With five ESUI plenary sessions on the agenda, the meeting began with the ‘The future of prostate cancer screening programme in EU: Evidence, technologies and strategies’, led by Prof. Lars Budäus (DE) and ESUI Chair Prof. Francesco Sanguedolce (ES).

Customised and risk-based screening

EAU Policy Office Chair Prof. Hein Van Poppel (BE) presented the opening lecture, ‘EU recommendations on PCa screening programme: What we expect in the next 5 years’. He stated that 417,000 men in Europe are diagnosed with prostate cancer (PCa) every year, more than two million European men are living with prostate cancer, and 92,200 European men die of PCa each year.

Prof. Van Poppel: “We convinced policymakers of the problem and the need to decrease PCa deaths.  Stop the increasing rate of too-late diagnosis, stop the costly and inappropriate/inefficient opportunistic testing, and improve the quality of life (QoL) of PCa patients”. He stated that the solution is organised screening throughout Europe, and emphasised the importance of early detection in well-informed men.

The EU4Health called for proposals for innovative approaches to PCa screening, and in partnership with a network of consortium members, PRAISE-U (Prostate cancer Awareness and Initiative for Screening European Union) was set up to encourage early detection and diagnosis of PCa through customised and risk-based screening programmes. According to Prof. Van Poppel there will be five pilot studies in the EU in 2024, and a report submitted to the European Commission in 2026.

MRI challenges

Looking into the complexities of screening populations, radiologist Dr. Ivo Schoots (NL) delivered a lecture on ‘Challenges of MRI in (any) screening programmes’.

Dr. Schoots: “For prostate MRI, population PCa screening is now a new indication, however, PCa screening with MRI needs to be clearly understood by radiological and urological services, and MRI needs to be optimised before implementation into the screening pathway”.

“I want to stress that PCa screening is only acceptable if it is programmatic, and we can reduce harm (while maintaining and improving detection rates), such as using MRI to avoid biopsies, stop doing systemic (blind) biopsies, perform safer and more accurate MRI-directed biopsy, and increase uptake of active surveillance.”

According to Dr. Schoots, MRI-pathway limitations in secondary care will also be translated into primary screening. He discusses the harm of false positives, limited availability of high-quality MRI’s, requirements of specialised equipment, and training.

An update on lung cancer screening model

Continuing on the topic of screening models, Prof. Torsten Gerriet Blum (DE) presented a lecture on ‘The lung cancer screening model’. He stated that low-dose CT lung cancer screening is very promising but it does need time, joint actions and resilience to successfully implement.

Prof. Blum: “When reviewing low-dose CT lung cancer screening, there is RCT-based evidence demonstrating efficacy and cost-effectiveness in risk populations. Overdiagnosis and over therapy is probably the most relevant problem. There are implementation studies (Croatian national programme) demonstrating efficacy and safety.”

He also pointed out the essential need for a structured programme with robust algorithms for LDCT (low-dose computed tomography) reading and nodule management, as well as quality assurance.

This Plenary Session also included a session on “Prostate cancer screening: The PSA/biomarker implemented pathway”, with presentations on the GOTEBORG-2 trial, and ProSa trial. The Prostagram Trial and Re-Imagine trial were presented in the “PCa screening – The MRI only pathway”.

Watch the full presentations from ESUI Plenary Session 1 via the Resource Centre – EMUC23 (uroweb.org).

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The ESU/ESUI Hands-on Training Course in Prostate MRI reading for urologists was designed to help urologists understand the role of magnetic resonance imaging (MRI) in the management of patients with prostate cancer (PCa) and how they can use the procured information.

The faculty members of the HoT course were comprised of internationally-known experts such as Course Chair Dr. Jochen Walz (FR), Prof. Dr. Jurgen Futterer (NL), Dr. Gianluca Giannarini (IT), Prof. Valeria Panebianco (IT) and Dr. Francesco Sanguedolce (ES).

“Why is MRI important to the urologist? For the same reason as computerized tomography (CT) scan has become fundamental in our practice,” said Dr. Sanguedolce. 

Delegates were familiarised with the imaging workstation; the basic concepts/principles behind different MRI sequences such as T2-weighted imaging, Diffusion Weighted Imaging (DWI) and Dynamic Contrast Enhanced (DCE) imaging; and the viewing order of sequences when interpreting prostate MRI.

The delegates also learned how to use the PI-RADS and Likert scoring system to score MRIs, know more about the standards for a prostate MRI and the quality criteria to meet. Prof. Futterer gave an overview of the minimum requirements to achieve quality MRI images. Prof. Panebianco discussed assessment categories of PI-RADSv2 and the roles of different scores.

