Novel pathways in the diagnosis of prostate cancer

Whilst prostate cancer is among the leading causes of cancer-related death in men, the majority of prostate cancer is indolent and unlikely to progress to biological significance in the absence of treatment. This complexity has resulted in the development of new diagnostic tools specifically aiming at clinically significant prostate cancer as the standard diagnostic pathway with systematic biopsies results in overdiagnosis and overtreatment of insignificant prostate cancer. Especially, risk-based patient selection and improved prostate cancer imaging capabilities with multiparametric magnetic resonance imaging have initiated a transition towards risk-stratified and imaging-focused pathways in the diagnosis of prostate cancer. This thesis describes this transition and the clinical studies in the first two parts of the thesis have analyzed diagnostic yields, overdiagnosis rates, and the number of biopsies of (risk-stratified) imaging-focused and (risk-stratified) biopsy-focused pathways, to determine whether their default use is justified. The third and last part of this thesis demonstrates a new multiparametric framework for ultrasound imaging in the diagnosis of prostate cancer. Multiparametric ultrasound, whether or not combined with computer-aided algorithms to facilitate interpretation, shows potential as an accessible novel imaging tool in the diagnosis of prostate cancer. In the future more individualized risk-stratified diagnostic pathways should be investigated that will hopefully allow us to walk a patient from elevated prostate-specific antigen, to confirmatory testing, to imaging and biopsy.