EAU guidelines on prostate cancer. Part 1: screening, diagnosis, and treatment of clinically localised disease. EAU guidelines on prostate cancer. part 1: screening, diagnosis, and local treatment with curative intent-update 2013. 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. 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. Outcomes of men with screen-detected prostate cancer eligible for active surveillance who were managed expectantly. Prediction of Prostate Cancer Risk Among Men Undergoing Combined MRI-targeted and Systematic Biopsy Using Novel Pre-biopsy Nomograms That Incorporate MRI Findings. Screening for prostate cancer: results of the Rotterdam section 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. 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. Ejaculation Frequency and Risk of Prostate Cancer: Updated Results with an Additional Decade of Follow-up. The effect of benign lower urinary tract symptoms on subsequent prostate cancer testing and diagnosis. Prostate cancer mortality in screen and clinically detected prostate cancer: estimating the screening benefit. 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). Clinical utility of the PCA3 urine assay in European men scheduled for repeat biopsy. Screening program for prostate cancer at a university hospital in eastern Saudi Arabia. Screening for prostate cancer using serum prostate-specific antigen: a randomised, population-based pilot study in Finland. Prostate Imaging-Reporting and Data System Steering Committee: PI-RADS v2 Status Update and Future Directions. [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]. Prediction of prostate cancer in unscreened men: external validation of a risk calculator. Comparison of Chromogranin A, Insulin-Like Growth Factor 1 and Prostate-Specific Antigen Serum Markers in Prostate Adenocarcinoma and Benign Prostatic Hyperplasia Screening for prostate cancer with prostate-specific antigen testing: American Society of Clinical Oncology Provisional Clinical Opinion. Diagnostic Pathway with Multiparametric Magnetic Resonance Imaging Versus Standard Pathway: Results from a Randomized Prospective Study in Biopsy-naïve Patients with Suspected Prostate Cancer. Characteristics of screening detected prostate cancer in men 50 to 66 years old with 3 to 4 ng./ml. Prostate specific antigen.
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 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 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 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 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 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 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 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 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 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 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 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 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 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 OBJECTIVE Implementation of a pilot screening program for prostate cancer among Saudi patients that would serve as a nucleus for a Kingdom-wide screening program . METHODS A prospect i ve study on 1,213 Saudi males between 50 - 80 years of age who attended the Outpatient Department at King Fahd Hospital of King Faisal University , Al-Khobar , Kingdom of Saudi Arabia during a period of 18 months ( April 2001-October 2002 ) . They were included at r and om from different clinics including the urology clinic .  Free and total prostate specific antigen ( PSA ) , and digital rectal examination ( DRE ) of the prostate  were performed in all patients . Patients with abnormal  DRE or PSA  were scheduled for transrectal ultrasound ( TRUS ) and ultrasound guided biopsy of the prostate . RESULTS Abnormal DRE or PSA were present in 84 out of 1,213 patients . Only 63 patients agreed to have TRUS and ultrasound guided biopsies . Prostate cancer was confirmed in 14 out of 1,192 patients who completed the study ( 1.17 % ) . CONCLUSION The incidence of prostate cancer among Saudi men in this hospital based study is low . A population based screening for prostate cancer may reveal the incidence of this disease The possibility of screening the general population for prostate cancer using serum prostate-specific antigen ( PSA ) level ( alone or in combination with other tests ) as screening test has recently been discussed . A number of studies are on the way , but the published reports have almost exclusively been based on men volunteering for screening . We assessed the feasibility of a screening study based on men identified from a central population registry . A r and om sample of 600 men in the age groups 55 , 60 and 65 years was identified from the Finnish Population Registry as the study population . Half of them were r and omised to the intervention group and an invitation to participate was sent to them . The participation rate was 77 % ( 230 out of 300 ) . Twenty-five men had a serum PSA concentration of 4.0 micrograms l-1 or above and were invited for further examination including digital rectal examination , transrectal ultrasound and transrectal Tru-cut biopsies  ( directed and /or r and om ) . Six cases of cancer were detected among the 230 participating men , which corresponds to a detection rate of 2.6 % and a positive predictive value of 24 % . The number of cases detected is equivalent to the expected number of prostate cancer cases during a 10 year follow-up in this population . The ratio of free to total PSA was also measured and a cut-off level of 0.20 was chosen . Its use as an additional criterion of the screening test would have decreased the prevalence of false-positive screening tests from 8 % ( 19 of 230 ) to 3 % ( 7 of 230 ) at a cost of missing one of the six cancers compared with serum total PSA concentration alone . Of the six cancers , five were clinical ly regarded as localised and locally confined disease was confirmed pathologically in four of them . In conclusion , a population -based study in Finl and seems feasible and the properties of the PSA test can be regarded as suitable for a r and omised screening study . Thus , all prerequisites for a multicentre study , which is planned , seem to exist 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 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 Prediction models need external validation to assess their value beyond the setting where the model was derived from . OBJECTIVE To assess the external validity of the European R and omized study of Screening for Prostate Cancer ( ERSPC ) risk calculator ( www.prostatecancer-riskcalculator.com ) for the probability of having a positive prostate biopsy ( P(posb ) ) . DESIGN , SETTING AND PARTICIPANTS The ERSPC risk calculator was based on data of the initial screening round of the ERSPC section Rotterdam and vali date d in 1825 and 531 men biopsied at the initial screening round in the Finnish and Swedish sections of the ERSPC respectively .  