***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: BACKGROUND The comparative effectiveness of treatments for prostate cancer that is detected by prostate-specific antigen ( PSA ) testing remains uncertain . METHODS We compared active monitoring , radical prostatectomy , and external-beam radiotherapy for the treatment of clinical ly localized prostate cancer . Between 1999 and 2009 , a total of 82,429 men 50 to 69 years of age received a PSA test ; 2664 received a diagnosis of localized prostate cancer , and 1643 agreed to undergo r and omization to active monitoring ( 545 men ) , surgery ( 553 ) , or radiotherapy ( 545 ) . The primary outcome was prostate-cancer mortality at a median of 10 years of follow-up . Secondary outcomes included the rates of disease progression , metastases , and all-cause deaths . RESULTS There were 17 prostate-cancer-specific deaths overall : 8 in the active-monitoring group ( 1.5 deaths per 1000 person-years ; 95 % confidence interval [ CI ] , 0.7 to 3.0 ) , 5 in the surgery group ( 0.9 per 1000 person-years ; 95 % CI , 0.4 to 2.2 ) , and 4 in the radiotherapy group ( 0.7 per 1000 person-years ; 95 % CI , 0.3 to 2.0 ) ; the difference among the groups was not significant ( P=0.48 for the overall comparison ) . In addition , no significant difference was seen among the groups in the number of deaths from any cause ( 169 deaths overall ; P=0.87 for the comparison among the three groups ) . Metastases developed in more men in the active-monitoring group ( 33 men ; 6.3 events per 1000 person-years ; 95 % CI , 4.5 to 8.8 ) than in the surgery group ( 13 men ; 2.4 per 1000 person-years ; 95 % CI , 1.4 to 4.2 ) or the radiotherapy group ( 16 men ; 3.0 per 1000 person-years ; 95 % CI , 1.9 to 4.9 ) ( P=0.004 for the overall comparison ) . Higher rates of disease progression were seen in the active-monitoring group ( 112 men ; 22.9 events per 1000 person-years ; 95 % CI , 19.0 to 27.5 ) than in the surgery group ( 46 men ; 8.9 events per 1000 person-years ; 95 % CI , 6.7 to 11.9 ) or the radiotherapy group ( 46 men ; 9.0 events per 1000 person-years ; 95 % CI , 6.7 to 12.0 ) ( P<0.001 for the overall comparison ) . CONCLUSIONS At a median of 10 years , prostate-cancer-specific mortality was low irrespective of the treatment assigned , with no significant difference among treatments . Surgery and radiotherapy were associated with lower incidences of disease progression and metastases than was active monitoring . ( Funded by the National Institute for Health Research ; ProtecT Current Controlled Trials number , IS RCT N20141297 ; Clinical Trials.gov number , NCT02044172 . ) BACKGROUND The Prostate Cancer Research International Active Surveillance ( PRIAS ) study was initiated a decade ago to study the most optimal selection and follow-up of men on active surveillance ( AS ) . OBJECTIVE We report on 10 yr of follow-up of men on AS in the PRIAS study and evaluate if criteria used to recommend a switch to active treatment truly predict unfavorable outcome on subsequent radical prostatectomy ( RP ) . DESIGN , SETTING , AND PARTICIPANTS Men with low-risk prostate cancer were included and followed prospect ively on AS . Follow-up consisted of regular prostate-specific antigen ( PSA ) tests , digital rectal examinations , and biopsies .  Men with Gleason > 3 + 3 , more than two positive biopsy cores , or stage higher than cT2 were advised to switch to active treatment ( until 2014 , a PSA doubling time [ PSA DT ] of 0 - 3 yr was also used ) . OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Reclassification rates , treatment after discontinuation , and outcome on RP after discontinuing AS were reported . Regression analysis on the outcome of RP was used to evaluate the predictive value of criteria currently used to recommend a switch to active treatment . Kaplan-Meier and competing risk analysis were used to report discontinuation rates over time and long-term oncologic end points . RESULTS AND LIMITATIONS A total of 5302 men were included in PRIAS across 18 countries . Reclassification rates remained stable on all subsequent biopsies , with 22 - 33 % of men having either Gleason > 3 + 3 or more than two positive cores on any repeat biopsy . At 5 and 10 yr of follow-up , 52 % and 73 % of men , respectively , had discontinued AS , most of them