EAU guidelines on prostate cancer. part 1: screening, diagnosis, and local treatment with curative intent-update 2013. EAU guidelines on prostate cancer. Part 1: screening, diagnosis, and treatment of clinically localised disease. Prebiopsy Multiparametric Magnetic Resonance Imaging for Prostate Cancer Diagnosis in Biopsy-naive Men with Suspected Prostate Cancer Based on Elevated Prostate-specific Antigen Values: Results from a Randomized Prospective Blinded Controlled Trial. Prostate-specific antigen-based early detection of prostate cancer--validation of screening without rectal examination. A 16-yr Follow-up of the European Randomized study of Screening for Prostate Cancer. Multicentric oncologic outcomes of high-intensity focused ultrasound for localized prostate cancer in 803 patients. Performance of the prostate cancer antigen 3 (PCA3) gene and prostate-specific antigen in prescreened men: exploring the value of PCA3 for a first-line diagnostic test. Prospective study of diagnostic accuracy comparing prostate cancer detection by transrectal ultrasound-guided biopsy versus magnetic resonance (MR) imaging with subsequent MR-guided biopsy in men without previous prostate biopsies. Focal High-intensity Focused Ultrasound Targeted Hemiablation for Unilateral Prostate Cancer: A Prospective Evaluation of Oncologic and Functional Outcomes. Prediction of Prostate Cancer Risk Among Men Undergoing Combined MRI-targeted and Systematic Biopsy Using Novel Pre-biopsy Nomograms That Incorporate MRI Findings. Prostate Imaging-Reporting and Data System Steering Committee: PI-RADS v2 Status Update and Future Directions. Screening for prostate cancer: results of the Rotterdam section of the European randomized study of screening for prostate cancer. Prostate cancer mortality reduction by prostate-specific antigen-based screening adjusted for nonattendance and contamination in the European Randomised Study of Screening for Prostate Cancer (ERSPC). Urine TMPRSS2:ERG fusion transcript integrated with PCA3 score, genotyping, and biological features are correlated to the results of prostatic biopsies in men at risk of prostate cancer. Prostate cancer mortality in screen and clinically detected prostate cancer: estimating the screening benefit. Diagnostic Pathway with Multiparametric Magnetic Resonance Imaging Versus Standard Pathway: Results from a Randomized Prospective Study in Biopsy-naïve Patients with Suspected Prostate Cancer. Morbidity of focal therapy in the treatment of localized prostate cancer. Ejaculation Frequency and Risk of Prostate Cancer: Updated Results with an Additional Decade of Follow-up. Whole-gland ablation of localized prostate cancer with high-intensity focused ultrasound: oncologic outcomes and morbidity in 1002 patients. Novel biparametric MRI and targeted biopsy improves risk stratification in men with a clinical suspicion of prostate cancer (IMPROD Trial) Comparison of Chromogranin A, Insulin-Like Growth Factor 1 and Prostate-Specific Antigen Serum Markers in Prostate Adenocarcinoma and Benign Prostatic Hyperplasia Outcomes of men with screen-detected prostate cancer eligible for active surveillance who were managed expectantly. [Mortality due to prostate cancer in the Spanish arm of the European Randomized Study of Screening for Prostate Cancer (ERSPC). Results after a 15-year follow-up]. The effect of benign lower urinary tract symptoms on subsequent prostate cancer testing and diagnosis. Prostate cancer antigen 3 score accurately predicts tumour volume and might help in selecting prostate cancer patients for active surveillance. Clinical utility of the PCA3 urine assay in European men scheduled for repeat biopsy. Prediction of High-grade Prostate Cancer Following Multiparametric Magnetic Resonance Imaging: Improving the Rotterdam European Randomized Study of Screening for Prostate Cancer Risk Calculators. Prostate cancer and adiponectin. Prostate cancer detection is also relevant in low prostate specific antigen ranges. Natural history of early, localized prostate cancer: a final report from three decades of follow-up. Insulin-like growth factor 1 (IGF-1), IGF-1 density, and IGF-1/PSA ratio for prostate cancer detection. Multiparametric MRI of the prostate with three functional techniques in patients with PSA elevation before initial TRUS-guided biopsy. A "PSA pyramid" for men with initial prostate-specific antigen ≤3 ng/ml: a plea for individualized prostate cancer screening. Population-based case-control study of PSA and DRE screening on prostate cancer mortality. TOP: Prospective Evaluation of a Volume Based, Computer Assisted Method for Transperineal Optimized Prostate Biopsy Generalizability of the Prostate Cancer Intervention Versus Observation Trial (PIVOT) Results to Contemporary North American Men with Prostate Cancer. Prostate cancer diagnosis: multiparametric MR-targeted biopsy with cognitive and transrectal US-MR fusion guidance versus systematic biopsy--prospective multicenter study. Transrectal quantitative shear wave elastography in the detection and characterisation of prostate cancer Evaluation of the Prostate Imaging Reporting and Data System for Magnetic Resonance Imaging Diagnosis of Prostate Cancer in Patients with Prostate-specific Antigen <20 ng/ml Multiparametric Magnetic Resonance Imaging/Transrectal Ultrasound Fusion Targeted Biopsy of the Prostate: Preliminary Results of a Prospective Single-Centre Study Using PSA to guide timing of androgen deprivation in patients with T0-4 N0-2 M0 prostate cancer not suitable for local curative treatment (EORTC 30891).
CONTEXT The most recent summary of the European Association of Urology ( EAU ) guidelines on prostate cancer ( PCa ) was published in 2011 . OBJECTIVE To present a summary of the 2013 version of the EAU guidelines on screening , diagnosis , and local treatment with curative intent of clinical ly organ-confined PCa . EVIDENCE ACQUISITION A literature review of the new data emerging from 2011 to 2013 has been performed by the EAU PCa guideline group . The guidelines have been up date d , and levels of evidence and grade s of recommendation have been added to the text based on a systematic review of the literature , which included a search of online data bases and bibliographic review s. EVIDENCE SYNTHESIS A full version of the guidelines is available at the EAU office or online ( www.uroweb.org ) . Current evidence is insufficient to warrant widespread population -based screening by prostate-specific antigen ( PSA ) for PCa . Systematic prostate biopsies under ultrasound guidance and local anesthesia are the preferred diagnostic method . Active surveillance represents a viable option in men with low-risk PCa and a long life expectancy . A biopsy progression indicates the need for active intervention , whereas the role of PSA doubling time is controversial . In men with locally advanced PCa for whom local therapy is not m and atory , watchful waiting ( WW ) is a treatment alternative to and rogen-deprivation therapy ( ADT ) , with equivalent oncologic efficacy . Active treatment is recommended mostly for patients with localized disease and a long life expectancy , with radical prostatectomy ( RP ) shown to be superior to WW in prospect i ve r and omized trials . Nerve-sparing RP is the approach of choice in organ-confined disease , while neoadjuvant ADT provides no improvement in outcome variables . Radiation therapy should be performed with ≥ 74 Gy in low-risk PCa and 78 Gy in intermediate- or high-risk PCa . For locally advanced disease , adjuvant ADT for 3 yr results in superior rates for disease-specific and overall survival and is the treatment of choice . Follow-up after local therapy is largely based on PSA and a disease-specific history , with imaging indicated only when symptoms occur . CONCLUSIONS Knowledge in the field of PCa is rapidly changing . These EAU guidelines on PCa summarize the most recent findings and put them into clinical practice . PATIENT SUMMARY A summary is presented of the 2013 EAU guidelines on screening , diagnosis , and local treatment with curative intent of clinical ly organ-confined prostate cancer ( PCa ) . Screening continues to be done on an individual basis , in consultation with a physician . Diagnosis is by prostate biopsy . Active surveillance is an option in low-risk PCa and watchful waiting is an alternative to and rogen-deprivation therapy in locally advanced PCa not requiring immediate local treatment . Radical prostatectomy is the only surgical option . Radiation therapy can be external or delivered by way of prostate implants . Treatment follow-up is based on the PSA level OBJECTIVE Our aim was to present a summary of the 2010 version of the European Association of Urology ( EAU ) guidelines on the screening , diagnosis , and treatment of clinical ly localised cancer of the prostate ( PCa ) . METHODS The working panel performed a literature review of the new data emerging from 2007 to 2010 . The guidelines were up date d , and level of evidence and grade of recommendation were added to the text based on a systematic review of the literature , which included a search of online data bases and bibliographic review s. RESULTS A full version is available at the EAU office or Web site ( www.uroweb.org ) . Current evidence is insufficient to warrant widespread population -based screening by prostate-specific antigen ( PSA ) for PCa . A systematic prostate biopsy under ultrasound guidance and local anaesthesia is the preferred diagnostic method . Active surveillance represents a viable option in men with low-risk PCa and a long life expectancy .  PSA doubling time in <3 yr or a biopsy progression indicates the need for active intervention . In men with locally advanced PCa in whom local therapy is not m and atory , watchful waiting ( WW ) is a treatment alternative to and rogen-deprivation therapy ( ADT ) with equivalent oncologic efficacy . Active treatment is mostly recommended for patients with localised disease and a long life expectancy with radical prostatectomy ( RP ) shown to be superior to WW in a prospect i ve r and omised trial . Nerve-sparing RP represents the approach of choice in organ-confined disease ; neoadjuvant and rogen deprivation demonstrates no improvement of outcome variables . Radiation therapy should be performed with at least 74 Gy and 78 Gy in low-risk and intermediate/high-risk PCa , respectively . For locally advanced disease , adjuvant ADT for 3 yr results in superior disease-specific and overall survival rates and represents the treatment of choice . Follow-up after local therapy is largely based on PSA , and a disease-specific history with imaging is indicated only when symptoms occur . CONCLUSIONS The knowledge in the field of PCa is rapidly changing . These EAU guidelines on PCa summarise the most recent findings and put them into clinical practice BACKGROUND Multiparametric magnetic resonance imaging ( MP-MRI ) may improve the detection of clinical ly significant prostate cancer ( PCa ) . OBJECTIVE To compare MP-MRI transrectal ultrasound (TRUS)-fusion targeted biopsy with routine TRUS-guided r and om biopsy for overall and clinical ly significant PCa detection among patients with suspected PCa based on prostate-specific antigen ( PSA ) values . DESIGN , SETTING , AND PARTICIPANTS This institutional review board-approved , single-center , prospect i ve , r and omized controlled trial ( April 2011 to December 2014 ) included 130 biopsy-naive patients referred for prostate biopsy based on PSA