Comparing conventional, peripheral, and transition zone prostate-specific antigen densities for the detection of clinically significant prostate cancer.

[AIM] Compare the diagnostic performance of whole-gland prostate-specific antigen density (wgPSAD) to zonal volume-adjusted prostate-specific antigen density (PSAD) for predicting prostate cancer in patients who underwent a prostate magnetic resonance imaging (MRI) followed by prostate biopsy.

[MATERIALS AND METHODS] A retrospective study of consecutive patients who underwent prostate MRI followed by systematic biopsy with or without targeted biopsy between January 2019 and December 2020 was performed. Whole-gland (wgPSAD), transition-zone prostate-specific antigen density (tzPSAD), and peripheral-zone prostate-specific antigen density (pzPSAD) were calculated using prostate-specific antigen (PSA) levels drawn before imaging, and volume estimates were derived from MRI using artificial intelligence (AI) software assistance. Diagnostic performance was assessed using logistic regression and estimating internally validated receiver operating characteristic area under the characteristic (AUC) curves.

[RESULTS] A total of 551 patients with a median age of 66 years (interquartile range [IQR]: 61-72) were included. The univariable analysis demonstrated superior AUC for wgPSAD (AUC: 0.71 and 0.71) and tzPSAD (AUC: 0.72 and 0.72) compared to pzPSAD (AUC: 0.51 and 0.56) for any cancer and clinically significant prostate cancer (csPCa). The multivariable analysis including age and 5α-reductase inhibitor therapy demonstrated a superior AUC of tzPSAD for predicting csPCa (AUC: 0.77 vs 0.75; P=0.02) compared to both wgPSAD and pzPSAD (AUC: 0.77 vs 0.67; P<0.001). Variable importance analysis suggested prescribed 5α-reductase inhibitor therapy may be protective against csPCa.

[CONCLUSION] wgPSAD and tzPSAD are superior to pzPSAD for the detection of csPCa. When accounting for key covariates, tzPSAD may be superior to wgPSAD.