because of protocol -based reclassification . A third of men undergoing subsequent RP had favorable pathologic tumor features ( Gleason 3 + 3 and pT2 ) . Of the criteria used to recommend a switch to active treatment , more than two positive cores and a PSA DT of 0 - 3 yr were not predictive of unfavorable pathologic outcome on RP . CONCLUSIONS A substantial group of men discontinued AS without subsequent unfavorable tumor features on RP ; therefore , we propose Gleason upgrading and cT3 as the only indicators for an immediate switch to active treatment . Surrogate indicators ( eg , more than two positive cores and a fast-rising PSA ) should not trigger immediate active treatment but rather further investigation to confirm the suspicion of higher risk disease . PATIENT SUMMARY We confirmed the safety of active surveillance as a treatment option for men with low-risk prostate cancer ; however , some changes could be made to the follow-up protocol to safely increase the number of men who remain on active surveillance OBJECTIVE To develop nomograms that predict the probability of overall prostate cancer ( PCa ) and clinical ly significant PCa ( Gleason ≥7 ) on magnetic resonance imaging (MRI)-targeted , and combined MRI-targeted and systematic , prostate biopsy . MATERIAL S AND METHODS From June 2012 to August 2014 , magnetic resonance imaging to ultrasound fusion-targeted prostate biopsy was performed on 464 men with suspicious regions identified on pre-biopsy 3 T MRI along with systematic 12 core biopsy .  Logistic regression modeling was used to evaluate predictors of overall and clinical ly significant PCa , and corresponding nomograms were generated for men who were not previously biopsied or had 1 or more prior negative biopsies . Models were created with 70 % of a r and omly selected training sample and bias-corrected using bootstrap resampling . The models were then vali date d with the remaining 30 % testing sample pool . RESULTS A total of 459 patients were included for analysis ( median age 66 years , prostate-specific antigen [ PSA ] 5.2 ng/mL , prostate volume 49 cc ) . Independent predictors of PCa on targeted and systematic prostate biopsy were PSA density , age , and MRI suspicion score . PCa probability nomograms were generated for each cohort using the predictors . Bias-corrected areas under the receiver-operating characteristic curves for overall and clinical ly significant PCa detection were 0.82 ( 0.78 ) and 0.91 ( 0.84 ) for men without prior biopsy and 0.76 ( 0.65 ) and 0.86 ( 0.87 ) for men with a prior negative biopsy in the training ( testing ) sample s. CONCLUSION PSA density , age , and MRI suspicion score predict PCa on combined MRI-targeted and systematic biopsy . Our generated nomograms demonstrate high diagnostic accuracy and may further aid in the decision to perform biopsy in men with clinical suspicion of PCa BACKGROUND Prostate Imaging-Reporting and Data System v. 2 ( PI-RADSv2 ) provides st and ardized nomenclature for interpretation of prostate multiparametric MRI ( mpMRI ) . Inclusion of additional features for categorization may provide benefit to stratification of disease . PURPOSE To prospect ively compare PI-RADSv2 to a qualitative in-house system for detecting prostate cancer on mpMRI . STUDY TYPE Prospect i ve . POPULATION In all , 338 patients who underwent mpMRI May 2015-May 2016 , with subsequent MRI/transrectal ultrasound fusion-guided biopsy .  FIELD STRENGTH 3 T mpMRI ( T2 W , diffusion-weighted [ DW ] , apparent diffusion coefficient [ ADC ] map , b-2000 DWI acquisition , and dynamic contrast-enhanced [ DCE ] MRI ) . ASSESSMENT One genitourinary radiologist prospect ively read mpMRIs using both in-house and PI-RADSv2 5-category systems . STATISTICAL TEST In lesion-based analysis , overall and clinical ly significant ( CS ) tumor detection rates ( TDR ) were calculated for all PI-RADSv2 and in-house categories . The ability of each scoring system to detect cancer was assessed by area under receiver operator characteristic curve ( AUC ) . Within each PI-RADSv2 category , lesions were further stratified by their in-house categories to determine if TDRs can be increased by combining features of both systems . RESULTS In 338 patients ( median prostate-specific antigen [ PSA ] 6.5 [ 0.6 - 113.6 ] ng/mL ; age 64 [ 44 - 84 ] years ) , 