NCCN Guidelines® Insights: Prostate Cancer Early Detection, Version 1.2023

Featured Updates to the NCCN Guidelines

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Kelvin A. MosesVanderbilt-Ingram Cancer Center

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Preston C. SprenkleYale Cancer Center/Smilow Cancer Hospital

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Clinton BahlerIndiana University Melvin and Bren Simon Comprehensive Cancer Center

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Geoffrey BoxThe Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute

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Sigrid V. CarlssonMemorial Sloan Kettering Cancer Center

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William J. CatalonaRobert H. Lurie Comprehensive Cancer Center of Northwestern University

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Douglas M. DahlMassachusetts General Hospital Cancer Center

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Marc Dall’EraUC Davis Comprehensive Cancer Center

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John W. DavisThe University of Texas MD Anderson Cancer Center

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Bettina F. DrakeSiteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine

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Jonathan I. EpsteinThe Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins

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Ruth B. EtzioniFred Hutchinson Cancer Center

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Thomas A. FarringtonProstate Health Education Network

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Isla P. GarrawayUCLA Jonsson Comprehensive Cancer Center

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David JarrardUniversity of Wisconsin Carbone Cancer Center

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Eric KauffmanRoswell Park Comprehensive Cancer Center

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Deborah KayeDuke Cancer Institute

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Adam S. KibelDana-Farber/Brigham and Women’s Cancer Center

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Chad A. LaGrangeFred & Pamela Buffett Cancer Center

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Paul MaroniUniversity of Colorado Cancer Center

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Lee PonskyCase Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute

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Brian ReysUT Southwestern Simmons Comprehensive Cancer Center

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Simpa S. SalamiUniversity of Michigan Rogel Cancer Center

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Alejandro SanchezHuntsman Cancer Institute at the University of Utah

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Tyler M. SeibertUC San Diego Moores Cancer Center

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Terrence M. ShaneyfeltO’Neal Comprehensive Cancer Center at UAB

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Marc C. SmaldoneFox Chase Cancer Center

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Geoffrey SonnStanford Cancer Institute

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Mark D. TysonMayo Clinic Cancer Center

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Neha VapiwalaAbramson Cancer Center at the University of Pennsylvania

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Robert WakeSt. Jude Children’s Research Hospital/The University of Tennessee Health Science Center

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Samuel WashingtonUCSF Helen Diller Family Comprehensive Cancer Center

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Alice YuMoffitt Cancer Center

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Bertram YuhCity of Hope National Medical Center

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Ryan A. BerardiNational Comprehensive Cancer Network

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Deborah A. Freedman-CassNational Comprehensive Cancer Network

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The NCCN Guidelines for Prostate Cancer Early Detection provide recommendations for individuals with a prostate who opt to participate in an early detection program after receiving the appropriate counseling on the pros and cons. These NCCN Guidelines Insights provide a summary of recent updates to the NCCN Guidelines with regard to the testing protocol, use of multiparametric MRI, and management of negative biopsy results to optimize the detection of clinically significant prostate cancer and minimize the detection of indolent disease.

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  • 1.

    Gosselaar C, Roobol MJ, Roemeling S, et al. The role of the digital rectal examination in subsequent screening visits in the European randomized study of screening for prostate cancer (ERSPC), Rotterdam. Eur Urol 2008;54:581588.

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  • 2.

    Halpern JA, Oromendia C, Shoag JE, et al. Use of digital rectal examination as an adjunct to prostate specific antigen in the detection of clinically significant prostate cancer. J Urol 2018;199:947953.

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  • 3.

    Gosselaar C, Roobol MJ, Roemeling S, et al. Screening for prostate cancer at low PSA range: the impact of digital rectal examination on tumor incidence and tumor characteristics. Prostate 2007;67:154161.

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  • 4.

    Catalona WJ, Richie JP, Ahmann FR, et al. Comparison of digital rectal examination and serum prostate specific antigen in the early detection of prostate cancer: results of a multicenter clinical trial of 6,630 men. J Urol 1994;151:12831290.

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  • 5.

    Catalona WJ, Smith DS, Ratliff TL, et al. Detection of organ-confined prostate cancer is increased through prostate-specific antigen-based screening. JAMA 1993;270:948954.

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  • 6.

    Catalona WJ, Richie JP, Ahmann FR, et al. Comparison of digital rectal examination and serum prostate specific antigen in the early detection of prostate cancer: results of a multicenter clinical trial of 6,630 men. J Urol 2017;197(Suppl 2):S200207.