values ( PSA < 20 ng/ml or free-to-total PSA ratio ≤0.15 and PSA < 10 ng/ml ) . Patients were r and omized 1:1 to the MP-MRI or control group . Patients in the MP-MRI group  underwent prebiopsy MP-MRI followed by 10- to 12-core TRUS-guided r and om biopsy and cognitive MRI/TRUS fusion targeted biopsy . The control group underwent TRUS-guided r and om biopsy alone . INTERVENTION MP-MRI 3-T phased-array surface coil . OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The primary outcome was the number of patients with biopsy-proven PCa  in the MP-MRI and control groups . Secondary outcome measures included the number of positive prostate biopsies and the proportion of clinical ly significant PCa in the MP-MRI and control groups . Between-group analyses were performed . RESULTS AND LIMITATIONS Overall , 53 and 60 patients were evaluable in the MP-MRI and control groups , respectively . The overall PCa detection rate and the clinical ly significant cancer detection rate were similar between the MP-MRI and control groups , respectively ( 64 % [ 34 of 53 ] vs 57 % [ 34 of 60 ] ; 7.5 % difference [ 95 % confidence interval ( CI ) , -10 to 25 ] , p=0.5 , and 55 % [ 29 of 53 ] vs 45 % [ 27 of 60 ] ; 9.7 % difference [ 95 % CI , -8.5 to 27 ] , p=0.8 ) . The PCa detection rate was higher than assumed during the planning of this single-center trial . CONCLUSIONS MP-MRI/TRUS-fusion targeted biopsy did not improve PCa detection rate compared with TRUS-guided biopsy alone in patients with suspected PCa based on PSA values . PATIENT SUMMARY In this r and omized clinical trial , additional prostate magnetic resonance imaging ( MRI ) before prostate biopsy appeared to offer similar diagnostic accuracy compared with routine transrectal ultrasound-guided r and om biopsy in the diagnosis of prostate cancer . Similar numbers of cancers were detected with and without MRI . TRIAL REGISTRATION Clinical Trials.gov identifier : NCT01357512 OBJECTIVES The evaluation of the screening procedures for prostate cancer ( PCa ) was a part of the protocol of the European R and omized Study of Screening for Prostate Cancer ( ERSPC ) , section Rotterdam , The Netherl and s. We sought to establish an improved strategy for the early detection of PCa using a prostate-specific antigen ( PSA ) cutoff of 3.0 ng/mL or greater as the only indication for prostate biopsy with omission of the digital rectal examination ( DRE ) . METHODS In June 1996 , 8612 men , 55 to 74 years old , were r and omized to screening and were screened within the ERSPC Rotterdam by a PSA level of 4.0 ng/mL or greater or positive DRE or transrectal ultrasound findings as the indication for biopsy .  Four hundred thirty men had PCa . Those treated by radical prostatectomy provided the tumor characteristics considered essential for a change in the screening strategies . Various options were evaluated and predictions made by logistic regression analyses . The protocol change was implemented in February 1997 . Another 7943 men were screened according to the new protocol ( PSA 3.0 ng/mL or greater ) . The result ing data were used to compare the two protocol s. RESULTS The detection rate ( proportion of PCa in those screened ) turned out to be very similar , with rates of 5.0 and 4.7 at a PSA cutoff of 4.0 ng/mL or greater and 3.0 ng/mL or greater , respectively . This was due to a much larger number of cases of PCa per biopsy in the PSA range of 3 to 3.9 ng/mL than expected . The positive predictive value of the PSA range 3.0 to 3.9 ng/mL in the two protocol s was 18.0 % and 6.4 % , respectively . Tumor characteristics were studied on radical prostatectomy specimens from the original protocol . PCa detected with the new screening regimen had a similar distribution of Gleason scores but a larger proportion of confined disease . Tumor volumes were smaller in patients with PSA levels of less than 2.9 ng/mL ; the proportion of " minimal disease " in that group was 50 % compared with 28 % in the group with a PSA level between 3.0 and 3.9 ng/mL. CONCLUSIONS Lowering the biopsy indication to a PSA cutoff of 3.0 ng/mL or greater without a DRE improved the positive predictive value from 18.2 % to 24.3 % . The number of biopsies necessary to detect 1 case of PCa accordingly changed from 5.2 to 3.4 . The overall characteristics of the cases detected at that PSA cutoff differed very little from those detected with the regimen based on PSA , DRE , and transrectal ultrasound BACKGROUND The European R and omized study of Screening for Prostate Cancer ( ERSPC ) has previously demonstrated that prostate-specific antigen ( PSA ) screening decreases prostate cancer ( PCa ) mortality . OBJECTIVE To determine whether PSA screening decreases PCa mortality for up to 16yr and to assess results following adjustment for nonparticipation and the number of screening rounds attended . DESIGN , SETTING , AND PARTICIPANTS This multicentre population -based r and omised screening trial was conducted in eight European countries . Report includes 182160 men , followed up until 2014 ( maximum of 16yr ) , with a predefined core age group of 162389 men ( 55 - 69yr ) , selected from population registry . OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The outcome was PCa mortality , also assessed with adjustment for nonparticipation and the number of screening rounds attended . RESULTS AND LIMITATIONS The rate ratio of PCa mortality was 0.80 ( 95 % confidence interval [ CI ] 0.72 - 0.89 , p<0.001 ) at 16yr . The difference in absolute PCa mortality increased from 0.14 % at 13yr to 0.18 % at 16yr . The number of men needed to be invited for screening to prevent one PCa death was 570 at 16yr compared with 742 at 13yr . The number needed to diagnose was reduced to 18 from 26 at 13yr . Men with PCa detected during the first round had a higher prevalence of PSA > 20ng/ml ( 9.9 % compared with 4.1 % in the second round , p<0.001 ) and higher PCa mortality ( hazard ratio=1.86 , p<0.001 ) than those detected subsequently . CONCLUSIONS Findings corroborate earlier results that PSA screening significantly reduces PCa mortality , showing larger absolute benefit with longer follow-up and a reduction in excess incidence . Repeated screening may be important to reduce PCa mortality on a population level . PATIENT SUMMARY In this report , we looked at the outcomes from prostate cancer in a large European population . We found that repeated screening reduces the risk of dying from prostate cancer BACKGROUND High-intensity focused ultrasound ( HIFU ) is an emerging treatment for select patients with localized prostate cancer ( PCa ) . OBJECTIVES To report the oncologic outcome of HIFU as a primary care option for localized prostate cancer from a multicenter data base . DESIGN , SETTING , AND PARTICIPANTS Patients with localized PCa treated with curative intent and presenting at least a 2-yr follow-up from February 1993 were considered in this study . Previously irradiated patients were excluded from this analysis . In case of any residual or recurrent PCa , patients were systematic ally offered a second session . Kaplan-Meier analysis was performed to determine disease-free survival rates ( DFSR ) . MEASUREMENTS Prostate-specific antigen ( PSA ) , clinical stage , and pathologic results were measured pre- and post-HIFU . RESULTS AND LIMITATIONS A total of 803 patients from six urologic departments met the inclusion criteria . Stratification according to d'Amico 's risk group was low , intermediate , and high in 40.2 % , 46.3 % , and 13.5 % of patients , respectively . Mean follow-up was 42+/-33 mo . Mean PSA nadir was 1.0+/-2.8 ng/ml with 54.3 % reaching a nadir of < or = 0.3 ng/ml . Control biopsies were negative in 85 % of cases . The overall and cancer-specific survival rates at 8 yr were 89 % and 99 % , respectively . The metastasis-free survival rate at 8 yr was 97 % . Initial PSA value and Gleason score value significantly influence the DFSR . The 5- and 7-yr biochemical-free survival rates ( Phoenix criteria ) were 83 - 75 % , 72 - 63 % , and 68 - 62 % ( p=0.03 ) and the additional treatment-free survival rates were 84 - 79 % , 68 - 61 % , and 52 - 54 % ( p<0.001 ) for low- , intermediate- , and high-risk patients , respectively . PSA nadir was a major predictive factor for HIFU success : negative biopsies , stable PSA , and no additional therapy . CONCLUSIONS Local control and DFSR achieved with HIFU were similar to those expected with conformal external-beam radiation therapy ( EBRT ) . The excellent cancer-specific survival rate is also explained by the possibility to repeat HIFU and use salvage EBRT BACKGROUND The performance characteristics of serum prostate-specific antigen ( PSA ) as a diagnostic test for prostate cancer ( PCa ) are poor . The performance of the PCa antigen 3 ( PCA3 ) gene as a primary diagnostic is unknown . OBJECTIVE Assess the value of PCA3 as a first-line diagnostic test . DESIGN , SETTING AND PARTICIPANTS Participants included men aged 63 - 75 who were invited for rescreening in the period from September 2007 to February 2009 within the European R and omised Study of Screening for Prostate Cancer , Rotterdam section . INTERVENTIONS Lateral sextant biopsies were performed if the serum PSA value was > or = 3.0 ng/ml and /or the PCA3 score was > or = 10 . MEASUREMENTS Measurements included distribution and correlation of PSA value and PCA3 score and their relation to the number of cases and the characteristics of PCa detected . Additional value of PCA3 was included in men with previous negative biopsy and /or PSA < 3.0 ng/ml . RESULTS AND LIMITATIONS In 721 men , all biopsied , 122 PCa cases ( 16.9 % ) were detected . Correlation between PSA and PCA3 is poor ( Spearman rank correlation : ρ=0.14 ; p<0.0001 ) . A PSA > or = 3.0 ng/ml misses 64.7 % of the total PCa that can be detected with the sextant biopsy technique and 57.9 % of serious PCa ( T2a or higher and /or Gleason grade > or = 4 , n=19 ) , and 68.2 % of biopsies could have been avoided ; the respective data for PCA3 > or = 35 are 32 % , 26.3 % , and 51.7 % . Performance of PCA3 in men with low PSA ( area under the curve [ AUC ] : 0.63 ) and /or previous negative biopsy ( AUC : 0.68 ) is unclear but has limited reliability due to small numbers . CONCLUSIONS PCA3 as a first-line screening test shows improvement of the performance characteristics and identification of serious disease compared with PSA in this prescreened population BACKGROUND The current diagnosis of prostate cancer ( PCa ) uses transrectal ultrasound-guided biopsy ( TRUSGB ) . TRUSGB leads to sampling errors causing delayed diagnosis , overdetection of indolent PCa , and misclassification . Advances in multiparametric magnetic resonance imaging ( mpMRI ) suggest that imaging and selective magnetic resonance (MR)-guided biopsy ( MRGB ) may be superior to TRUSGB . OBJECTIVE To compare the diagnostic efficacy of the magnetic resonance imaging ( MRI ) pathway with TRUSGB . DESIGN , SETTING , AND PARTICIPANTS A total of 223 consecutive biopsy-naive men referred to a urologist with elevated prostate-specific antigen participated in a single-institution , prospect i ve , investigator-blinded , diagnostic study from July 2012 through January 2013 . INTERVENTION All participants had mpMRI and TRUSGB . Men with equivocal or suspicious lesions on mpMRI also underwent MRGB . OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The primary outcome was PCa detection . Secondary outcomes were histopathologic details of biopsy and radical