?
Because a negative mpMRI can miss between 8% and 24% of patients with csPCa.
Under what conditions should an mpMRI be performed?
Only if there is availability of high-quality mpMRI interpretation and operators with experience in performing targeted biopsies.
How is “Prior negative TRUS-SB” defined?
No cancer of any grade group on prior biopsy.
When is mpMRI recommended according to the CCO guideline panel?
Only for patients where there is intent of curative treatment in the case of a positive biopsy, due to its limited availability.
: What has evidence shown about the benefits of mpMRI in the context of prostate biopsies?
mpMRI, with the use of targeted and standard biopsies, can lead to a significant reduction in unnecessary prostate biopsies while improving the detection of csPCa.
What practical limitations have been recognized by the CUA regarding the use of mpMRI?
Timely access to mpMRI and mpMRI-TB, and variations in quality and interpretation.
For which patients should the use of mpMRI be limited?
Only for patients for whom the test result is likely to influence their management. It shouldn’t be used for men with clear clinical signs of csPCa or for men suspected of prostate cancer but won’t consider active management regardless of the result.
What should be commenced for men with clear clinical signs of csPCa?
Systematic prostate biopsy or disease management, depending on the situation.
What is the significance of PSA kinetics in prostate cancer early diagnosis?
PSA kinetics involve the evaluation of the rate of change of PSA levels over time. It can help in understanding the risk and prognosis of prostate cancer.
Define PSA velocity (PSAV) and PSA doubling time (PSADT).
PSAV refers to the rate at which PSA levels increase annually. PSADT is the time taken for PSA levels to double.
Historical reports identified that a PSAV greater than what value may indicate an increased risk of prostate cancer?
A PSAV greater than 0.75ng/ml/year.
When the total PSA is less than 4.0 ng/ml, what PSAV is associated with a higher relative risk of prostate cancer death?
A PSAV greater than 0.35ng/ml/year.
Is a stable or declining PSA reassuring?
Yes, a stable or declining PSA is reassuring, especially in men with PSA levels that slightly exceed PSA thresholds.
What does the Canadian Urological Association (CUA) recommend regarding the use of PSAV alone for clinical decision-making in men undergoing routine screening?
The CUA does not recommend using PSAV alone for clinical decision-making in men undergoing routine screening. However, PSAV can provide additional information about a patient’s risk of prostate cancer.
What is the stance on the incremental value of PSAV over absolute PSA level?
There is conflicting evidence on the incremental value of PSAV over absolute PSA level alone. Some studies suggest it provides value, while others do not.
In the context of PSA kinetics, what is a concerning finding?
A sustained and substantial rise in PSA over time is a concerning finding that warrants investigation.
What does PSAD stand for in the context of prostate cancer diagnosis?
PSA density.
How is PSA density (PSAD) calculated?
PSAD is calculated as the serum PSA divided by prostate volume.
What PSAD threshold has been suggested to identify men at risk from prostate cancer?
A PSAD threshold of >0.15 ng/ml/cm^3.
True or False: Higher PSAD has always been linked with adverse pathological features at the time of prostatectomy.
False. While some studies have linked higher PSAD with adverse pathological features, others have failed to validate these findings.
What concerns arise from the estimation of prostate volume on ultrasound in relation to PSAD?
There is substantial inter-observer variability, raising questions regarding the reliability of PSAD.
Is the use of PSAD alone for clinical decision-making encouraged according to the 2022 Canadian Urological Association recommendations?
No. Due to the lack of empirical validation, the use of PSAD alone for clinical decision-making is discouraged.
Under what circumstances can PSAD be considered for use, as per the 2022 Canadian Urological Association recommendations?
PSAD can be considered adjunctively in men with known prostate volumes.
What is the purpose of measuring percent free PSA in prostate cancer screening
The measurement of percent free PSA is studied as a risk-stratifying tool aimed at distinguishing men at risk from prostate cancer vs. those with elevations in PSA from benign causes.
In a multicenter, prospective study, what percentage of men with a free-to-total PSA ratio of less than 0.10 (for men with a PSA between 4 and 10 ng/ml) were detected with prostate cancer?
56%
For men with a PSA between 4 and 10 ng/ml, what percentage of men with a free-to-total PSA ratio greater than 0.25 were detected with prostate cancer?