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  • 7.

    Flanigan RC, Catalona WJ, Richie JP, et al. Accuracy of digital rectal examination and transrectal ultrasonography in localizing prostate cancer. J Urol 1994;152:15061509.

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  • 8.

    Schröder FH, van der Maas P, Beemsterboer P, et al. Evaluation of the digital rectal examination as a screening test for prostate cancer. J Natl Cancer Inst 1998;90:18171823.

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  • 9.

    Halpern JA, Shoag JE, Mittal S, et al. Prognostic significance of digital rectal examination and prostate specific antigen in the prostate, lung, colorectal and ovarian (PLCO) cancer screening arm. J Urol 2017;197:363368.

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  • 10.

    Okotie OT, Roehl KA, Han M, et al. Characteristics of prostate cancer detected by digital rectal examination only. Urology 2007;70:11171120.

  • 11.

    Mahal BA, Aizer AA, Efstathiou JA, et al. Association of very low prostate-specific antigen levels with increased cancer-specific death in men with high-grade prostate cancer. Cancer 2016;122:7883.

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  • 12.

    Falchook AD, Martin NE, Basak R, et al. Stage at presentation and survival outcomes of patients with Gleason 8–10 prostate cancer and low prostate-specific antigen. Urol Oncol 2016;34:119.e1926.

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  • 13.

    Hugosson J, Carlsson S, Aus G, et al. Mortality results from the Göteborg randomised population-based prostate-cancer screening trial. Lancet Oncol 2010;11:725732.

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  • 14.

    Andriole GL, Crawford ED, Grubb RL III, et al. Prostate cancer screening in the randomized Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial: mortality results after 13 years of follow-up. J Natl Cancer Inst 2012;104:125132.

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  • 15.

    Schröder FH, Hugosson J, Roobol MJ, et al. Screening and prostate- cancer mortality in a randomized European study. N Engl J Med 2009;360:13201328.

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  • 16.

    Schaeffer EM, Carter HB, Kettermann A, et al. Prostate specific antigen testing among the elderly—when to stop? J Urol 2009;181:16061614.

  • 17.

    Sun L, Caire AA, Robertson CN, et al. Men older than 70 years have higher risk prostate cancer and poorer survival in the early and late prostate specific antigen eras. J Urol 2009;182:22422248.

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  • 18.

    Bechis SK, Carroll PR, Cooperberg MR. Impact of age at diagnosis on prostate cancer treatment and survival. J Clin Oncol 2011;29:235241.

  • 19.

    Clark R, Vesprini D, Narod SA. The effect of age on prostate cancer survival. Cancers 2022;14:4149.

  • 20.

    Scosyrev E, Messing EM, Mohile S, et al. Prostate cancer in the elderly: frequency of advanced disease at presentation and disease-specific mortality. Cancer 2012;118:30623070.

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  • 21.

    Pettersson A, Robinson D, Garmo H, et al. Age at diagnosis and prostate cancer treatment and prognosis: a population-based cohort study. Ann Oncol 2018;29:377385.

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  • 22.

    Roobol MJ, Roobol DW, Schröder FH. Is additional testing necessary in men with prostate-specific antigen levels of 1.0 ng/mL or less in a population-based screening setting? (ERSPC, section Rotterdam). Urology 2005;65:343346.

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  • 23.

    Vickers AJ, Cronin AM, Björk T, et al. Prostate specific antigen concentration at age 60 and death or metastasis from prostate cancer: case-control study. BMJ 2010;341:c4521.

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  • 24.

    Vertosick EA, Häggström C, Sjoberg DD, et al. Prespecified 4-kallikrein marker model at age 50 or 60 for early detection of lethal prostate cancer in a large population based cohort of asymptomatic men followed for 20 years. J Urol 2020;204:281288.

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  • 25.

    Vickers AJ, Ulmert D, Sjoberg DD, et al. Strategy for detection of prostate cancer based on relation between prostate specific antigen at age 40-55 and long term risk of metastasis: case-control study. BMJ 2013;346:f2023.

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  • 26.

    Preston MA, Batista JL, Wilson KM, et al. Baseline prostate-specific antigen levels in midlife predict lethal prostate cancer. J Clin Oncol 2016;34:27052711.

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  • 27.

    Preston MA, Gerke T, Carlsson SV, et al. Baseline prostate-specific antigen level in midlife and aggressive prostate cancer in black men. Eur Urol 2019;75:399407.