prostatectomy specimens , adverse events , and MRI reader performance . Sensitivity , specificity , negative predictive values ( NPVs ) , and positive predictive values were estimated and basic statistics presented by number ( percentage ) or median ( interquartile range ) . RESULTS AND LIMITATIONS Of 223 men , 142 ( 63.7 % ) had PCa . TRUSGB detected 126 cases of PCa in 223 men ( 56.5 % ) including 47 ( 37.3 % ) classed as low risk . MRGB detected 99 cases of PCa in 142 men ( 69.7 % ) with equivocal or suspicious mpMRI , of which 6 ( 6.1 % ) were low risk . The MRGB pathway reduced the need for biopsy by 51 % , decreased the diagnosis of low-risk PCa by 89.4 % , and increased the detection of intermediate/high-risk PCa by 17.7 % . The estimated NPVs of TRUSGB and MRGB for intermediate/high-risk disease were 71.9 % and 96.9 % , respectively . The main limitation is the lack of long follow-up . CONCLUSIONS We found that mpMRI/MRGB reduces the detection of low-risk PCa and reduces the number of men requiring biopsy while improving the overall rate of detection of intermediate/high-risk PCa . PATIENT SUMMARY We compared the results of st and ard prostate biopsies with a magnetic resonance ( MR ) image-based targeted biopsy diagnostic pathway in men with elevated prostate-specific antigen . Our results suggest patient benefits of the MR pathway . Follow-up of negative investigations is required BACKGROUND In selected patients with unilateral , organ-confined prostate cancer ( PCa ) , hemiablation of the affected lobe might be feasible to achieve acceptable cancer control with fewer complications . OBJECTIVES To assess the oncologic and functional outcomes of focal high-intensity focused ultrasound ( HIFU ) hemiablation in unilateral organ-confined PCa . DESIGN , SETTING AND PATIENTS Single-center prospect i ve evaluation of HIFU hemiablation for unilateral organ-confined PCa was performed from July 2009 through December 2013 . INTERVENTION Cancer localization was done with transrectal ultrasound-guided biopsy and multiparametric magnetic resonance imaging followed by HIFU hemiablation . OUTCOME MEASUREMENT AND STATISTICAL ANALYSIS Oncologic outcomes were analyzed with control biopsies and prostate-specific antigen ( PSA ) measurement . Functional outcomes were assessed with vali date d question naires for genitourinary symptoms . RESULTS AND LIMITATIONS Of 71 HIFU hemiablation patients , 67 completed the study protocol . The mean age was 70.2 yr ( st and ard deviation : 6.8 yr ) , and median PSA was 6.1 ng/ml ( interquartile range [ IQR ] : 1.6 - 15.5 ng/ml ) . Median maximum cancer-core length was 3 mm ( IQR : 2 - 10 mm ) , and total cancer length was 6.5 mm ( IQR : 2 - 24 mm ) . Gleason score was 6 ( 3 + 3 ) in 58 patients ( 86.6 % ) and 7 ( 3 + 4 ) in 9 patients ( 13.4 % ) . Median follow-up was 12 mo ( IQR : 6 - 50 mo ) , and at 12 mo , 56 of 67 patients had a negative control biopsy in the treated lobe . At 3 mo , all patients were continent , and potency was maintained in 11 of 21 preoperatively potent patients ( confidence interval , 0.18 - 0.69 ) . Complications included 8 % Clavien-Dindo grade 2 and 2.8 % grade 3 events . CONCLUSIONS Focal HIFU hemiablation appears to achieve acceptable oncologic outcomes with low morbidity and minimal functional changes . Longer follow-up will establish future considerations . PATIENT SUMMARY This study showed that high-intensity focused ultrasound hemiablation in selected patients with unilateral organ-confined prostate cancer can be used for satisfactory cancer control with minimal effect on genitourinary functions OBJECTIVE To develop nomograms that predict the probability of overall prostate cancer ( PCa ) and clinical ly significant PCa ( Gleason ≥7 ) on magnetic resonance imaging (MRI)-targeted , and combined MRI-targeted and systematic , prostate biopsy . MATERIAL S AND METHODS From June 2012 to August 2014 , magnetic resonance imaging to ultrasound fusion-targeted prostate biopsy was performed on 464 men with suspicious regions identified on pre-biopsy 3 T MRI along with systematic 12 core biopsy .  Logistic regression modeling was used to evaluate predictors of overall and clinical ly significant PCa , and corresponding nomograms were generated for men who were not previously biopsied or had 1 or more prior negative biopsies . Models were created with 70 % of a r and omly selected training sample and bias-corrected using bootstrap resampling . The models were then vali date d with the remaining 30 % testing sample pool . RESULTS A total of 459 patients were included for analysis ( median age 66 years , prostate-specific antigen [ PSA ] 5.2 ng/mL , prostate volume 49 cc ) . Independent predictors of PCa on targeted and systematic prostate biopsy were PSA density , age , and MRI suspicion score . PCa probability nomograms were generated for each cohort using the predictors . Bias-corrected areas under the receiver-operating characteristic curves for overall and clinical ly significant PCa detection were 0.82 ( 0.78 ) and 0.91 ( 0.84 ) for men without prior biopsy and 0.76 ( 0.65 ) and 0.86 ( 0.87 ) for men with a prior negative biopsy in the training ( testing ) sample s. CONCLUSION PSA density , age , and MRI suspicion score predict PCa on combined MRI-targeted and systematic biopsy . Our generated nomograms demonstrate high diagnostic accuracy and may further aid in the decision to perform biopsy in men with clinical suspicion of PCa CONTEXT The Prostate Imaging-Reporting and Data System ( PI-RADS ) v2 analysis system for multiparametric magnetic resonance imaging ( mpMRI ) detection of prostate cancer ( PCa ) is based on PI-RADS v1 , accumulated scientific evidence , and expert consensus opinion . OBJECTIVE To summarize the accuracy , strengths and weaknesses of PI-RADS v2 , discuss pathway implication s of its use and outline opportunities for improvements and future developments . EVIDENCE ACQUISITION For this consensus expert opinion from the PI-RADS steering committee , clinical studies , systematic review s , and professional guidelines for mpMRI PCa detection were evaluated . We focused on the performance characteristics of PI-RADS v2 , comparing data to systems based on clinicoradiologic Likert scales and non-PI-RADS v2 imaging only . Evidence selection s were based on high- quality , prospect i ve , histologically verified data , with minimal patient selection and verifications biases . EVIDENCE SYNTHESIS It has been shown that the test performance of PI-RADS v2 in research and clinical practice retains higher accuracy over systematic transrectal ultrasound ( TRUS ) biopsies for PCa diagnosis . PI-RADS v2 fails to detect all cancers but does detect the majority of tumors capable of causing patient harm , which should not be missed . Test performance depends on the definition and prevalence of clinical ly significant disease . Good performance can be attained in practice when the quality of the diagnostic process can be assured , together with joint working of robustly trained radiologists and urologists , conducting biopsy procedures within multidisciplinary teams . CONCLUSIONS It has been shown that the test performance of PI-RADS v2 in research and clinical practice is improved , retaining higher accuracy over systematic TRUS biopsies for PCa diagnosis . PATIENT SUMMARY Multiparametric magnetic resonance imaging ( MRI ) and MRI-directed biopsies using the Prostate Imaging-Reporting and Data System improves the detection of prostate cancers likely to cause harm , and at the same time decreases the detection of disease that does not lead to harms if left untreated . The keys to success are high- quality imaging , reporting , and biopsies by radiologists and urologists working together in multidisciplinary teams BACKGROUND Evidence from r and omized trials on the effects of screening for prostate cancer ( PCa ) on disease-specific mortality accumulates slowly with increasing follow-up . OBJECTIVE To assess data on PCa-specific mortality in the Rotterdam section of the European R and omized Study of Screening for Prostate Cancer ( ERSPC ) trial . DESIGN , SETTING , AND PARTICIPANTS A r and omized controlled trial with r and omization after signed , written informed consent ( efficacy trial ) . In the period 1993 - 1999 , a total of 42 376 men aged 54 - 74 yr were r and omized to a screening arm ( S-arm )  ( n = 21 210 with screening every 4 yr , applying a total prostate-specific antigen [ PSA ] level cut-off ≥ 3.0 ng/ml as biopsy indication ) or a control arm ( C-arm ) ( n = 21 166 ; no intervention ) . OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Number of PCas detected per arm depicted by predefined time periods and prognostic groups . PCa-specific mortality analyses using Poisson regression in age group 55 - 74 yr at r and omization and separately in the predefined age group of 55 - 69 yr . RESULTS AND LIMITATIONS After a median follow-up of 12.8 yr , 19 765 men ( 94.2 % ) were screened at least once and 2674 PCas were detected ( of which 561 [ 21.0 % ] were interval PCas ) . In the C-arm , 1430 PCas were detected , result ing in an excess incidence of 59 PCas per 1000 men r and omized ( 61 PCas per 1000 in age group 55 - 69 yr ) . Thirty-two percent of all men r and omized have died . PCa-specific mortality relative-risk ( RR ) reductions of 20.0 % overall ( age : 55 - 74 yr ; p = 0.042 ) and 31.6 % ( age : 55 - 69 yr ; p = 0.004 ) were found . A 14.1 % increase was found in men aged 70 - 74 yr ( not statistically significant ) . Absolute PCa mortality was 1.8 per 1000 men r and omized ( 2.6 per 1000 men r and omized in age group 55 - 69 yr ) . The number needed to invite and number needed to manage were 565 and 33 , respectively , for age group 55 - 74 yr , and 392 and 24 , respectively , for age group 65 - 69 yr . Given the slow natural history of the disease , follow-up might be too short . CONCLUSIONS Systematic PSA-based screening reduced PCa-specific mortality by 32 % in the age range of 55 - 69 yr . The roughly twofold higher incidence in the S-arm underlines the importance of tools to better identify those men who would benefit from screening BACKGROUND Prostate-specific antigen ( PSA ) based screening for prostate cancer ( PCa ) has been shown to reduce prostate specific mortality by 20 % in an intention to screen ( ITS ) analysis in a r and omised trial ( European R and omised Study of Screening for Prostate Cancer [ ERSPC ] ) . This effect may be diluted by nonattendance in men r and omised to the screening arm and contamination in men r and omised to the control arm . OBJECTIVE To assess the magnitude of the PCa-specific mortality reduction after adjustment for nonattendance and contamination . DESIGN , SETTING , AND PARTICIPANTS We analysed the occurrence of PCa deaths during an average follow-up of 9 yr in 162,243 men 55 - 69 yr of age r and omised in seven participating centres of the ERSPC . Centres were also grouped according to the type of r and omisation ( ie , before or after informed written consent ) . INTERVENTION Nonattendance was defined as nonattending the initial screening round in ERSPC . The estimate of contamination was based on PSA use in controls in ERSPC Rotterdam . MEASUREMENTS Relative risks ( RRs ) with 95 % confidence intervals ( CIs ) were compared between an ITS analysis and analyses adjusting for nonattendance and contamination using a statistical method developed for this purpose . RESULTS AND LIMITATIONS In the ITS analysis , the RR of PCa death in men allocated to the intervention arm relative to the control arm was 0.80 ( 95 % CI , 0.68 - 0.96 ) . Adjustment for nonattendance result ed in a RR of 0.73 ( 95 % CI , 0.58 - 0.93 ) , and additional adjustment for contamination using two different estimates led to estimated reductions of 0.69 ( 95 % CI , 0.51 - 0.92 ) to 0.71 ( 95 % CI , 0.55 - 0.93 ) , respectively . Contamination data were obtained through extrapolation of single-centre data . No heterogeneity was found between the groups of centres . CONCLUSIONS PSA screening reduces the risk of dying of PCa by up to 31 % in men actually screened . This benefit should be weighed against a degree of overdiagnosis and overtreatment inherent in PCa screening BACKGROUND Detection of fusion gene TMPRSS2:ERG transcripts in urine have been recently described in order to refine urine-based detection of prostate cancer ( PCa ) , but data its clinical impact remain scarce . We aim ed at investigating the correlation of TMPRSS2:ERG , prostate cancer antigen 3 ( PCA3 ) , prostate specific antigen ( PSA ) density , genetic variants , and and rogenic status with outcome and pathological findings at prostatic biopsy . METHODS Between 2007 and 2011 , 291 patients at risk of PCa because of PSA > 3.0 ng/ml ( 55 % ) or c and i date to active surveillance protocol justifying restaging biopsy management ( 45 % ) were recruited .  