8%
In a study with 6982 percent free and total PSA measurements over a 12-year time span, what percentage of unnecessary prostate biopsies could percent free PSA spare as a reflex marker?
66%
True or False: Percent free PSA values remain consistent and do not fluctuate.
False. Similar to PSA, percent free PSA can also fluctuate, emphasizing the need for repeat confirmatory testing prior to clinical decision-making.
Is it recommended to use percent free PSA alone for clinical decision-making?
No, the use of percent free PSA alone for clinical decision-making is not recommended. However, it can be useful in estimating the risk of underlying disease in men with elevations in PSA.
What is the level of evidence and grade of recommendation for the use of percent free PSA in estimating the risk of underlying disease in men with elevations in PSA?
Level of evidence: 2; Grade of recommendation: C
What is the 4Kscore®?
The 4Kscore® is a commercially available test that combines total PSA, free PSA, intact PSA, and human kallikrein 2 with age, DRE results, and prior biopsy status. It’s designed to generate a risk estimate of harbouring Gleason ≥7 prostate cancer.
From which studies was the four-kallikrein panel (4Kscore®) initially developed?
The 4Kscore® was originally developed using data from the ERSPC (European Randomized Study of Screening for Prostate Cancer) and the ProtecT (Prostate Testing for Cancer and Treatment) studies.
How does the 4Kscore® compare to PSA alone in predicting the presence of high-grade prostate cancer?
The 4Kscore® offers evidence of clinical utility over PSA alone for predicting the presence of high-grade prostate cancer.
The 4Kscore® offers evidence of clinical utility over PSA alone for predicting the presence of high-grade prostate cancer.
The AUC values for the 4Kscore® ranged from 0.71 to 0.82 based on various validation studies.
In a prospective study of 1012 men from 26 U.S. centers, how did the 4Kscore® perform in predicting Gleason ≥7 cancer compared to the modified Prostate Cancer Prevention Trial Risk Calculator 2.0 model?
The 4Kscore® demonstrated better discrimination with an AUC of 0.82, compared to the modified Prostate Cancer Prevention Trial Risk Calculator 2.0 model, which had an AUC of 0.74.
What influence does the 4Kscore® have on biopsy decision-making?
The 4Kscore® influenced biopsy decision-making in 89% of men, and it reduced the number of biopsies by 65% in a study of 611 men evaluated by both academic and community urologists.
For which PSA levels was the 4Kscore® originally developed? Has its use been extended?
The 4Kscore® was originally developed for men with a PSA <10 ng/ml. However, its use has since been extended and validated for men with a PSA up to 25 ng/ml.
What does AUC stand for and what does it represent in the context of model performance?
AUC stands for “Area Under the Receiver Operating Characteristic Curve”. It measures the performance of a binary classification model. The value of the AUC ranges from 0 to 1, with 1 indicating perfect classification and 0.5 suggesting the model’s performance is no better than random chance.
What is the Prostate Health Index (PHI)?
The Prostate Health Index (PHI) is a commercially available test derived from PSA and its isoforms (total PSA, free PSA, and [-2] pro PSA). It was originally developed to estimate the risk of harbouring Gleason 7 or greater disease in men with a PSA between 2 and 10 ng/ml.
What was the purpose of the initial validation study for PHI?
: The initial validation study aimed to evaluate the ability of PHI to discriminate patients with or without clinically significant disease compared to PSA and free-to-total PSA.
How did the PHI perform in the initial validation study in terms of AUC compared to PSA and free-to-total PSA?
The AUC for PHI was 0.72, while the AUC for PSA and free-to-total PSA was 0.67.
What benefits does PHI offer over total and percent free PSA in predicting high-risk disease?
PHI can outperform total and percent free PSA in predicting high-risk disease, including in biopsy-naive men.
How does the PHI impact the performance of the PCPT and ERSPC risk calculators?
In a large, multicenter, prospective study, PHI significantly improved the performance of the PCPT and ERSPC risk calculators in men with a PSA between 2 and 10 ng/ml for predicting the risk of Gleason ≥7 prostate cancer.
What was the clinical utility of PHI in terms of reducing unnecessary biopsies and missing high-grade cancers?