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  • 28.

    Kovac E, Carlsson SV, Lilja H, et al. Association of baseline prostate- specific antigen level with long-term diagnosis of clinically significant prostate cancer among patients aged 55 to 60 years: a secondary analysis of a cohort in the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial. JAMA Netw Open 2020;3:e1919284.

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  • 29.

    Ulmert D, Cronin AM, Björk T, et al. Prostate-specific antigen at or before age 50 as a predictor of advanced prostate cancer diagnosed up to 25 years later: a case-control study. BMC Med 2008;6:6.

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  • 30.

    Carlsson S, Assel M, Sjoberg D, et al. Influence of blood prostate specific antigen levels at age 60 on benefits and harms of prostate cancer screening: population based cohort study. BMJ 2014;348:g2296.

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  • 31.

    Heijnsdijk EAM, Gulati R, Tsodikov A, et al. Lifetime benefits and harms of prostate-specific antigen-based risk-stratified screening for prostate cancer. J Natl Cancer Inst 2020;112:10131020.

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  • 32.

    Lillard JW Jr, Moses KA, Mahal BA, et al. Racial disparities in Black men with prostate cancer: a literature review. Cancer 2022;128:37873795.

  • 33.

    Wang M, Chi G, Bodovski Y, et al. Temporal and spatial trends and determinants of aggressive prostate cancer among Black and White men with prostate cancer. Cancer Causes Control 2020;31:6371.

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  • 34.

    Mahal BA, Berman RA, Taplin ME, et al. Prostate cancer-specific mortality across Gleason scores in Black vs nonblack men. JAMA 2018;320:24792481.

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  • 35.

    Tsodikov A, Gulati R, de Carvalho TM, et al. Is prostate cancer different in black men? Answers from 3 natural history models. Cancer 2017;123:23122319.

  • 36.

    Nyame YA, Gulati R, Heijnsdijk EA, et al. The impact of intensifying prostate cancer screening in Black men: a model-based analysis. J Natl Cancer Inst 2021;113:13361342.

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  • 37.

    Kasivisvanathan V, Rannikko AS, Borghi M, et al. MRI-targeted or standard biopsy for prostate-cancer diagnosis. N Engl J Med 2018;378:17671777.

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  • 38.

    Rouvière O, Puech P, Renard-Penna R, et al. Use of prostate systematic and targeted biopsy on the basis of multiparametric MRI in biopsy-naive patients (MRI-FIRST): a prospective, multicentre, paired diagnostic study. Lancet Oncol 2019;20:100109.

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  • 39.

    van der Leest M, Cornel E, Israël B, et al. Head-to-head comparison of transrectal ultrasound-guided prostate biopsy versus multiparametric prostate resonance imaging with subsequent magnetic resonance-guided biopsy in biopsy-naïve men with elevated prostate-specific antigen: a large prospective multicenter clinical study. Eur Urol 2019;75:570578.

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  • 40.

    Klotz L, Chin J, Black PC, et al. Comparison of multiparametric magnetic resonance imaging-targeted biopsy with systematic transrectal ultrasonography biopsy for biopsy-naive men at risk for prostate cancer: a phase 3 randomized clinical trial. JAMA Oncol 2021;7:534542.

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  • 41.

    Sathianathen NJ, Omer A, Harriss E, et al. Negative predictive value of multiparametric magnetic resonance imaging in the detection of clinically significant prostate cancer in the prostate imaging reporting and data system era: a systematic review and meta-analysis. Eur Urol 2020;78:402414.

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  • 42.

    Lo G, Burton KR, Haider MA, et al. Negative predictive value of prostate multiparametric magnetic resonance imaging among men with negative prostate biopsy and elevated prostate specific antigen: a clinical outcome retrospective cohort study. J Urol 2019;202:11591165.

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  • 43.

    Richenberg J, Løgager V, Panebianco V, et al. The primacy of multiparametric MRI in men with suspected prostate cancer. Eur Radiol 2019;29:69406952.

  • 44.

    Boesen L, Nørgaard N, Løgager V, et al. Clinical outcome following low suspicion multiparametric prostate magnetic resonance imaging or benign magnetic resonance imaging guided biopsy to detect prostate cancer. J Urol 2017;198:310315.

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  • 45.

    Hansen NL, Barrett T, Kesch C, et al. Multicentre evaluation of magnetic resonance imaging supported transperineal prostate biopsy in biopsy-naïve men with suspicion of prostate cancer. BJU Int 2018;122:4049.