Each delegate was provided with a laptop to work with to follow the lectures and partake in exercises. 

MRI Fusion biopsy

Through the guidance of Course Chair Dr. Lars Budäus (DE) with mentors Asst. Prof. Jan Philipp Radtke (DE), Dr. Karsten Gunzel (DE), Dr. Silvan Boxler (CH), Dr. Angelika Borkowetz (DE) and Dr. Andreas Maxeiner (DE), delegates learned about the advantages, handling and limitations of MRI Ultrasound fusion biopsies during the HOT course the ESU/ESUI Hands-on Training Course in MRI Fusion biopsy.

The course delivered an overview on MRI reading, technical basics, and different prostate biopsy approaches. Technical considerations, the transrectal or transperineal approach were reviewed and discussed. 

The delegates were divided into small groups to gain familiarity with the 5 different Fusion biopsy machines provided during the HOT course. The groups on each machine rotated every 10 minutes.

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The experts gave their view on the continued use of PSA as a screening tool and the current state (and future potential) of imaging or biomarker-based alternatives.

The 11th edition of the European Multidisciplinary Meeting on Urological Cancers is taking place in Vienna on 15-17 November. It was preceded by the 8th Meeting of the EAU Section of Urological Imaging and other supplementary meetings on the 14th. EMUC19 is a collaboration of the European Society for Medical Oncology (ESMO), the European Society for Radiotherapy & Oncology (ESTRO) and the European Association of Urology (EAU).

A case for timely detection

Prof. Chris Bangma (Rotterdam, NL), urologist, co-chaired the session on early detection and the 40 years of PSA. He suggested that the audience use the coffee break after the session to celebrate the milestone. Its discovery in 1979 had a huge impact on the medical profession, patients and governments alike.

As an illustration of how far we’ve come (and perhaps as a warning if PSA testing is recklessly abandoned) Prof. Roobol (Rotterdam, NL) painted a picture of prostate cancer diagnosis and treatment in the 1970s and 80s. Patients were diagnosed at a point where the cancer had spread to bones and only one in 2-3 patients survived. Following a huge rise in PSA testing in the early 2000s, there followed a reflective period and fear of overdiagnosis. “But stopping PSA testing is not the way to go,” warned Roobol, fearing a return to mortality levels of the 1980s.

“We have to preserve the achievements of recent decades and work on preventing the excesses. In two words: Risk Assessment.” Roobol proposed an approach for 2019 and beyond that started with baseline PSA, then risk stratification, imaging, further risk stratification, biopsy, and then treatment  (including active surveillance) if required.

Earlier in the session, Prof. Hein Van Poppel lamented the recent decline in PSA screening and the associated increase in mortality in several Western European countries. “This could be prevented with early detection and appropriate treatment.” Van Poppel warned the audience for what he termed “anti-PSA propaganda” and the discouragement of PSA use. He concluded that effective use of supplementary tools and technologies like new biomarkers and MRI can avoid overdiagnosis and overtreatment.

Crucially, Van Poppel argued that Europe’s adult male population “needs to be informed” directly, thereby increasing awareness of PSA testing and the importance of early detection. The EAU is also working in a wider coalition of experts and patient organisations to lobby the European Commission to recommend population-based screening and hopefully change national guidelines. This is part of a longer strategy that was outlined at the EAU’s National Societies Meeting earlier this year and further detailed in an opinion piece on behalf of the EAU.

Van Poppel also hailed EMUC as a major achievement, a real multidisciplinary meeting that reflected the reality that urinary cancers no longer belong to a single specialty.

A voice to be heard

The morning’s session progressed to include the current state and (near-)future potential of various early detection options including MRI (specifically PI-RADS), the grading system used by pathologists, and biomarkers and genomics. A lot of discussions took place in between the talks, covering topics like certification for hypothetical prostate imaging centres, and the role of artificial intelligence in risk stratification.

One discussion focused on the needs of patients and their experiences with their GPs: Dr. Erik Briers (Hasselt, BE) who was in the audience and identified himself as a prostate cancer patient mentioned the “own way of thinking” that general practitioners had when it came to their patients and prostate cancer.

“They feel that they have to protect men from overdiagnosis and overtreatment. But actually, men want to know about their prostate cancer when it is still curable. It might help to adjust the training of GPs, they have to learn that urologists and other disciplines are not out to take our prostates. They want to help us in the best possible way, and our doctors should not be afraid to refer us to a specialist.”

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