TMPRSS2:ERG  was detected by urine assay ( Progensa ™ ) . PCA3-score , PSA level , bioavailable testosterone level , prostate volume , rs1447295 and rs6983267 genotypes were prospect ively assessed . Univariate and multivariate analysis by logistic regression model ( logit ) were conducted to study the correlation of TMPRSS2:ERG status , PCA3 , and PSA density with biopsy results , and Gleason score . RESULTS Of 291 patients , 173 had PCa and 118 had negative biopsy . PCA3 score , PSA density and TMPRSS2:ERG-score were correlated with presence of PCa ( P < 0.0001 , P = 0.046 , and P < 0.0001 , respectively ) . This correlation remained strong on multivariable analysis model ( area under curve 0.743 ) . PCA3 score and PSA density were significantly associated with presence of Grade 4 through multivariable analysis . PCA3 score was also correlated to the percentage of positive cores at biopsy ( P = 0.008 ) . CONCLUSIONS Integration of levels TMPRSS2:ERG transcripts in urine , with PCA3-score , and rogenic status , genetic status and traditional clinical variables could significantly increase detection of high risk localized PCa BACKGROUND To estimate the benefits of prostate-specific antigen ( PSA ) screening on prostate cancer ( Pca ) metastasis and Pca-specific mortality , we compared two population s with a well-defined difference in intensity of screening . METHODS Between 1997 and 1999 , a total of 11,970 men , aged 55 - 74 years , were included in the intervention arm of the European R and omised Study of Screening for Prostate Cancer ( ERSPC ) section Rotterdam . Control population consisted of 133,287 men , aged 55 - 74 years , between 1998 and 1999 in Northern Irel and ( NI ) . Men were followed for Pca incidence , Pca metastasis and cause of death until 31st December 2006 . RESULTS Median age in both groups was 63 years at study entry ( p=0.184 ) . In Rotterdam 94.2 % of men and in NI 6 % of men underwent PSA testing . In Rotterdam , 1153 men ( 9.6 % ) were diagnosed with Pca with median baseline PSA of 5.1 ng/ml . In NI , 3962 men ( 3.0 % , p<0.001 ) were diagnosed with Pca with median baseline PSA of 18.0 ng/ml ( p<0.001 ) . The relative risk of Pca metastasis during observation in the intervention population compared to control population was 0.47 ( 95 % confidence interval ( CI ) , 0.35 - 0.63 ; p<0.001 ) . The relative risk of Pca-specific mortality was also lower in the intervention population compared to the control population after a median follow-up of 8.5 years : 0.63 ( 95 % CI , 0.45 - 0.88 ; p=0.008 ) ; absolute mortality reduction was 1.8 deaths per 1000 men . CONCLUSIONS A relative reduction in Pca metastasis of 53 % and Pca mortality of 37 % was observed in the intervention population after 8.5 years of observation . The impact of overdiagnosis , quality of life benefits and cost-effectiveness need to be assessed before population -based PSA screening can be recommended BACKGROUND An approach based on multiparametric magnetic resonance imaging ( mpMRI ) might increase the detection rate ( DR ) of clinical ly significant prostate cancer ( csPCa ) . OBJECTIVE To compare an mpMRI-based pathway with the st and ard approach for the detection of prostate cancer ( PCa ) and csPCa . DESIGN , SETTING , AND PARTICIPANTS Between November 2014 and April 2016 , 212 biopsy-naïve patients with suspected PCa ( prostate specific antigen level ≤15 ng/ml and negative digital rectal examination results ) were included in this r and omized clinical trial . Patients were r and omized into a prebiopsy mpMRI group ( arm A , n=107 ) or a st and ard biopsy ( SB ) group ( arm B , n=105 ) . INTERVENTION In arm A , patients with mpMRI evidence of lesions suspected for PCa  underwent mpMRI/transrectal ultrasound fusion software-guided targeted biopsy ( TB ) ( n=81 ) . The remaining patients in arm A ( n=26 ) with negative mpMRI results and patients in arm B underwent 12-core SB . OUTCOMES MEASUREMENTS AND STATISTICAL ANALYSIS The primary end point was comparison of the DR of PCa and csPCa between the two arms of the study ; the secondary end point was comparison of the DR between TB and SB . RESULTS AND LIMITATIONS The overall DRs were higher in arm A versus arm B for PCa ( 50.5 % vs 29.5 % , respectively ; p=0.002 ) and csPCa ( 43.9 % vs 18.1 % , respectively ; p<0.001 ) . Concerning the biopsy approach , that is , TB in arm A , SB in arm A , and SB in arm B , the overall DRs were significantly different for PCa ( 60.5 % vs 19.2 % vs 29.5 % , respectively ; p<0.001 ) and for csPCa ( 56.8 % vs 3.8 % vs 18.1 % , respectively ; p<0.001 ) . The reproducibility of the study could have been affected by the single-center nature . CONCLUSIONS A diagnostic pathway based on mpMRI had a higher DR than the st and ard pathway in both PCa and csPCa . PATIENT SUMMARY In this r and omized trial , a pathway for the diagnosis of prostate cancer based on multiparametric magnetic resonance imaging ( mpMRI ) was compared with the st and ard pathway based on r and om biopsy . The mpMRI-based pathway had better performance than the st and ard pathway BACKGROUND Focal therapy ( FT ) for prostate cancer ( PCa ) seems to be part of a natural evolution in the quest to improve the management of early organ-confined disease . OBJECTIVE To assess the morbidity of the initial experience of FT in a tertiary referral center for PCa management . DESIGN , SETTING , AND PARTICIPANTS From 2009 to 2011 , a total of 1213 patients with clinical ly localized PCa were treated at our institution . Of these patients , 547 were considered to have indolent disease according to the D'Amico criteria for low-risk disease plus unilateral disease with a maximum of three positive biopsies . A total of 106 patients underwent FT using high-intensity focused ultrasonography ( HIFU ) , brachytherapy , cryotherapy , or vascular-targeted photodynamic therapy ( VTP ) . OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Complications were prospect ively recorded and grade d according to the Clavien-Dindo scale . Data were prospect ively collected and retrospectively analyzed . RESULTS AND LIMITATIONS This study included 106 patients , median age 66.5 yr ( interquartile range [ IQR ] ) : 61 - 73 ) , who had a prostate hemiablation ; 50 patients ( 47 % ) had cryotherapy , 23 patients ( 22 % ) had VTP , 21 patients ( 20 % ) received HIFU , and 12 patients ( 11 % ) had brachytherapy . The median prostate-specific antigen ( PSA ) level was 6.1 ng/ml ( IQR : 5 - 8.1 ) , all the patients had a biopsy Gleason score of 6 , and the median prostate weight was 43 g ( IQR : 33 - 55 ) . The median International Prostate Symptom Score was 6 ( IQR : 3 - 10 ) , and the median International Index of Erectile Function score was 20 ( IQR : 15 - 23 ) . After treatment , the median PSA at 3 , 6 , and 12 mo was 3.1 2.9 , and 2.7 ng/ml ( IQR : 2 - 5.1 , 1.1 - 4.7 , and 1 - 4.4 ) , respectively . Thirteen percent of the patients experienced treatment-related complications . There were 11 minor medical complications ( 10 grade 1 complications and 1 grade 2 complication ) , 2 grade 3 complications , and no grade 4 or higher complications . CONCLUSIONS FT for a highly selected population with PCa is feasible and had an acceptable morbidity with < 2 % major complications BACKGROUND Evidence suggests that ejaculation frequency may be inversely related to the risk of prostate cancer ( PCa ) , a disease for which few modifiable risk factors have been identified . OBJECTIVE To incorporate an additional 10 yr of follow-up into an original analysis and to comprehensively evaluate the association between ejaculation frequency and PCa , accounting for screening , clinical ly relevant disease subgroups , and the impact of mortality from other causes . DESIGN , SETTING , AND PARTICIPANTS A prospect i ve cohort study of participants in the Health Professionals Follow-up Study utilizing self-reported data on average monthly ejaculation frequency . The study includes 31925 men who answered questions on ejaculation frequency on a 1992 question naire and followed through to 2010 . The average monthly ejaculation frequency was assessed at three time points : age 20 - 29 yr , age 40 - 49 yr , and the year before question naire distribution . OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Incidence of total PCa and clinical ly relevant disease subgroups . Cox models were used to estimate hazard ratios ( HRs ) and 95 % confidence intervals ( CIs ) . RESULTS AND LIMITATIONS During 480831 person-years , 3839 men were diagnosed with PCa .  Ejaculation frequency at age 40 - 49 yr was positively associated with age-st and ardized body mass index , physical activity , divorce , history of sexually transmitted infections , and consumption of total calories and alcohol . Prostate-specific antigen ( PSA ) test utilization by 2008 , number of PSA tests , and frequency of prostate biopsy were similar across frequency categories . In multivariable analyses , the hazard ratio for PCa incidence for ≥21 compared to 4 - 7 ejaculations per month was 0.81 ( 95 % confidence interval [ CI ] 0.72 - 0.92 ; p<0.0001 for trend ) for frequency at age 20 - 29 yr and 0.78 ( 95 % CI 0.69 - 0.89 ; p<0.0001 for trend ) for frequency at age 40 - 49 yr . Associations were driven by low-risk disease , were similar when restricted to a PSA-screened cohort , and were unlikely to be explained by competing causes of death . CONCLUSIONS These findings provide additional evidence of a beneficial role of more frequent ejaculation throughout adult life in the etiology of PCa , particularly for low-risk disease . PATIENT SUMMARY We evaluated whether ejaculation frequency throughout adulthood is related to prostate cancer risk in a large US-based study . We found that men reporting higher compared to lower ejaculatory frequency in adulthood were less likely to be subsequently diagnosed with prostate cancer BACKGROUND High-intensity focused ultrasound ( HIFU ) is a nonsurgical therapy for selected patients with localized prostate cancer ( PCa ) . OBJECTIVE The long-term oncologic and morbidity outcomes of primary HIFU therapy for localized PCa were evaluated in a prospect i ve , single-arm , single-institution cohort study . DESIGN , SETTING , AND PARTICIPANTS Participants were patients treated with HIFU for localized PCa from 1997 to 2009 . Excluded were patients with local recurrence following radiotherapy .  