Abstract Title: Evolution of Prostate Cancer Screening in Patients with Elevated PSA

Background: Prostate cancer (PCa) is the second-leading cause of death in men in the United States. There is uncertainty regarding the most appropriate PCa screening algorithm. Previously, the standard practice for PCa screening was based on prostate-specific antigen (PSA) testing followed by systematic transrectal ultrasound-guided biopsy (TRUS bx). Unfortunately, PCa screening using that method was burdened by a high degree of overdiagnosis of clinically insignificant PCa and by underdiagnosis of up to 35% of clinically significant PCa. The recent advancement of multiparametric prostate MRI (mpMRI) has proven to be an accurate tool in diagnosing PCa, with high positive and negative predictive values in detecting cancer. Patients with elevated PSA may benefit from initial prostate MRI to screen for clinically significant PCa before TRUS bx. Prior studies have demonstrated this screening method has resulted in fewer diagnosis of clinically insignificant PCa without losing sensitivity in detecting clinically significant cancer. Thus, we expect to see a shift from the traditional systematic biopsy toward MRI based screening. This study aims to retrospectively evaluate the change in PCa screening algorithms over a 10-year period at one institution, which may provide insight to the current state of prostate cancer screening and provide guidance for referring physicians.

Methods: After obtaining IRB approval, we retrospectively identified and reviewed prostate mpMRI studies performed at VCU Health in the years 2012 and 2022. The study only included patients who had elevated PSA with or without prior prostate TRUS bx. Patient records were also noted for prostate volume, PSA, PSA density, and age. Chi-squared test and two-sample t-tests were used for statistical analysis.

Results: For clinical indication of PCa screening, there were 196 prostate MRI studies performed in 2012 compared to 1,005 studies performed in 2022. Among them, 89.7% of patients had undergone TRUS bx prior to mpMRI in 2012 compared to 18.2% in 2022 (P < 0.05). Average PSA density decreased from 0.34 in 2012 to 0.22 in 2022 among patients for screening mpMRI (P < 0.05). Average age increased from 63.4 to 66.4 years (P < 0.05).

Conclusion: The frequency of patients undergoing TRUS Bx for PCa screening prior to mpMRI has significantly decreased from years 2012 to 2022. This demonstrates a change in paradigm among clinicians who prefer prostate mpMRI-based screening over TRUS Bx. This practice has likely reduced diagnosis of clinically insignificant PCa, reduced unnecessary invasive procedures, and increased diagnosis of clinically significant PCa.