Prostate cancer screening beyond PSA – STHLM3 and/or MRI Prostate cancer screening beyond PSA – STHLM3 and/or MRI? Goran Ahlgren, M.D. Ph.D. Lund University, Malmö Sweden

Diagnostic goals 2017 To diagnose intermediate – high risk in time To avoide overdiagnosis of low risk tumour To correctly classify tumour at diagnosis

Why screening of prostate cancer? Cancer i siffror 2015

Almost 30% of 10 000 new cases yearly in Sweden is ”very low” or ”low risk”

”Latent prostate cancer” At autopsy a microscopic prostate cancer is detectable in Men 30-40 years: 10% Men 40-50 years: 20% Men 50-60 years: 30% Men 60-70 years: 40% Men 70-80 years: 50% Men >80 years: 60%

Avoide overdiagnosis = less biopsies! Swedish guidelines: Biopsy not indicated if Normal DRE PSA 3-10 ng/ml (unless fast rise) PSA-f/T > 0,2 PSA-density < 0,1 ng/ml/cm3 BPH - Finasterid? If PSA rise: STHLM3? MRI?

Andriole, J Urol 2006 (ARIA-studierna) Effect of dutasteride on PSA-kinetic in patients with BPH and prostate cancer Andriole, J Urol 2006 (ARIA-studierna)

Avoid Rebiopsy; Gothenburg part of the ERSPC study 322 with PSA >3 ng/ml without PCa at first biopsy. What happened? 56 normalised PSA (17%) 182 har benign repeat biopsies (56%) 84 had prostate cancer (26%) 2nd biopsy – 52/246 PCa (21,9%) 3rd biopsy – 32/194 PCa (16,5%) All patients with PSA >3ng/ml and a Prostate volume < 20cc hade PCa None of patients with P vol >70cc had PCa Zachrisson et al Eur Urol 2003;43

Better use of PSA tests? STHLM0 EUROPEAN UROLOGY 6 3 ( 2 0 1 3 ) 4 1 9 – 4 2 5

STHLM0 study shows that present PSA testing in Sweden also underdetects significant tumours Percent of men with an elevated PSA that had a biopsy taken within 2 years from the first PSA above normal! PSA-value Age 50-59 years Age 60-69 years 3-4 45% 30% 4-10 65% 55% >10 70% 17.5% of all men who was diagnosed with advanced prostate cancer (T3/4, N1, M1, PSA>20) had a PSA ≥3 taken more than 6 months before without diagnostic action EUROPEAN UROLOGY 6 3 ( 2 0 1 3 ) 4 1 9 – 4 2 5

Patients that had a prostate biopsy

STHLM3 - algotithm

STHLM3 is a algoritm for risk of significant prostate cancer >10% risk för Sign cancer GS≥7

Eur Urol 2016

Eur Urol 2016

Eur Urol 2016

Can we trust a negative MRI?? Itatani, Eur J Radiol 2014 193 men with negative mpMRI = PI-RADS 1-2 F-U 5 years: PSA + biopsy + mpMRI NPV mpMRI: 90 %

Conclusions STHLM3 can reduce benign biopsies with 44% STHLM3 does not increase Gleason score ≥7 but reduces GS6 with 17% mpMRI double the significant cancer detection rate mpMRI significantly reduces the detection rate of GS6 cancer (≈50%) and benign biopsies (≈25-30%) Patients without clinical suspicion of prostate cancer should be evaluated with mpMRI