A second HIFU session was systematic ally performed in patients with biopsy-proven local recurrence . INTERVENTION Whole-gl and prostate ablation with transrectal HIFU . OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Incontinence was assessed using the Ingelman-Sundberg score , and potency was assessed using the five-item version of the International Index of Erectile Function ( IIEF-5 ) scores . Primary outcomes were survival rates ( biochemical-free , cancer-specific , metastasis-free , and overall survival ) . Secondary outcomes were morbidity rates . Median follow-up was 6.4 yr ( range : 0.2 - 13.9 ) . The Kaplan-Meier method was used to determine survival estimates , and multivariate analysis was used to determine predictive factors of biochemical progression . RESULTS AND LIMITATIONS A total of 1002 patients were included . The median nadir prostate-specific antigen ( PSA ) was 0.14 ng/ml , with 63 % of patients reaching a nadir PSA ≤0.3 ng/ml . Sixty percent of patients received one HIFU session , 38 % received two sessions , and 2 % received three sessions . The 8-yr biochemical-free survival rates ( Phoenix definition ) were 76 % , 63 % , and 57 % for low- , intermediate- , and high-risk patients , respectively ( p < 0.001 ) . At 10 yr , the PCa-specific survival rate and metastasis-free survival rate ( MFSR ) were 97 % and 94 % , respectively . Salvage therapies included external-beam radiation therapy ( EBRT ) ( 13.8 % ) , EBRT plus and rogen-deprivation therapy ( ADT ) ( 9.7 % ) , and ADT alone ( 12.1 % ) . Severe incontinence and bladder outlet obstruction decreased with refinement in the technology , from 6.4 % and 34.9 % to 3.1 % and 5.9 % , respectively . Limitations included the fact that the study was a single-arm study without a comparison group , technological improvements , changes in surgical protocol during the study , and the use of ADT to downsize the prostate in 39 % of patients . CONCLUSIONS HIFU is a potentially effective treatment of localized PCa , with a low PCa-specific mortality rate and a high MFSR at 10 yr as well as acceptable morbidity PURPOSE To evaluate the role of a 3 T biparametric magnetic resonance imaging ( bpMRI ) , T2 -weighted imaging , and three separate diffusion-weighted imaging acquisitions combined with targeted biopsy ( TB ) for improving risk stratification of men with elevated prostate-specific antigen ( PSA ) . MATERIAL S AND METHODS Between March 2013 and February 2015 , 175 men with a clinical suspicion of prostate cancer ( PCa ) were offered bpMRI  ( NCT01864135 ) based on a suspicion of PCa ( two repeated PSA measurements in the range 2.5 - 20.0 ng/ml and /or abnormal digital rectal examination ) . Men with an equivocal to high suspicion of PCa had two TBs of the dominant lesion using cognitive ultrasound guidance , followed by systematic biopsy ( SB ) . Men with a low to very low suspicion had only SB . In total , 161 ( 161/175 , 92 % ) prospect ively enrolled men completed the trial and were included in the final analyses . The primary endpoint of the trial was the cancer detection rate ( CDR ) of TB and SB . Clinical ly significant cancer ( SPCa ) was defined as Gleason score ≥3 + 4 . RESULTS TB compared with SB had higher CDR for SPCa ( 45 % , 72/161 vs. 39 % , 63/161 , respectively ; P > 0.05 ) and a lower CDR for Gleason score 3 + 3 ( 8 % , 15/161 vs. 16 % , 30/161 ; P < 0.05 ) . Restricting biopsy to men with equivocal to highly suspicious bpMRI findings would have result ed in a 24 % ( 38/161 ) reduction in the number of men undergoing biopsy , while missing 4 ( 2 % ) with SPCa . All anonymized data sets , including bpMRI reports and follow up information , are freely available on the trial server . CONCLUSION Prebiopsy bpMRI and TB in men with a clinical suspicion of PCa improved risk stratification . LEVEL OF EVIDENCE 1 Technical Efficacy : Stage 5 J. Magn . Reson . Imaging 2017;46:1089 - 1095 Background / Aim : To compare serum chromogranin A ( CgA ) and insulin-like growth factor 1 ( IGF-1 ) with the classical prostate-specific antigen ( PSA ) marker in clinical ly localized prostate adenocarcinomas . Material s and Methods : This is a prospect i ve single-center study that included 64 consecutive men with newly diagnosed clinical ly localized prostate adenocarcinoma and 20 consecutive men with histologically confirmed benign prostatic hyperplasia ( BPH ) . A blood sample for the determination of serum total PSA , CgA and IGF-1 levels ( RIA )  was obtained from all cases . Analysis of variance was performed to evaluate their variations according to disease and the pathological characteristics of prostate adenocarcinoma . Results : Only serum PSA levels ( p < 0.0001 ) and not IGF-1 ( p = 0.5475 ) or CgA ( p = 0.5043 ) were significantly higher in the prostate cancer ( PCa ) group as compared to the BPH group . A significant variance between BPH and PCa divided on the basis of pT stage was found for PSA levels ( p < 0.0001 ) but not for CgA ( p = 0.0869 ) and IGF-1 ( p = 0.6883 ) levels . Dividing PCa on the basis of Gleason score , a significant variance was found for CgA ( p = 0.0100 ) and for PSA ( p < 0.001 ) , but not for IGF-1 ( p = 0.6895 ) levels . Conclusions : In our population the quantification of  PSA and CgA serum levels and not of IGF-1 provides independent significant information in the diagnosis and aggressiveness of PCa , respectively BACKGROUND The incidence of small , localised , well-differentiated prostate cancer ( PCa ) is increasing , mainly as a result of screening . Many of these cancers will not progress , and radical therapy may lead to substantial overtreatment . Active surveillance ( AS ) has emerged as an alternative . OBJECTIVE To retrospectively vali date the currently used criteria for eligibility for AS . DESIGN , SETTING , AND PARTICIPANTS For this cohort study , data from 616 men who were diagnosed with PCa between 1994 and 2007 at a mean age of 66.3 yr in four centres of the European R and omized Study of Screening for Prostate Cancer ( ERSPC ) were combined . All patients fit the criteria for AS ( prostate-specific antigen [ PSA ] < or = 10.0 ng/ml , PSA-density < 0.2 ng/ml per ml , stage T1C/T2 , Gleason score < or = 3 + 3 = 6 , and < or = 2 positive biopsy cores ) , and initially they were managed expectantly . Median follow-up was 3.91 yr . MEASUREMENTS Disease specific- , overall- , and treatment-free survival were studied . Present PSA characteristics were assessed and also compared between men who were switching to deferred active therapy during follow-up and men remaining untreated . RESULTS AND LIMITATIONS The calculated ( Kaplan-Meier ) 10-yr PCa-specific survival ( 21 patients at risk ) was 100 % , which sharply contrasted with 77 % overall survival . Men still alive showed favourable PSA characteristics . Although the calculated 10-yr treatment-free survival was only 43 % , objective signs of progression often did not indicate the shift to radical treatment . The cohort consisted of men on AS and those on watchful waiting ( WW ) ; information on comorbidity or psychological distress was not available . CONCLUSIONS AS seems justified in selected men with screen-detected PCa . Prospect i ve protocol -based AS programs are necessary to optimise selection criteria and to find the appropriate trigger points for switching to active therapy . Possible negative psychological reactions with AS against improved quality of life by withholding side-effects from radical treatment should be considered OBJECTIVE To address if prostate cancer ( PCa ) screening decreases PCa mortality in the asymptomatic population , within the setting of the Spanish arm of the European R and omized Study of Screening for Prostate Cancer ( ERSPC ) . MATERIAL AND METHODS From 1996 to 1999 , 4,278 men aged 45 - 70 years were recruited and r and omized to the screening arm ( PSA every 4 years , prostate biopsy when PSA ≥3 ng/ml ) and control arm ( no tests ) . Date s and causes of death were collected on an annual basis . A Kaplan-Meier analysis was used to calculate overall and cancer-specific survival . RESULTS A total of 2,416 men were recruited in the screening arm and 1,862 in the control arm . Mean age was 57.8 years , median follow-up was 13.3 years . At the end of the follow-up period , 427 deaths ( 9 from PCa ) were observed . Survival analysis did not show any difference between the study arms with respect to overall and cancer-specific survival ( p=0.939 and p=0.544 respectively ) . Most relevant causes of death were malignant tumors ( 52.9 % ) , cardiovascular disease ( 17.3 % ) and respiratory ( 8.9 % ) . Only 2.1 % of deaths ( 0.2 % of all recruited men ) were due to PCa ( 2.5 % screening , 1.6 % control ) . CONCLUSIONS The Spanish arm of ERSPC failed to reproduce the long-term results shown in the whole study . No differences in mortality ( overall or cancer-specific ) were observed after 15 years of follow-up . PCa mortality was infrequent ( less than 1 % ) . These results suggest limited yield of PCa screening in our setting BACKGROUND Lower urinary tract symptoms ( LUTS ) are common and have been associated with the subsequent diagnosis of prostate cancer ( PCa ) in population cohorts . OBJECTIVE To determine whether the association between LUTS and PCa is due to the intensity of PCa testing after LUTS diagnosis . DESIGN , SETTING , AND PARTICIPANTS We prospect ively followed a representative , population -based cohort of 1922 men , aged 40 - 79 yr , from 1990 until 2010 with interviews , question naires , and abstract ing of medical records for prostate outcomes . Men were excluded if they had a previous prostate biopsy or PCa diagnosis .  Self-reported LUTS was defined as an American Urological Association symptom index score > 7 ( n=621 ) . Men treated for LUTS ( n=168 ) were identified from review of medical records and /or self report . Median follow-up was 11.8 yr ( interquartile range : 10.7 - 12.3 ) . OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Associations between self-reported LUTS , or treatment for LUTS , and risk of subsequent prostate biopsy and PCa were estimated using Cox proportional hazard models . RESULTS AND LIMITATIONS Fifty-five percent of eligible men enrolled in the study . Men treated for LUTS were more likely to undergo a prostate biopsy ( hazard ratio [ HR ] : 2.4 ; 95 % confidence interval [ CI ] , 1.7 - 3.3 ) . Men younger than 65 yr who were treated for LUTS were more likely to be diagnosed with PCa ( HR : 2.3 , 95 % CI , 1.5 - 3.5 ) , while men aged > 65 yr were not ( HR : 0.89 , 95 % CI , 0.35 - 1.9 ) . Men with self-reported LUTS were not more likely to be biopsied or diagnosed with PCa . Neither definition of LUTS was associated with subsequent intermediate- to high-risk cancer . The study is limited by lack of histologic or prostate-specific antigen level data for the cohort . CONCLUSIONS These results indicate that a possible cause of the association between LUTS and PCa is increased diagnostic intensity among men whose LUTS come to the attention of physicians . Increased symptoms themselves were not associated with intensity of testing or diagnosis BACKGROUND The optimal selection of prostate cancer ( PCa ) patients for active surveillance ( AS ) is currently being debated . OBJECTIVE To assess the impact of urinary prostate cancer antigen 3 ( PCA3 ) score as an AS criterion instead of and in addition to the current criteria . DESIGN , SETTING , AND PARTICIPANTS We prospect ively studied 106 consecutive low-risk PCa patients ( prostate-specific antigen [ PSA ] ≤10 ng/ml , clinical stage T1c-T2a , and biopsy Gleason score 6 ) who underwent a PCA3 urine test before radical prostatectomy ( RP ) .  