Risk stratification of prostate cancer in the modern era

Novel tools have become available to the practicing urologist in recent years that endeavor to improve on commonly utilized prostate cancer (PCa) risk-stratification techniques. In this review, we provide an overview of these modalities in the context of active surveillance.

Multiparametric MRI (MP-MRI) has a rapidly growing body of evidence that suggests it provides the necessary sensitivity and negative predictive value to rule out clinically significant disease. MRI-guided targeted biopsy has the potential to improve detection of clinically significant cancers and for rebiopsy of patients with continued suspicion for PCa. Prostate-specific antigen isoforms and Prostate Health Index outperform PSA alone and improve risk stratification when combined with the established criteria, but need further prospective studies using template and MRI-targeted biopsies. Urinary biomarkers tend to fall short in predicting adverse pathology when used alone, but improve risk stratification when used in conjunction and with the established criteria. Finally, tissue biomarkers and gene assays allow patient-specific molecular and genetic characterization of cancer phenotype, showing significant promise in predicting adverse pathology, and in some cases have already been incorporated into and altered clinical practice.

These novel modalities show remarkable promise in improving the risk stratification of patients with PCa, and as the body of evidence grows will likely become incorporated into major oncologic guidelines and standard urologic practice. Further prospective clinical studies are needed, as well as analysis of cost-effectiveness.