1. 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

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

3. Why screening of prostate cancer?
Cancer i siffror 2015

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

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

6. 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?

7. 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)

8. 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

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

10. 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 years
Age 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 ( ) – 4 2 5

12. Patients that had a prostate biopsy

13. STHLM3 - algotithm

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

17. Eur Urol 2016

18. Eur Urol 2016

19. Eur Urol 2016

20. 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 %

21. 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