BACKGROUND The harm of screening (unnecessary biopsies and overdiagnosis) generally outweighs the benefit of reducing prostate cancer (PCa) mortality in men aged ≥70 yr. Patient selection for biopsy using risk stratification and magnetic resonance imaging (MRI) may improve this benefit-to-harm ratio. OBJECTIVE To assess the potential of a risk-based strategy including MRI to selectively identify men aged ≥70 yr with high-grade PCa. DESIGN, SETTING, AND PARTICIPANTS Three hundred and thirty-seven men with prostate-specific antigen ≥3.0 ng/ml at a fifth screening (71-75 yr) in the European Randomized study of Screening for Prostate Cancer Rotterdam were biopsied. One hundred and seventy-nine men received six-core transrectal ultrasound biopsy (TRUS-Bx), while 158 men received MRI, 12-core TRUS-Bx, and fusion TBx in case of Prostate Imaging Reporting and Data System ≥3 lesions. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The primary outcome was the overall, low-grade (Gleason Score 3+3) and high-grade (Gleason Score ≥ 3+4) PCa rate. Secondary outcome was the low- and high-grade PCa rate detected by six-core TRUS-Bx, 12-core TRUS-Bx, and MRI ± TBx. Tertiary outcome was the reduction of biopsies and low-grade PCa detection by upfront risk stratification with the Rotterdam Prostate Cancer Risk Calculator 4. RESULTS AND LIMITATIONS Fifty-five percent of men were previously biopsied. The overall, low-grade, and high-grade PCa rates in biopsy naïve men were 48%, 27%, and 22%, respectively. In previously biopsied men these PCa rates were 25%, 20%, and 5%. Sextant TRUS-Bx, 12-core TRUS-Bx, and MRI ± TBx had a similar high-grade PCa rate (11%, 12%, and 11%) but a significantly different low-grade PCa rate (17%, 28%, and 7%). Rotterdam Prostate Cancer Risk Calculator 4-based stratification combined with 12-core TRUS-Bx ± MRI-TBx would have avoided 65% of biopsies and 68% of low-grade PCa while detecting an equal percentage of high-grade PCa (83%) compared with a TRUS-Bx all men approach (79%). CONCLUSIONS After four repeated screens and ≥1 previous biopsies in half of men, a significant proportion of men aged ≥70 yr still harbor high-grade PCa. Upfront risk stratification and the combination of MRI and TRUS-Bx would have avoided two-thirds of biopsies and low-grade PCa diagnoses in our cohort, while maintaining the high-grade PCa detection of a TRUS-Bx all men approach. Further studies are needed to verify these results. PATIENT SUMMARY Prostate cancer screening reduces mortality but is accompanied by unnecessary biopsies and overdiagnosis of nonaggressive tumors, especially in repeatedly screened elderly men. To tackle these drawbacks screening should consist of an upfront risk-assessment followed by magnetic resonance imaging and transrectal ultrasound-guided biopsy.

中文翻译：

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在欧洲鹿特丹前列腺癌筛查随机研究中第五次筛查发现的前列腺癌特征：我们可以通过前期多变量风险分层和磁共振成像选择性地检测高级别前列腺癌吗？

背景 在 70 岁以上的男性中，筛查（不必要的活检和过度诊断）的危害通常超过降低前列腺癌 (PCa) 死亡率的益处。使用风险分层和磁共振成像 (MRI) 进行活检的患者选择可能会提高这种益处/危害比。目的 评估基于风险的策略（包括 MRI）在选择性识别年龄≥70 岁的高级别 PCa 男性中的潜力。设计、设置和参与者 在欧洲鹿特丹前列腺癌筛查随机研究中，对 337 名在第五次筛查（71-75 岁）中前列腺特异性抗原≥3.0 ng/ml 的男性进行了活检。179 名男性接受了六核经直肠超声活检 (TRUS-Bx)，而 158 名男性接受了 MRI、12 核 TRUS-Bx、在前列腺成像报告和数据系统≥3 个病变的情况下，融合 TBx。结果测量和统计分析 主要结果是总体、低级别（Gleason 评分 3+3）和高级别（Gleason 评分 ≥ 3+4）PCa 率。次要结果是六核 TRUS-Bx、12 核 TRUS-Bx 和 MRI ± TBx 检测到的低级别和高级别 PCa 率。三级结果是使用鹿特丹前列腺癌风险计算器 4 通过前期风险分层减少活检和低级别 PCa 检测。结果和限制 55% 的男性之前进行过活检。未接受活检的男性的总体、低级别和高级别 PCa 率分别为 48%、27% 和 22%。在先前进行活检的男性中，这些 PCa 发生率为 25%、20% 和 5%。六分仪 TRUS-Bx、12 核 TRUS-Bx 和 MRI ± TBx 具有相似的高级 PCa 率（11%，12% 和 11%），但低级 PCa 率显着不同（17%、28% 和 7%）。基于鹿特丹前列腺癌风险计算器 4 的分层结合 12 核 TRUS-Bx ± MRI-TBx 可以避免 65% 的活检和 68% 的低级别 PCa，同时检测到等百分比的高级别 PCa (83%)与 TRUS-Bx 所有男性方法相比（79%）。结论 在一半男性中进行四次重复筛查和 ≥1 次活检后，相当大比例的≥70 岁男性仍有高级别 PCa。前期风险分层以及 MRI 和 TRUS-Bx 的组合可以避免我们队列中三分之二的活检和低级别 PCa 诊断，同时保持 TRUS-Bx 全男性方法的高级别 PCa 检测。需要进一步的研究来验证这些结果。患者总结 前列腺癌筛查可降低死亡率，但伴随着不必要的活检和对非侵袭性肿瘤的过度诊断，尤其是在反复筛查的老年男性中。为了解决这些缺点，筛查应包括前期风险评估，然后进行磁共振成像和经直肠超声引导活检。