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  • 46.

    Lu AJ, Syed JS, Nguyen KA, et al. Negative multiparametric magnetic resonance imaging of the prostate predicts absence of clinically significant prostate cancer on 12-core template prostate biopsy. Urology 2017;105:118122.

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  • 47.

    Simmons LA, Kanthabalan A, Arya M, et al. The PICTURE study: diagnostic accuracy of multiparametric MRI in men requiring a repeat prostate biopsy. Br J Cancer 2017;116:11591165.

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  • 48.

    van Leeuwen PJ, Hayen A, Thompson JE, et al. A multiparametric magnetic resonance imaging-based risk model to determine the risk of significant prostate cancer prior to biopsy. BJU Int 2017;120:774781.

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  • 49.

    Borofsky S, George AK, Gaur S, et al. What are we missing? False- negative cancers at multiparametric MR imaging of the prostate. Radiology 2018;286:186195.

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  • 50.

    Pagniez MA, Kasivisvanathan V, Puech P, et al. Predictive factors of missed clinically significant prostate cancers in men with negative magnetic resonance imaging: a systematic review and meta-analysis. J Urol 2020;204:2432.

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  • 51.

    Westphalen AC, McCulloch CE, Anaokar JM, et al. Variability of the positive predictive value of PI-RADS for prostate MRI across 26 centers: experience of the society of abdominal radiology prostate cancer disease-focused panel. Radiology 2020;296:7684.

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  • 52.

    Rosenkrantz AB, Ginocchio LA, Cornfeld D, et al. Interobserver reproducibility of the PI-RADS version 2 lexicon: a multicenter study of six experienced prostate radiologists. Radiology 2016;280:793804.

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  • 53.

    Sonn GA, Fan RE, Ghanouni P, et al. Prostate magnetic resonance imaging interpretation varies substantially across radiologists. Eur Urol Focus. Published online December 7, 2017. doi:j.euf.2017.11.010

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  • 54.

    Bostwick DG, Cheng L. Precursors of prostate cancer. Histopathology 2012;60:427.

  • 55.

    Ericson KJ, Wenger HC, Rosen AM, et al. Prostate cancer detection following diagnosis of atypical small acinar proliferation. Can J Urol 2017;24:87148720.

  • 56.

    Dorin RP, Wiener S, Harris CD, et al. Prostate atypia: does repeat biopsy detect clinically significant prostate cancer? Prostate 2015;75:673678.

  • 57.

    Wiener S, Haddock P, Cusano J, et al. Incidence of clinically significant prostate cancer after a diagnosis of atypical small acinar proliferation, high-grade prostatic intraepithelial neoplasia, or benign tissue. Urology 2017;110:161165.

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  • 58.

    Taneja SS, Morton R, Barnette G, et al. Prostate cancer diagnosis among men with isolated high-grade intraepithelial neoplasia enrolled onto a 3-year prospective phase III clinical trial of oral toremifene. J Clin Oncol 2013;31:523529.

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  • 59.

    Leone A, Rotker K, Butler C, et al. Atypical small acinar proliferation: repeat biopsy and detection of high grade prostate cancer. Prostate Cancer 2015;2015:810159.

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  • 60.

    Ynalvez LA, Kosarek CD, Kerr PS, et al. Atypical small acinar proliferation at index prostate biopsy: rethinking the re-biopsy paradigm. Int Urol Nephrol 2018;50:16.

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  • 61.

    Kawa SM, Stroomberg HV, Larsen SB, et al. A nationwide analysis of risk of prostate cancer diagnosis and mortality following an initial negative transrectal ultrasound biopsy with long-term followup. J Urol 2022;208:100108.

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  • 62.

    Morote J, Schwartzmann I, Celma A, et al. The current recommendation for the management of isolated high-grade prostatic intraepithelial neoplasia. BJU Int 2022;129:627633.

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  • 63.

    Grivas N, Lardas M, Espinós EL, et al. Prostate cancer detection percentages of repeat biopsy in patients with positive multiparametric magnetic resonance imaging (Prostate Imaging Reporting and Data System/Likert 3-5) and negative initial biopsy. A mini systematic review. Eur Urol 2022;82:452457.

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  • 64.

    Kotb AF, Spaner S, Crump T, et al. The role of mpMRI and PSA density in patients with an initial negative prostatic biopsy. World J Urol 2018;36:20212025.

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