MEASUREMENTS Performance of AS criteria ( biopsy criteria , PCA3 score , PSA density , and magnetic resonance imaging [ MRI ] findings ) was tested in predicting four prognostic pathologic findings in RP specimens : ( 1 ) pT3 - 4 disease ; ( 2 ) overall unfavourable disease ( OUD ) defined by pT3 - 4 disease and /or pathologic primary Gleason pattern 4 ; ( 3 ) tumour volume < 0.5 cm(3 ) ; and ( 4 ) insignificant PCa . RESULTS AND LIMITATIONS The PCA3 score was strongly correlated with the tumour volume in a linear regression analysis ( p<0.001 , r=0.409 ) . The risk of having a cancer ≥0.5 cm(3 ) and a significant PCa was increased three-fold in men with a PCA3 score of ≥25 compared with men with a PCA3 score of < 25 with most AS biopsy criteria used . There was a trend towards higher PCA3 scores in patients with unfavourable and non-organ-confined disease and Gleason > 6 cancers . In a multivariate analysis taking into account each AS criterion , a high PCA3 score ( ≥25 ) was an important predictive factor for tumour volume ≥0.5 cm(3 ) ( odds ratio [ OR ] : 5.4 ; p=0.010 ) and significant PCa ( OR : 12.7 ; p=0.003 ) . Biopsy criteria and MRI findings were significantly associated with OUD ( OR : 3.9 and 5.0 , respectively ; p=0.030 and p=0.025 , respectively ) . CONCLUSIONS PCA3 score may be a useful marker to improve the selection for AS in addition to the current AS criteria . With a predictive cut-off of 25 , PCA3 score is strongly indicative for tumour volume and insignificant PCa BACKGROUND The Prostate CAncer gene 3 ( PCA3 ) assay has shown promise as an aid in prostate cancer ( pCA ) diagnosis in identifying men with a high probability of a positive ( repeat ) biopsy . OBJECTIVE This study evaluated the clinical utility of the PROGENSA PCA3 assay . DESIGN , SETTING , AND PARTICIPANTS This European prospect i ve , multicentre study enrolled men with one or two negative biopsies scheduled for repeat biopsy . MEASUREMENTS After digital rectal examination ( DRE ) , first-catch urine was collected to measure PCA3 mRNA concentration and to calculate the PCA3 score . The PCA3 score was compared to biopsy outcome . The diagnostic accuracy of the PCA3 assay was compared to percent of free prostate-specific antigen ( % fPSA ) . RESULTS AND LIMITATIONS In 463 men , the positive repeat biopsy rate was 28 % . The higher the PCA3 score , the greater the probability of a positive repeat biopsy . The PCA3 score ( cut-off of 35 ) had a greater diagnostic accuracy than % fPSA ( cut-off of 25 % ) . The PCA3 score was independent of the number of previous biopsies , age , prostate volume , and total prostate-specific antigen ( PSA ) level . Moreover , the PCA3 score was significantly higher in men with high- grade prostate intraepithelial neoplasia ( HGPIN ) versus those without HGPIN , clinical stage T2 versus T1 , Gleason score > or=7 versus < 7 , and " significant " versus " indolent " ( clinical stage T1c , PSA density [ PSAD ] < 0.15ng/ml , Gleason score in biopsy < or=6 , and percent positive cores < or=33 % ) pCA . CONCLUSIONS The probability of a positive repeat biopsy increases with rising PCA3 scores . The PCA3 score was superior to % fPSA for predicting repeat prostate biopsy outcome and may be indicative of clinical stage and significance of pCa BACKGROUND The Rotterdam European R and omized Study of Screening for Prostate Cancer risk calculators ( ERSPC-RCs ) help to avoid unnecessary transrectal ultrasound-guided systematic biopsies ( TRUS-Bx ) . Multivariable risk stratification could also avoid unnecessary biopsies following multiparametric magnetic resonance imaging ( mpMRI ) . OBJECTIVE To construct MRI-ERSPC-RCs for the prediction of any- and high- grade ( Gleason score ≥3 + 4 ) prostate cancer ( PCa ) in 12-core TRUS-Bx±MRI-targeted biopsy ( MRI-TBx ) by adding Prostate Imaging Reporting and Data System ( PI-RADS ) and age as parameters to the ERSPC-RC3 ( biopsy-naïve men ) and ERSPC-RC4 ( previously biopsied men ) . DESIGN , SETTING , AND PARTICIPANTS A total of 961 men received mpMRI and 12-core TRUS-Bx±MRI-TBx ( in case of PI-RADS ≥3 ) in five institutions . Data of 504 biopsy-naïve and 457 previously biopsied men were used to adjust the ERSPC-RC3 and ERSPC-RC4 . OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Logistic regression models were constructed . The areas under the curve ( AUCs ) of the original ERSPC-RCs and MRI-ERSPC-RCs ( including PI-RADS and age ) for any- and high- grade PCa were compared . Decision curve analysis was performed to assess the clinical utility of the MRI-ERSPC-RCs . RESULTS AND LIMITATIONS MRI-ERSPC-RC3 had a significantly higher AUC for high- grade PCa compared with the ERSPC-RC3 : 0.84 ( 95 % confidence interval [ CI ] 0.81 - 0.88 ) versus 0.76 ( 95 % CI 0.71 - 0.80 , p<0.01 ) . Similarly , MRI-ERSPC-RC4 had a higher AUC for high- grade PCa compared with the ERSPC-RC4 : 0.85 ( 95 % CI 0.81 - 0.89 ) versus 0.74 ( 95 % CI 0.69 - 0.79 , p<0.01 ) . Unlike for the MRI-ERSPC-RC3 , decision curve analysis showed clear net benefit of the MRI-ERSPC-RC4 at a high- grade PCa risk threshold of ≥5 % . Using a ≥10 % high- grade PCa risk threshold to biopsy for the MRI-ERSPC-RC4 , 36 % biopsies are saved , missing low- and high- grade PCa , respectively , in 15 % and 4 % of men who are not biopsied . CONCLUSIONS We adjusted the ERSPC-RCs for the prediction of any- and high- grade PCa in 12-core TRUS-Bx±MRI-TBx . Although the ability of the MRI-ERSPC-RC3 for biopsy-naïve men to avoid biopsies remains question able , application of the MRI-ERSPC-RC4 in previously biopsied men in our cohort would have avoided 36 % of biopsies , missing high- grade PCa in 4 % of men who would not have received a biopsy . PATIENT SUMMARY We have constructed magnetic resonance imaging-based Rotterdam European R and omized study of Screening for Prostate Cancer ( MRI-ERSPC ) risk calculators for prostate cancer prediction in transrectal ultrasound-guided biopsy and MRI-targeted biopsy by incorporating age and Prostate Imaging Reporting and Data System score into the original ERSPC risk calculators . The MRI-ERSPC risk calculator for previously biopsied men could be used to avoid one-third of biopsies following MRI OBJECTIVES To search for any relation between plasma adiponectin levels and the cellular differentiation or progression of prostate cancer ( PCa ) . PCa is becoming an increasingly important public health problem , particularly for those countries with a trend toward an aging population . Because insulin resistance in the setting of obesity is associated with the development of PCa , we hypothesized that decreased adiponectin levels might underlie the association between PCa and obesity/insulin resistance . METHODS In this study , we investigated plasma adiponectin levels in 30 patients with PCa , 41 subjects with benign prostatic obstruction , and 36 healthy individuals . The body mass index and age of the groups were similar . Patients with PCa were stratified into two groups according to the spread of the disease as organ-confined and advanced disease and into three groups according to grade ( low , intermediate , and high grade determined by a Gleason sum of less than 5 , between 5 and 7 , and more than 7 , respectively ) . RESULTS Plasma adiponectin levels were significantly lower in the PCa group than in the benign prostatic obstruction group or controls ( P < 0.001 for both ) . Additionally , the plasma adiponectin levels were significantly lower in the advanced disease group than in the organ-confined PCa group ( P = 0.012 ) . Significant negative associations were found between plasma adiponectin levels and prostate-specific antigen levels or biopsy Gleason scores in the PCa group . The plasma adiponectin levels of those with high- grade PCa were also significantly lower than those for both the low- grade and intermediate- grade groups ( P < 0.001 for both ) . CONCLUSIONS The results of the present study imply that plasma adiponectin levels are not only lower in patients with PCa but are also negatively associated with the histologic grade and disease stage . Future prospect i ve studies are recommended to establish any causal relation between PCa and plasma adiponectin levels OBJECTIVE To address detection rates and clinical features of the cancers detected with low prostate specific antigen ( PSA ) levels . METHODS In the context of a prostate cancer ( PCa ) screening program 1097 men attended to a new rescreen round .  Sextant prostate biopsy was recommended when PSA > or =3 ng/ml . We also recommended to undergo biopsy in the range 1.0 - 2.99 ng/ml when free to total ( f/t ) PSA ratio < or = 20 % . Detection rate was calculated and clinical features of the cancers detected were studied . RESULTS Mean age was 61.1 years . A total of 497 ( 45.3 % ) had total PSA < 1.0 ng/ml , 439 ( 40 % ) between 1.0 and 2.99 ng/ml , and 161 ( 14.7 % ) > or = 3.0 ng/ml . In the group with PSA between 1.0 and 2.99 ng/ml and f/t PSA ratio < or = 20 % a total of 249 biopsies were indicated ( 159 performed , acceptance 63.9 % ) , and 15 cancers detected ( detection rate 9.4 % ) . Biopsy was recommended to 72 men with PSA between 3.0 and 3.99 ng/ml , performed in 56 ( 77.8 % ) , and 12 tumors detected ( detection rate 21.4 % ) . All cancers in the study were clinical ly localized . Only 4 out of 15 cancers with PSA in the range 1.0 - 2.99 ng/ml ( 26.7 % ) fulfilled clinical criteria of insignificant cancer . Two were poorly differentiated and found to have patologically extracapsular disease . None of the 12 patients with PCa and PSA between 3.0 and 3.99 ng/ml had poorly differentiated features and only one complied with criteria of insignificant cancer . One out of seven who underwent RRP was found to have extracapsular disease . CONCLUSIONS Cancer detection in low PSA ranges is lower but still relevant . The detection of potentially aggresive cancers is still of concern BACKGROUND Most localized prostate cancers are believed to have an indolent course . Within 15 yr of diagnosis , most deaths among men with prostate cancer ( PCa ) can be attributed to other competing causes . However , data from studies with extended follow-up are insufficient to determine appropriate treatment for men with localized disease . OBJECTIVE To investigate the long-term natural history of untreated , early-stage PCa . DESIGN , SETTING , AND PARTICIPANTS We conducted a population -based , prospect ive-cohort study using a consecutive sample of 223 patients with untreated , localized PCa from a regionally well-defined catchment area in central Sweden . All subjects were initially managed with observation . And rogen deprivation therapy was administered when symptomatic tumor progression occurred . OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Based on > 30 yr of follow-up , the main outcome measures were : progression-free , cause-specific , and overall survival , and rates of progression and mortality per 1000 person-years . RESULTS AND LIMITATIONS After 32 yr of follow-up , all but 3 ( 1 % ) of the 223 men had died . We observed 90 ( 41.4 % ) local progression events and 41 ( 18.4 % ) cases of progression to distant metastasis . In total , 38 ( 17 % ) men died of PCa . Cause-specific survival decreased between 15 and 20 yr , but stabilized with further follow-up . All nine men with Gleason grade 8 - 10 disease died within the first 10 yr of follow-up , five ( 55 % ) from PCa . Survival for men with well-differentiated , nonpalpable tumors declined slowly through 20 yr , and more rapidly between 20 and 25 yr ( from 75.2 % [ 95 % confidence interval , 48.4 - 89.3 ] to 25 % [ 95 % confidence interval , 22.0 - 72.5 ] ) . It is unclear whether these data are relevant for tumors detected by elevated prostate-specific antigen levels . CONCLUSIONS Although localized PCa most often has an indolent course , local progression and distant metastasis can develop over the long term , even among patients considered low risk at diagnosis OBJECTIVES Recent studies suggest an association between increased serum levels of insulin-like growth factor 1 ( IGF-1 ) and an increased risk of prostate cancer ( PCa ) . We prospect ively analyzed the value of IGF-1 , IGF-density ( IGFD ) , and IGF-1/prostate-specific antigen ( PSA ) ratio for early detection of prostate cancer . METHODS IGF-1 , IGFD , and IGF-1/PSA  ratio were determined prospect ively during an 11-month period in the serum from 245 consecutive white men with PSA levels between 2.5 and 15 ng/mL.  