P(posb ) was calculated using  serum prostate specific antigen ( PSA ) , outcome of digital rectal examination ( DRE ) , transrectal ultrasound and ultrasound assessed prostate volume .  MEASUREMENTS The external validity was assessed for the presence of cancer at biopsy by calibration ( agreement between observed and predicted outcomes ) , discrimination ( separation of those with and without cancer ) , and decision curves ( for clinical usefulness ) . RESULTS AND LIMITATIONS  Prostate cancer was detected in 469 men ( 26 % ) of the Finnish cohort and in 124 men ( 23 % ) of the Swedish cohort .  Systematic miscalibration was present in both cohorts ( mean predicted probability 34 % versus 26 % observed , and 29 % versus 23 % observed , both p<0.001 ) . The areas under the curves were 0.76 and 0.78 , and substantially lower for the model with PSA only ( 0.64 and 0.68 respectively ) . The model proved clinical ly useful for any decision threshold compared with a model with PSA only , PSA and DRE , or biopsying all men . A limitation is that the model is based on sextant biopsies results . CONCLUSIONS The ERSPC risk calculator discriminated well between those with and without prostate cancer among initially screened men , but overestimated the risk of a positive biopsy . Further research is necessary to assess the performance and applicability of the ERSPC risk calculator when a clinical setting is considered rather than a screening setting 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 PURPOSE An American Society of Clinical Oncology ( ASCO ) provisional clinical opinion ( PCO ) offers timely clinical direction to the ASCO membership after publication or presentation of potentially practice -changing data from major studies . This PCO addresses the role of prostate-specific antigen ( PSA ) testing in the screening of men for prostate cancer . CLINICAL CONTEXT Prostate cancer is the second leading cause of cancer deaths among men in the United States . The rationale for screening men for prostate cancer is the potential to reduce the risk of death through early detection . RECENT DATA Evidence from a 2011 Agency for Healthcare Research and Quality systematic review primarily informs this PCO on the benefits and harms of PSA-based screening . An up date search was conducted to March 16 , 2012 , for additional evidence related to the topic . RESULTS In one r and omized trial ,  PSA testing in men who would not otherwise have been screened result ed in reduced death rates from prostate cancer , but it is uncertain whether the size of the effect was worth the harms associated with screening and subsequent unnecessary treatment . Although there are limitations to the existing data , there is evidence to suggest that men with longer life expectancy may benefit from PSA testing . Adverse events associated with prostate biopsy are low for the majority of men ; however , several population -based studies have shown increasing rates of infectious complications after prostate biopsy , which is a concern 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 PURPOSE We defined the yield and nature of prostate cancer in the setting of population based , r and omized prostate specific antigen ( PSA ) guided screening in men with PSA levels between 3 and 4 ng./ml . who were 50 to 65 years old at the time of r and omization . MATERIAL S AND METHODS  Sextant biopsies  were performed in 243 men with PSA of 3 to 4 ng./ml . Therapy decisions were based on core cancer length , histological grade and life expectancy . RESULTS Of the men 32 ( 13.2 % ) had prostate cancer constituting 23 % of all of the 137 prostate cancers to data detected in the first round of our screening study . Age and PSA were similar in men with and without prostate cancer . Men with prostate cancer had significantly lower free PSA and free-to-total PSA ratio , and higher PSA density . Cancer was clinical stage T1c in 27 cases and stage T2 in 5 . Hypoechoic areas were noted at transrectal ultrasound in 10 cases .  Digital rectal examination and transrectal ultrasound  were normal in 21 cases ( 66 % ) . To date 14 patients have undergone prostatectomy . Surgical specimens showed a mean tumor volume of 1.8 cc ( range 0.6 to 4.4 ) and significant amounts of high grade tumor were present in only 3 cases . Margins were positive in 5 cases , and pathological stage was pT2 in 8 cases and pT3 in 6 . CONCLUSIONS By lowering the PSA cutoff from 4 to 3 ng./ml . an increase in cancer detection by 30 % was achieved . While the addition of free-to-total ratio and PSA density may reduce the number of biopsies by about 15 % with sensitivity maintained at 90 % , systematic sextant biopsies were necessary in most of these mean as 66 % of the tumors were negative on transrectal ultrasound and digital rectal examination . The majority of these cancers were clinical ly significant and suitable for curative treatment . If therapy decisions are based on the pathological findings of the biopsies , the risk of treating insignificant cancers seems low
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 .
For locally advanced disease , adjuvant ADT for 3 yr results in superior disease-specific and overall survival rates and represents the treatment of choice .
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 ) .
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 .