A multicenter cohort study found that the clinical utility of PHI reduced unnecessary biopsies by 36% and only missed 2.5% of high-grade cancers.
How do the discriminatory abilities of PHI and the 4K score compare for predicting high-risk prostate cancer in men with a PSA between 3 and 15 ng/ml?
Both tests demonstrate similar discriminatory ability, with the AUC for the 4K score being 0.718 and for PHI being 0.711.
What is PCA3, and where is it expressed?
Prostate cancer antigen 3 (PCA3) is a non-coding RNA gene expressed solely in the prostate and is overexpressed in prostate cancer. It’s measured from a urine sample obtained after a DRE.
How does the PCA3 test differ from the 4Kscore and PHI?
Unlike the 4Kscore and PHI, which are based on serum measurements, PCA3 is measured from a urine sample.
How does the diagnostic accuracy of PCA3 for prostate cancer detection compare to PSA alone?
Multiple studies have shown that PCA3 has an improved diagnostic accuracy for prostate cancer detection relative to PSA alone.
In men with a history of a negative biopsy, what does a PCA3 score of less than 25 indicate?
Those with a PCA3 score of less than 25 are almost five times more likely to have a negative repeat biopsy compared to those with a score ≥25.
What is the role of PCA3 in men with no history of a prior biopsy?
The role is uncertain. However, in a biopsy-naive setting, a PCA3 score <20 led to a high rate of undiagnosed high-grade cancers (13%), compared to 3% in the repeat setting.
How do the 4Kscore, PHI, and PCA3 tests augment the prediction of prostate cancer in men with moderately elevated PSA?
These tests can improve the prediction of clinically significant prostate cancer and offer additional information over PSA alone.
What is the Canadian Urological Association’s (CUA) position on the widespread use of the 4Kscore, PHI, and PCA3 tests?
The CUA recognizes that these tests are expensive and not publicly funded in Canada. Currently, based on available data, the CUA does not encourage their widespread use.
What is the purpose of prostate cancer risk nomograms?
They aid in the detection of clinically significant prostate cancer.
What is the range of discrimination properties for prostate cancer detection in adequately validated nomograms?
AUC 0.66–0.79.
How many of the available prostate cancer risk nomograms have been adequately validated across several study populations?
Six.
Which factors does the PCPT prostate cancer risk calculator (PCPT-RC) use to estimate the risk of prostate cancer?
Age, PSA level, ethnic background, family history, DRE results, and prior biopsy results.
Which factors does the ERSPC prostate cancer risk calculator (ERSPC-RC) use to determine the risk of prostate cancer?
PSA level, DRE results, prior biopsy results, prostate volume, and TRUS findings.
What does the prostate risk calculator developed using data from Canadian men use to estimate the risk of prostate cancer?
PSA level, free-to-total PSA, age, voiding symptoms, ethnicity, family history, and DRE results.
How would you describe the predictive accuracy of prostate risk calculators?
Moderate, and it varies across different study populations.
When can prostate risk calculators be used?
To estimate the risk of clinically significant prostate cancer in men presenting with an elevated PSA.
What is the primary consideration for deciding the threshold for performing a prostate biopsy?
The decision should be individualized. No uniform PSA cutoff can be recommended for all men.
Why should a single PSA measurement not be solely relied upon for biopsy decision-making?
Due to the documented changes and fluctuations in PSA levels over time.
What was the observation in the Canadian study with over 1000 men with elevated PSA (>4 ng/ml)?
By repeating PSA testing, 25% of the cohort had resolution to low levels, negating the need for further investigation.
What factors should be considered when deciding to proceed with a prostate biopsy?
PSA level, results from adjunct tests or risk calculators, competing comorbidities, patient preferences, and potentially suspicious findings on DRE.
What is the stance on the utility of DRE in addition to PSA?
It’s controversial. However, DRE may increase the detection of clinically significant disease and should be performed at the same interval as PSA testing.
How does the CUA feel about the implementation of a successful screening program?
It must consider individual variations in patient preferences, and men should be involved in decision-making regarding prostate biopsy.
What should the decision to pursue a biopsy be based upon?
A discussion of the best evidence for estimating the risk for aggressive prostate cancer, according to Expert opinion.