Octant biopsy ( including transition zone biopsy ) was performed . A second biopsy was performed 6 weeks later if the first biopsy was negative . Prostate volume was measured using transrectal ultrasound and the prolate ellipsoid method . Receiver operating characteristic curves were performed to compare tests . RESULTS No evidence of malignancy was found in 174 patients ( 71 % ) , and PCa was found in 71 ( 29 % ) . The mean age for patients with no evidence of malignancy and those with PCa was 67.7+/-9 and 65.7+/-6 years , respectively ( P = 0.17 ) . IGF-1 , IGFD , IGF-1/PSA ratio , and PSA were significantly higher in patients with PCa than in those with benign disease ( P = 0.03 , P = 0.045 , P = 0.001 , and P = 0.018 , respectively ) . The area under the curve value derived from the receiver operating characteristic curves for IGF-1/PSA ratio , PSA , IGFD , and IGF-1 was 71 % , 61 % , 60 % , and 58 % , respectively . At 95 % sensitivity , the specificity of the IGF-1/PSA ratio was significantly greater than that of all other parameters ( P<0.0001 ) . An IGF-1/PSA cutoff value of 25 afforded a 95 % sensitivity for detecting PCa and would have avoided unnecessary biopsies in 24.1 % of patients . CONCLUSIONS Although IGF-1 and IGFD were unable to enhance the performance of PSA in our study , the IGF-1/PSA ratio significantly improved PCa detection over the use of PSA alone . Thus , increased IGF-1 levels ( i.e. , the IGF-1/PSA ratio ) may not only be associated with an increased PCa risk but may also be a useful tool for early detection OBJECTIVE Multiparametric MRI ( mp-MRI ) of the prostate is increasingly being used for local staging and detection of recurrence of prostate cancer ( PCA ) . In patients with elevated prostate-specific antigen ( PSA ) , mp-MRI could provide information on the position of the cancer , allowing adjustments to be made to the needle depth and direction before repeat transrectal ultrasound (TRUS)-guided biopsy to ensure accurate sampling of lesions . The purpose of the prospect i ve study was to evaluate mp-MRI of the prostate in patients with PSA elevation before initial TRUS-guided biopsy . METHODS  mp-MRI was performed in 94 patients using a 1.5-T scanner ( MAGNETOM Aera ( ® ) ; Siemens Healthcare , Erlangen , Germany ) and 16-channel phased-array body coil ( Siemens Healthcare ) . T2 weighted images ( T2WI ) , diffusion-weighted imaging ( DWI ) , dynamic contrast-enhanced ( DCE ) MRI and MR spectroscopy were obtained . TRUS-guided r and om biopsies and additional targeted biopsies of suspicious MRI areas were performed . RESULTS Additional targeted biopsies were obtained in 17 of 43 ( 40 % ) patients with PCA . 11 of 17 targeted biopsies contained PCA . 5 of 11 PCAs were diagnosed only by additional targeted biopsies . Sensitivity of mp-MRI  in patients was 97.7 % and specificity was 11.8 % .  mp-MRI was false negative in one patient . Sensitivity of mp-MRI in 207 lesions was 80.9 % and specificity was 44.7 % . In a logistic regression model , the apparent diffusion coefficient value was the only significant parameter to differentiate malignant and benign lesions . CONCLUSION mp-MRI should be performed in patients with PSA elevation before initial TRUS-guided biopsy to allow additional targeted biopsies from suspicious areas of MRI . We recommend mp-MRI with T2WI , DWI , DCE MRI and MR spectroscopy . DWI as the most reliable technique should be used in every mp-MRI . ADVANCES IN KNOWLEDGE DWI is the most reliable technique in mp-MRI of the prostate BACKGROUND In daily routine business , various prostate-specific antigen ( PSA ) retest strategies are being promoted . OBJECTIVE To investigate rescreening intervals according to baseline PSA <3 ng/ml stratified by any and aggressive prostate cancer ( PCa ) . DESIGN , SETTING , AND PARTICIPANTS From 1998 to 2012 , data from 4350 men aged 55 - 70 yr were analyzed from a population -based prospect i ve screening study ( median follow-up : 11.6 yr ) . OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The primary end point was detection of aggressive PCa ( Gleason score 7 - 10 ) .  Cox regression analysis was used to examine the relationship between covariates . RESULTS AND LIMITATIONS Baseline PSA of < 1.0 ng/ml , 1 - 1.9 ng/ml , and 2 - 2.9 ng/ml was present in 2416 men ( 55.5 % : group 1 ) , 1371 men ( 31.6 % : group 2 ) , and 563 men ( 12.9 % : group 3 ) , respectively . Stratified according to these PSA groups , aggressive PCa was detected in 25 patients ( 1.0 % ) , 80 patients ( 5.8 % ) , and 34 patients ( 6.0 % ) , respectively . During 4 yr , these numbers were 0.0 % , 0.29 % , and 1.8 % , whereas during 8 yr , the numbers were 0.2 % , 1.4 % , and 2.5 % , respectively . In multivariable Cox regression analysis , the only independent risk factor for aggressive PCa was baseline PSA ( hazard ratio [ HR ] : 6.06 ; 95 % confidence interval [ CI ] , 3.82 - 9.61 ; p<0.0001 , group 2 vs group 1 ; and HR : 7.33 ; 95 % CI , 4.29 - 12.52 ; p<0.0001 , group 3 vs group 1 ) . CONCLUSIONS Baseline PSA was the only predictor regarding aggressive PCa . According to the low rate of potentially missed PCa in these groups , rescreening intervals can be safely adapted to baseline PSA values corresponding to a " PSA pyramid " : 6 - 8 yr if baseline PSA is < 1.0 ng/ml , 3 - 4 yr if baseline PSA is 1 - 1.99 ng/ml , and yearly if baseline PSA is 2 - 2.99 ng/ml . PATIENT SUMMARY We observed men with a prostate-specific antigen ( PSA ) value ≤3 ng/ml during 12 yr and found that men can be retested according to their initial PSA value ( " PSA pyramid " ) : PSA < 1 ( base ) , retest interval every 8 yr ; PSA 1 - 2 ( center ) , retest interval every 4 yr ; and PSA 2 - 3 ( top ) , retest yearly after risk stratification OBJECTIVES The efficacy of screening for prostate cancer ( PCa ) with digital rectal examination ( DRE ) and prostate-specific antigen ( PSA ) measurement has not been proved in r and omized clinical trials . In an earlier case-control study , we found that DRE might reduce PCa mortality . The present case-control study assessed the association between PSA and DRE testing and PCa mortality . METHODS The case subjects included 74 Olmsted County residents who had died from 1992 to 2005 with PCa as the underlying cause of death . From 1 to 3 community control subjects ( alive at time of case subject 's death ) were matched to each case subject . The medical records were review ed to identify  DREs and PSA determinations  performed 0 to 5 years before the date the case was diagnosed ( index date ) . Tests performed in the absence of symptoms were considered to be " screening tests . " Conditional logistic regression analysis was used to estimate the odds ratios and 95 % confidence intervals for the association of screening ( defined in multiple ways ) and PCa mortality . RESULTS From 1 to 5 years before the index date , control subjects were more likely than case subjects to have undergone a previous screening PSA test or DRE  ( 81.3 % versus 60.8 % , P = 0.0005 ) . The unadjusted odds ratio associated with a previous screening PSA test or DRE  was 0.34 ( 95 % confidence interval 0.18 to 0.63 ) , and the odds ratio adjusted for potential confounders was 0.35 ( 95 % confidence interval 0.17 to 0.71 ) . PSA testing was frequently done in conjunction with DRE , making evaluation of the individual effects difficult . CONCLUSIONS The results of this case-control study suggest a potential benefit of screening by PSA testing and /or DRE on PCa mortality Objective : This study is a prospect i ve evaluation of a volume-based , computer-assisted method for transperineal optimized prostate ( TOP ) biopsy . The TOP algorithm automates core planning for systematic prostate biopsies using the 3-dimensional organ contour and an alterable volume for tumors to be excluded . Subjects and Methods : MRI-transrectal ultrasound fusion biopsy with MRI-targeted biopsies ( TBs ) and systematic -TOP biopsies were performed on 172 men between October 2013 and March 2014 .  Systematic biopsies were placed according to TOP for detection of tumor volumes > 0.5 mL with a minimum of 80 % organ coverage in prostates up to 50 mL ( 70 % in larger organs ) . Results : Median 24 TOP cores and 3 MRI-TBs have been placed . Prostate cancer ( PCa ) was detected in 112 of 172 ( 65 % ) of men ; TOP detected 109 ( 97 % ) and TB 62 ( 55 % ) .  Significant cancer  ( Gleason score ≥7 ) was detected in 75 ( 44 % ) of men and of these TOP detected 73 of 75 ( 97 % ) and TB 51 of 75 ( 68 % ) . Overall , systematic -TOP  sampling significantly outperformed TB for the detection of both , all PCa as well as significant PCa ( p < 0.0001 , p = 0.0005 ) . Conclusion : The TOP method is innovative by integrating the individual prostate volume and PCa volume detection thresholds . In the present cohort , it diagnosed more significant tumors than TB alone . However , at the same time , more low-risk tumors are detected The Prostate Cancer Intervention Versus Observation Trial ( PIVOT ) concluded that radical prostatectomy ( RP ) offered no survival benefit compared with observation in men with clinical ly localized prostate cancer ( PCa ) . We identified patients within the National Cancer Data base ( NCDB ) for the period 2004 - 2012 who met the inclusion criteria of PIVOT ( ie , histologically confirmed PCa , clinical stage T1 - 2NxM0 , prostate-specific antigen < 50 ng/ml , age < 75 yr , estimated life expectancy > 10 yr , and undergoing RP or observation as initial treatment within 12 mo of diagnosis ) to confirm the generalizability of the PIVOT results to the US population .  