Keywords: Primary Care; Prostate Cancer; Early Detection; Point-of-Care Ultrasound; PSA Density; PIRADS; Risk Stratification; Multiparametric Ultrasound

Background:

Early detection of clinically significant prostate cancer in primary care is limited by the low specificity of PSA and free PSA, resulting in unnecessary referrals and biopsies. Multiparametric ultrasound (mp-US), which integrates elastography, microflow imaging, Doppler vascularity, prostate volume assessment, and PIRADS scoring, may represent a more accessible alternative to mp-MRI, supporting risk stratification and shared decision-making in general practice.

Research questions:

Does the combination of mp-US parameters with PSA, free PSA, and PSA density (PSAD) improve identification of high-risk prostate lesions in primary care, and to what extent does this approach enhance agreement between general practitioners and urologists regarding biopsy decisions?

Method:

In a cross-sectional diagnostic accuracy study, 400 men were screened in primary care; 167 men (median age 65 years) with abnormal PSA values, lower urinary tract symptoms, or suspicious mp-US findings were included. Risk stratification incorporated PIRADS score, elastography, microflow, Doppler vascularity, PSA, free PSA, prostate volume, and PSAD. Analyses comprised descriptive statistics, ANOVA across PIRADS categories, correlation analysis, multivariate logistic regression, ROC curve analysis, age-stratified risk assessment, and inter-rater agreement using Cohen’s kappa.

Results:

PSAD increased significantly across PIRADS categories (p<0.001). Hard elastographic stiffness was present in 50% of PIRADS3 lesions and in all PIRADS4–5 lesions. PSAD correlated strongly with PIRADS(r=0.62), while elastography correlated with microflow(r=0.48). Independent predictors of high-risk pathology were PIRADS 4–5 (OR, 12.5), PSAD (OR, 8.2), elastography (OR, 3.1), microflow (OR, 2.7), and Doppler vascularity (OR, 1.6). The combined model demonstrated excellent diagnostic performance (AUC 0.94; sensitivity 92%; specificity 87%). GP–urologist agreement on biopsy decisions improved from moderate(κ=0.48) to excellent(κ=0.82).

Conclusions:

Mp-US combined with PSAD enables accurate identification of high-risk prostate pathology in primary care and substantially improves interprofessional agreement. Despite being based on a single-centre sample, the results suggest good applicability and potential to optimise referral pathways and resource use in general practice.

Points for discussion:

1. Feasibility and training requirements for implementing multiparametric ultrasound in routine general practice.

2. Impact of improved GP–urologist agreement on biopsy rates, patient experience, and healthcare resource utilisation.

3. Methodological challenges of mp-US in primary care, including operator dependence and external validity.