A Contemporary Prostate Biopsy Risk Calculator Based on Multiple Heterogeneous Cohorts

Background: Prostate cancer prediction tools provide quantitative guidance for doctor-patient decision- making regarding biopsy. The widely used online Prostate Cancer Prevention Trial Risk Calculator (PCPTRC) utilized data from the 1990s based on six-core biopsies and outdated grading systems. Objective: We prospectively gathered data from men undergoing prostate biopsy in multiple diverse North American and European institutions participating in the Prostate Biopsy Collaborative Group (PBCG) in order to build a state-of-the-art risk prediction tool. Design, setting, and participants: We obtained data from 15 611 men undergoing 16 369 prostate biopsies during 2006-2017 at eight North American institutions for model-building and three European institutions for validation. Outcome measurements and statistical analysis: We used multinomial logistic regression to estimate the risks of high-grade prostate cancer (Gleason score >= 7) on biopsy based on clinical characteristics, including age, prostate-specific antigen, digital rectal exam, African ancestry, firstdegree family history, and prior negative biopsy. We compared the PBCG model to the PCPTRC using internal cross-validation and external validation on the European cohorts. Results and limitations: Cross-validation on the North American cohorts (5992 biopsies) yielded the PBCG model are a under the receiver operating characteristic curve (AUC) as 75.5%(95% confidence interval: 74.2-76.8), a small improvement over the AUC of 72.3% (70.9-73.7) for the PCPTRC (p < 0.0001). However, calibration and clinical net benefit were far superior for the PBCG model. Using a risk threshold of 10%, clinical use of the PBCG model would lead to the equivalent of 25 fewer biopsies per 1000 patients without missing any high-grade cancers. Results were similar on external validation on 10 377 European biopsies. Conclusions: The PBCG model should be used in place of the PCPTRC for prediction of prostate biopsy outcome. Patient summary: A contemporary risk tool for outcomes on prostate biopsy based on the routine clinical risk factors is now available for informed decision-making. (C) 2018 European Association of Urology. Published by Elsevier B.V. All rights reserved.