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Comparison of Multiparametric Magnetic Resonance Imaging–Targeted Biopsy With Systematic Transrectal Ultrasonography Biopsy for Biopsy-Naive Men at Risk for Prostate CancerA Phase 3 Randomized Clinical Trial

Educational Objective
To learn the outcomes of magnetic resonance imaging (MRI)–targeted prostate biopsy compared with systematic transrectal ultrasonography biopsy in men at risk for prostate cancer.
1 Credit CME
Key Points

Question  Is magnetic resonance imaging (MRI) with targeted biopsy only noninferior to systematic biopsy for the diagnosis of clinically significant prostate cancer (PCa)?

Findings  In this prospective phase 3 randomized clinical trial of 453 men, clinically significant cancer was found in 35% vs 30% in the MRI and systematic biopsy arms, respectively, which demonstrated noninferiority. A total of 79 participants in the MRI arm (37%) avoided a biopsy, and diagnosis of grade group 1 PCa was reduced by more than 50%.

Meaning  Magnetic resonance imaging with targeted biopsy alone resulted in similar detection rates of clinically significant PCa while avoiding biopsy in more than one-third of men and reducing the diagnosis of clinically insignificant cancer.

Abstract

Importance  Magnetic resonance imaging (MRI) with targeted biopsy is an appealing alternative to systematic 12-core transrectal ultrasonography (TRUS) biopsy for prostate cancer diagnosis, but has yet to be widely adopted.

Objective  To determine whether MRI with only targeted biopsy was noninferior to systematic TRUS biopsies in the detection of International Society of Urological Pathology grade group (GG) 2 or greater prostate cancer.

Design, Setting, and Participants  This multicenter, prospective randomized clinical trial was conducted in 5 Canadian academic health sciences centers between January 2017 and November 2019, and data were analyzed between January and March 2020. Participants included biopsy-naive men with a clinical suspicion of prostate cancer who were advised to undergo a prostate biopsy. Clinical suspicion was defined as a 5% or greater chance of GG2 or greater prostate cancer using the Prostate Cancer Prevention Trial Risk Calculator, version 2. Additional criteria were serum prostate-specific antigen levels of 20 ng/mL or less (to convert to micrograms per liter, multiply by 1) and no contraindication to MRI.

Interventions  Magnetic resonance imaging–targeted biopsy (MRI-TB) only if a lesion with a Prostate Imaging Reporting and Data System (PI-RADS), v 2.0, score of 3 or greater was identified vs 12-core systematic TRUS biopsy.

Main Outcome and Measures  The proportion of men with a diagnosis of GG2 or greater cancer. Secondary outcomes included the proportion who received a diagnosis of GG1 prostate cancer; GG3 or greater cancer; no significant cancer but subsequent positive MRI results and/or GG2 or greater cancer detected on a repeated biopsy by 2 years; and adverse events.

Results  The intention-to-treat population comprised 453 patients (367 [81.0%] White, 19 [4.2%] African Canadian, 32 [7.1%] Asian, and 10 [2.2%] Hispanic) who were randomized to undergo TRUS biopsy (226 [49.9%]) or MRI-TB (227 [51.1%]), of which 421 (93.0%) were evaluable per protocol. A lesion with a PI-RADS score of 3 or greater was detected in 138 of 221 men (62.4%) who underwent MRI, with 26 (12.1%), 82 (38.1%), and 30 (14.0%) having maximum PI-RADS scores of 3, 4, and 5, respectively. Eighty-three of 221 men who underwent MRI-TB (37%) had a negative MRI result and avoided biopsy. Cancers GG2 and greater were identified in 67 of 225 men (30%) who underwent TRUS biopsy vs 79 of 227 (35%) allocated to MRI-TB (absolute difference, 5%, 97.5% 1-sided CI, −3.4% to ∞; noninferiority margin, −5%). Adverse events were less common in the MRI-TB arm. Grade group 1 cancer detection was reduced by more than half in the MRI arm (from 22% to 10%; risk difference, −11.6%; 95% CI, −18.2% to −4.9%).

Conclusions and Relevance  Magnetic resonance imaging followed by selected targeted biopsy is noninferior to initial systematic biopsy in men at risk for prostate cancer in detecting GG2 or greater cancers.

Trial Registration  ClinicalTrials.gov Identifier: NCT02936258

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Article Information

Accepted for Publication: November 6, 2020.

Published Online: February 4, 2021. doi:10.1001/jamaoncol.2020.7589

Corresponding Author: Laurence Klotz, CM, MD Sunnybrook Health Sciences Centre, 2075 Bayview Ave, #MG 408, Toronto, ON M4N 3M5, Canada (laurence.klotz@sunnybrook.ca).

Correction: This article was corrected on April 15, 2021, and May 27, 2021, to fix errors in multiple author names and affiliations.

Author Contributions: Drs Klotz and Haider had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Klotz, Chin, Black, Finelli, Ghai, Milot, Moore, Kasivisvanathan, Loblaw, Kebabdjian, Earle, Pond, Haider.

Acquisition, analysis, or interpretation of data: Klotz, Chin, Anidjar, Bladou, Mercado, Levental, Ghai, Chang, Milot, Patel, Kassam, Moore, Kasivisvanathan, Kebabdjian, Earle, Pond, Haider.

Drafting of the manuscript: Klotz, Kebabdjian, Pond, Haider.

Critical revision of the manuscript for important intellectual content: Klotz, Chin, Black, Finelli, Anidjar, Bladou, Mercado, Levental, Ghai, Chang, Milot, Patel, Kassam, Moore, Kasivisvanathan, Loblaw, Earle, Pond, Haider.

Statistical analysis: Pond.

Obtained funding: Klotz, Moore, Loblaw, Haider.

Administrative, technical, or material support: Klotz, Chin, Bladou, Mercado, Levental, Ghai, Milot, Patel, Kasivisvanathan, Kebabdjian, Haider.

Supervision: Klotz, Black, Finelli, Moore, Kebabdjian, Haider.

Other - Expertise in medical imaging: Kassam.

Other - Interpretation of all MRIs and performance of all biopsies at 1 of the 5 sites: Ghai.

Conflict of Interest Disclosures: Dr Chin reported grants from the Ontario Institute of Cancer Research (OICR) during the conduct of the study. Dr Levental reported grants from Prostate Cancer Canada (PCC) during the conduct of the study. Dr Moore reported grants from SpectraCure PDT, Movember, Medical Research Council, and Prostate Cancer UK as well as personal fees from Janssen, Astellas, and Steba Biotech Consultancy. Dr Kasivisvanathan reported personal fees from the European Association of Urology outside the submitted work. Dr Pond reported grants from the OICR during the conduct of the study, personal fees from AstraZeneca and Takeda outside the submitted work, and having a close family member who is an employee of Roche Canada Ltd and owns stock in Roche. No other disclosures were reported.

Funding/Support: This study was funded by grants from the OICR and PCC.

Role of the Funder/Sponsor: The funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: We thank Kathryn Cline, BSc, for her assistance in trial coordination and data management and the Ontario Clinical Oncology Group, which performed the data management and treatment randomization under the supervision of Dr Pond. Ms Cline and Dr Pond performed the data management and the statistical analysis for the study and were paid for this service.

Data Sharing Statement: See Supplement 4.

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