Life expectancy was calculated using the US Social Security Administration life tables and was adjusted for comorbidities at diagnosis . Compared with PIVOT , men in the NCDB were younger ( mean age 60.3 vs 67.0 yr ) and healthier ( Charlson-Deyo comorbidity index of 0 : 93 % vs 56 % ; both p < 0.001 ) . Furthermore , 42 % of men r and omized to receive RP in PIVOT harbored D'Amico low-risk PCa , whereas 32 % of men undergoing RP in the NCDB had low-risk disease . Our findings were confirmed in a sensitivity analysis including men regardless of life expectancy but satisfying all other inclusion criteria of PIVOT . Given that the NCDB represents nearly 70 % of all incident cancers diagnosed in the United States , our data provide further evidence that PIVOT results may not be generalizable to contemporary clinical practice . PATIENT SUMMARY We observed that men diagnosed with clinical ly localized prostate cancer within the National Cancer Data base ( 2004 - 2012 ) were younger , healthier , and more likely to have radical prostatectomy for higher risk disease than men in the Prostate Cancer Intervention Versus Observation Trial ( PIVOT ) , raising questions about the applicability of PIVOT conclusions to the contemporary US population PURPOSE To compare biopsy performance of two approaches for multiparametric magnetic resonance (MR)-targeted biopsy ( TB ) with that of extended systematic biopsy ( SB ) in prostate cancer ( PCa ) detection . MATERIAL S AND METHODS This institutional review board-approved multicenter prospect i ve study ( May 2009 to January 2011 ) included 95 patients with informed consent who were suspected of having PCa , with a suspicious abnormality ( target ) at prebiopsy MR . Patients underwent  12-core SB and four-core TB with transrectal ultrasonographic ( US ) guidance , with two cores aim ed visually ( cognitive TB [ TB-COG ] ) and two cores aim ed using transrectal US-MR fusion software ( fusion-guided TB [ TB-FUS ] ) . SB and TB positivity for cancer and sampling quality ( mean longest core cancer length , Gleason score ) were compared . Clinical ly significant PCa was any 3 mm or greater core cancer length or any greater than 3 Gleason pattern for SB or any cancer length for TB . Statistical analysis included t test , paired χ(2 ) test , and κ statistic . Primary end point ( core cancer length ) was calculated ( paired t test ) . RESULTS Among 95 patients ( median age , 65 years ;  mean prostate-specific antigen level  , 10.05 ng/mL [ 10.05 μg/L ] ) , positivity rate for PCa was 59 % ( n = 56 ) for SB and 69 % ( n = 66 ) for TB ( P = .033 ) ; rate for clinical ly significant PCa was 52 % ( n = 49 ) for SB and 67 % ( n = 64 ) for TB ( P = .0011 ) . Cancer was diagnosed through TB in 16 patients ( 17 % ) with negative SB results . Mean longest core cancer lengths were 4.6 mm for SB and 7.3 mm for TB ( P < .0001 ) . In 12 of 51 ( 24 % ) MR imaging targets with positive SB and TB results , TB led to Gleason score upgrading . In 79 MR imaging targets , positivity for cancer was 47 % ( n = 37 ) with TB-COG and 53 % ( n = 42 ) with TB-FUS ( P = .16 ) . Neither technique was superior for Gleason score assessment .  CONCLUSION Prebiopsy MR imaging combined with transrectal US-guided TB increases biopsy performance in detecting PCa , especially clinical ly significant PCa . No significant difference was observed between TB-FUS and TB-COG for TB guidance Background Shear wave imaging ( SWI ) is a new ultrasound technique whose application facilitates quantitative tissue elasticity assessment during transrectal ultrasound biopsies of the prostate gl and . The aim of this study was to determine whether SWI quantitative data can differentiate between benign and malignant areas within prostate gl and s in men suspected of prostate cancer ( PCa ) . Methods We conducted a protocol -based , prospect i ve , prebiopsy quantitative SWI of prostate gl and s in 50 unscreened men suspected of prostate cancer between July 2011 and May 2012 . The ultrasound image of whole prostate gl and was arbitrarily divided into 12 zones for sampling biopsies , as is carried out in routine clinical practice . Each region was imaged by grey scale and SWI imaging techniques . Each region was further biopsied irrespective of findings of grey scale or SWI on ultrasound . Additional biopsies were taken if SWI abnormal area was felt to be outside of these 12 zones . Quantitative assessment of SWI abnormal areas was obtained in kilopascals ( kPa ) from abnormal regions shown by SWI and compared with histopathology . Sensitivity , specificity , positive and negative predictive values , and likelihood ratios were calculated for SWI ( histopathology was a reference st and ard ) . Results Fifty patients , with a mean age of 69 ± 6.2 years , were recruited into the study . Thirty-three ( 66 % ) patients were diagnosed with PCa , while an additional 4 ( 8 % ) had atypia in at least one of the 12 prostate biopsies . Thirteen ( 26 % ) patients had a benign biopsy . Data analysed per core for SWI findings showed that for patients with PSA < 20 μg/L , the sensitivity and specificity of SWI for PCa detection were 0.9 and 0.88 , respectively , while in patients with PSA > 20 μg/L , the sensitivity and specificity were 0.93 and 0.93 , respectively . In addition , PCa had significantly higher stiffness values compared to benign tissues ( p < 0.05 ) , with a trend toward stiffness differences in different Gleason grade s. ConclusionS WI provides quantitative assessment of the prostatic tissues and , in our preliminary observation , provides better diagnostic accuracy than grey-scale ultrasound imaging Background : The European Society of Urogenital Radiology has built the Prostate Imaging Reporting and Data System ( PI-RADS ) for st and ardizing the diagnosis of prostate cancer ( PCa ) . This study evaluated the PI-RADS diagnosis method in patients with prostate-specific antigen ( PSA ) < 20 ng/ml . Methods : A total of 133 patients with PSA < 20 ng/ml were prospect ively recruited .  T2-weighted ( T2WI ) and diffusion-weighted ( DWI ) magnetic resonance images of the prostate were acquired before a 12-core transrectal prostate biopsy . Each patient 's peripheral zone was divided into six regions on the images ; each region corresponded to two of the 12 biopsy cores . T2WI , DWI , and T2WI + DWI scores were computed according to PI-RADS . The diagnostic accuracy of the PI-RADS score was evaluated using histopathology of prostate biopsies as the reference st and ard . Results : PCa was histologically diagnosed in 169 ( 21.2 % ) regions . Increased PI-RADS score correlated positively with increased cancer detection rate . The cancer detection rate for scores 1 to 5 was 2.8 % , 15.0 % , 34.6 % , 52.6 % , and 88.9 % , respectively , using T2WI and 12.0 % , 20.2 % , 48.0 % , 85.7 % , and 93.3 % , respectively , using DWI . For T2WI + DWI , the cancer detection rate was 1.5 % ( score 2 ) , 13.5 % ( scores 3–4 ) , 41.3 % ( scores 5–6 ) , 75.9 % ( scores 7–8 ) , and 92.3 % ( scores 9–10 ) . The area under the curve for cancer detection was 0.700 ( T2WI ) , 0.735 ( DWI ) and 0.749 ( T2WI + DWI ) . The sensitivity and specificity were 53.8 % and 89.2 % , respectively , when using scores 5–6 as the cutoff value for T2WI + DWI . Conclusions : The PI-RADS score correlates with the PCa detection rate in patients with PSA < 20 ng/ml . The summed score of T2WI + DWI has the highest accuracy in detection of PCa . However , the sensitivity should be further improved Purpose : To evaluate multiparametric magnetic resonance imaging/transrectal ultrasound ( mpMRI/TRUS ) fusion targeted biopsy ( TB ) of the prostate for prostate cancer ( PCa ) diagnosis . Patients and Methods : From April 2013 to January 2014 , 53 men were included in this prospect i ve single-centre study . The degree of PCa suspicion from mpMRI findings was classified according to the PI-RADS scoring system . Of these , 50 patients underwent both an mpMRI/TRUS fusion TB and a  10-core systematic biopsy ( SB ) of  the prostate and were eligible for analysis . Results : 225 targeted and 500 systematic cores were included in this study . PCa was histologically confirmed in 52.0 % of patients ( 26/50 ) , whereas TB revealed PCa in 46.0 % ( 23/50 ) and SB in 36.0 % ( 18/50 ) . TB identified PCa in 16.0 % of all patients ( 8/50 ) that were missed by SB . All told , the targeted core was 2.8 times more likely to be PCa-positive than the systematic core ( 29.3 vs. 10.4 % ) . Conclusions : mpMRI/TRUS fusion TB of the prostate is safe , practicable and may improve PCa diagnosis using fewer biopsy cores compared to SB OBJECTIVE EORTC trial 30891 compared immediate versus deferred and rogen-deprivation therapy ( ADT ) in T0 - 4 N0 - 2 M0 prostate cancer ( PCa ) . Many patients r and omly assigned to deferred ADT did not require ADT because they died before becoming symptomatic . The question arises whether serum prostate-specific antigen ( PSA ) levels may be used to decide when to initiate ADT in PCa not suitable for local curative treatment . METHODS PSA data at baseline , PSA doubling time ( PSADT ) in  patients receiving no ADT  , and time to PSA relapse ( > 2 ng/ml ) in patients whose PSA declined to < 2 ng/ml within the first year after immediate ADT  were analyzed in 939 eligible patients r and omly assigned to immediate ( n=468 ) or deferred ADT ( n=471 ) . RESULTS In both arms , patients with a baseline PSA>50 ng/ml were at a>3.5-fold higher risk to die of PCa than patients with a baseline PSA < or=8 ng/ml . If baseline PSA was between 8 and 50 ng/ml , the risk of PCa death was approximately 7.5-fold higher in patients with PSADT<12 mo than in patients with PSADT>12 mo . Time to PSA relapse after response to immediate ADT correlated significantly with baseline PSA , suggesting that baseline PSA may also reflect disease aggressiveness . CONCLUSIONS Patients with a baseline PSA>50 ng/ml and /or a PSADT<12 mo were at increased risk to die from PCa and might have benefited from immediate ADT , whereas patients with a baseline PSA<50 ng/ml and a slow PSADT ( > 12 mo ) were likely to die of causes unrelated to PCa , and thus could be spared the burden of immediate ADT
Active surveillance represents a viable option in men with low-risk PCa and a long life expectancy .
A biopsy progression indicates the need for active intervention , whereas the role of PSA doubling time is controversial .
In men with locally advanced PCa for whom local therapy is not m and atory , watchful waiting ( WW ) is a treatment alternative to and rogen-deprivation therapy ( ADT ) , with equivalent oncologic efficacy .
Active treatment is recommended mostly for patients with localized disease and a long life expectancy , with radical prostatectomy ( RP ) shown to be superior to WW in prospect i ve r and omized trials .
Nerve-sparing RP is the approach of choice in organ-confined disease , while neoadjuvant ADT provides no improvement in outcome variables .
For locally advanced disease , adjuvant ADT for 3 yr results in superior rates for disease-specific and overall survival and is the treatment of choice .
Active surveillance is an option in low-risk PCa and watchful waiting is an alternative to and rogen-deprivation therapy in locally advanced PCa not requiring immediate local treatment .
CONTEXT The most recent summary of the European Association of Urology ( EAU ) guidelines on prostate cancer ( PCa ) was published in 2011 .
OBJECTIVE To present a summary of the 2013 version of the EAU guidelines on screening , diagnosis , and local treatment with curative intent of clinical ly organ-confined PCa .
Current evidence is insufficient to warrant widespread population -based screening by prostate-specific antigen ( PSA ) for PCa .
Systematic prostate biopsies under ultrasound guidance and local anesthesia are the preferred diagnostic method .
CONCLUSIONS Knowledge in the field of PCa is rapidly changing .