733 lesions were identified ( 47 % tumor-positive ) . Predictive abilities of both systems were comparable for all ( AUC 76 - 78 % ) and CS cancers ( AUCs 79 % ) . The in-house system had higher overall and CS TDRs than PI-RADSv2 for categories 3 and 4 ( P < 0.01 for both ) , with the greatest difference between the scoring systems seen in lesions scored category 4 ( CS TDRs : in-house 65 % , PI-RADSv2 22.1 % ) . For lesions categorized as PI-RADSv2 = 4 , characterization of suspicious/indeterminate extraprostatic extension ( EPE ) and equivocal findings across all mpMRI sequences contributed to significantly different TDRs for both systems ( TDR range 19 - 75 % , P < 0.05 ) . DATA CONCLUSION PI-RADSv2 behaves similarly to an existing vali date d system that relies on the number of sequences on which a lesion is seen . This prospect i ve evaluation suggests that sequence positivity and suspicion of EPE can enhance PI-RADSv2 category 4 cancer detection . LEVEL OF EVIDENCE 1 Technical Efficacy : Stage 3 J. Magn . Reson . Imaging 2018;47:1326 - 1335 Purpose : We sought to determine whether saturation of the index lesion during magnetic resonance imaging‐transrectal ultrasound fusion guided biopsy would decrease the rate of pathological upgrading from biopsy to radical prostatectomy . Material s and Methods : We analyzed a prospect ively maintained , single institution data base for patients who underwent fusion and systematic biopsy followed by radical prostatectomy in 2010 to 2016 . Index lesion was defined as the lesion with largest diameter on T2‐weighted magnetic resonance imaging . In patients with a saturated index lesion transrectal fusion biopsy targets were obtained at 6 mm intervals along the long axis of the index lesion . In patients with a nonsaturated index lesion only 1 target was obtained from the lesion . Gleason 6 , 7 and 8‐10 were defined as low , intermediate and high risk , respectively . Results : Included in the study were 208 consecutive patients , including 86 with a saturated and 122 with a nonsaturated lesion . Median patient age was 62.0 years ( IQR 10.0 ) and median prostate specific antigen was 7.1 ng/ml ( IQR 8.0 ) .  The median number of biopsy cores per index lesion was higher in the saturated lesion group ( 4 vs 2 , p < 0.001 ) . The risk category up grade rate from systematic only , fusion only , and combined fusion and systematic biopsy results to prostatectomy was 40.9 % , 23.6 % and 13.8 % , respectively . The risk category up grade from combined fusion and systematic biopsy results was lower in the saturated than in the nonsaturated lesion group ( 7 % vs 18 % , p = 0.021 ) . There was no difference in the up grade rate based on systematic biopsy between the 2 groups . However , fusion biopsy results were significantly less up grade d in the saturated lesion group ( Gleason up grade 20.9 % vs 36.9 % , p = 0.014 and risk category up grade 14 % vs 30.3 % , p = 0.006 ) . Conclusions : Our results demonstrate that saturation of the index lesion significantly decreases the risk of upgrading on radical prostatectomy by minimizing the impact of tumor heterogeneity Purpose To vali date the dominant pulse sequence paradigm and limited role of dynamic contrast material -enhanced magnetic resonance ( MR ) imaging in the Prostate Imaging Reporting and Data System ( PI 
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EVIDENCE SYNTHESIS It has been shown that the test performance of PI-RADS v2 in research and clinical practice retains higher accuracy over systematic transrectal ultrasound ( TRUS ) biopsies for PCa diagnosis .
PI-RADS v2 fails to detect all cancers but does detect the majority of tumors capable of causing patient harm , which should not be missed .
Test performance depends on the definition and prevalence of clinical ly significant disease .
It has been shown that the test performance of PI-RADS v2 in research and clinical practice is improved , retaining higher accuracy over systematic TRUS biopsies for PCa diagnosis .
PATIENT SUMMARY Multiparametric magnetic resonance imaging ( MRI ) and MRI-directed biopsies using the Prostate Imaging-Reporting and Data System improves the detection of prostate cancers likely to cause harm , and at the same time decreases the detection of disease that does not lead to harms if left untreated .