LAUSR

Expert’s summary: The National Comprehensive Cancer Network guidelines provide multiple reflex testing options to help with repeat prostate biopsy decisions, including markers and multiparametric magnetic resonance imaging (mpMRI) [1]. The prospective study by Gnanapragasam et al [2] shows that the combination of the Prostate Health Index (PHI) and mpMRI can avoid unnecessary repeat biopsies while preserving the detection of high-grade prostate cancer (PCa). Among 279 men with one or more prior biopsies, PHI was a significant predictor of Gleason 7 PCa on targeted transperineal biopsy in a multivariable model with MRI findings. PHI plus MRI (area under the receiver operating characteristic curve [AUC] 0.75) outperformed PSA plus MRI (AUC 0.69) or MRI alone (AUC 0.64) in predicting high-grade disease, and was associated with a net benefit on decision curve analysis. A PHI threshold of 35 had 97% negative predictive value (NPV) for clinically significant PCa. Among men with negative mpMRI, PHI outperformed both prostate-specific antigen (PSA) and PSA density to identify significant PCa. Applying a PHI threshold of 35 among men with negative mpMRI would have spared 42% of biopsies, while only missing a single low-volume Gleason 7 tumor.