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Game-changers: Guideline changes in screening and diagnosis for PCa?

On day two of EAU24, the game-changing session featured first time results, and discussion on three prostate cancer (PCa) screening and diagnosis trials. Co-chaired by Prof. Peter Albers (DE) and Prof. Arnauld Villers (FR), these trial presentations featured potential solutions to reduce overdiagnosis and overscreening, but retain or improve screening quality, availability, and cost.

Is PRIME the solution?

Assoc. Prof. Veeru Kasivisvanathan (GB) presented the results for ‘Comparison of biparametric (bpMRI) and multiparametric magnetic resonance imaging (mpMRI) for prostate cancer (PCa) detection: The PRIME Study (NCT04571840)’. His summary of the main findings:

Biparametric MRI without dynamic contrast enhancement in the presence of good quality scans, results in:

  • No difference in clinically significant prostate cancer (csPCa) or insignificant cancer detection
  • No increase in biopsies
  • No difference in specificity/false positives
  • Minor differences in treatment eligibility decisions and treatment planning

Assoc. Prof. Kasivisvanathan: “Biparametric MRI without dynamic contrast enhancement should become the new standard of care for PCa diagnosis in men with suspected PCa, providing image quality is good. This will increase accessibility, cost-effectiveness, and adoption of prostate MRI. It will also help us to achieve our goal of ensuring every man who needs an MRI scan is able to get one.”

According to discussant Dr. Giorgio Gandaglia (IT), international guidelines currently recommend mpMRI for clinical suspicion of PCa but there is a capacity issue, and bpMRI, conducted without the use of contrast could offer a shorter and more cost-effective scanning process, thereby enhancing MRI accessibility. However, he concludes “maintaining MRI quality is crucial. The dynamic contrast enhancing (DCE) sequence might still play a role in specific settings (margin delineation, planning for focal therapy, post ablation evaluation).”

PROBASE – 45 or 50 years old?

“At what age should screening start, what is defined as low-risk, and how often to test?”, asked Prof. Peter Albers (DE) at the beginning of his presentation on ‘Challenging the EAU Guidelines on Prostate Cancer risk definition in the screening setting: Insights from the PROBASE Trial’.

According to Prof. Albers, the 2024 EAU Guideline suggests PSA<1.0ng/ml at age 40 is low-risk and recommends re-screening at 8 years. However, the PROBASE risk groups were defined according to two studies (Lane JA el al. BMJ 2027; and Vicker a et al. BMJ) showing that an initial PSA level of <1.5 ng/ml predicts men with a low risk to harbour or develop PCa.

From the new PROBASE results that compares the effects of risk-adapted screening starting at 45 or 50 years, Prof. Albers stated: “Men at 45 years with a baseline PSA <1.5 ng/ml have a very low risk of developing clinically significant PCa within the next 5 years.”

ProScreen trial

“The results are encouraging but they are only the first step” said Prof. Anssi Auvinen (FI) in his presentation “Results from the first screening round of the ProScreen screening trial with PSA, kallikrein panel and MRI.’

The ProScreen trial investigates the effectiveness of a screening strategy that combines PSA, kallikrein panel and MRI on PCa mortality over a 15-year period from randomisation.

According to Prof. Auvinen, the ProScreen trial results showed a substantially higher detection of high-grade than low-grade cancer at the first screening round. This was also shown in comparison with a control arm not offered screening. “Assuming that high-grade cancers represent benefit and low-grade cancer harm (overdiagnosis), the results suggest materially improved balance of benefits and harms compared with PSA-based screening.”

Prof. Auvinen: “We have started the second and third screening rounds and will also collect data on quality of life (QoL), costs and mortality.”

To (re)watch the full presentations of this Plenary Session, please visit the EAU24 Resource Centre.