The FUTURE Trial: A Multicenter Randomised Controlled Trial on Target Biopsy Techniques Based on Magnetic Resonance Imaging in the Diagnosis of Prostate Cancer in Patients with Prior Negative Biopsies

Background: Guidelines advise multiparametric magnetic resonance imaging (mpMRI) before repeat biopsy in patients with negative systematic biopsy (SB) and a suspicion of prostate cancer (PCa), enabling MRI targeted biopsy (TB). No consensus exists regarding which of the three available techniques of TB should be preferred. Objective: To compare detection rates of overall PCa and clinically significant PCa (csPCa) for the three MRI-based TB techniques. Design, setting, and participants: Multicenter randomised controlled trial, including 665 men with prior negative SB and a persistent suspicion of PCa, conducted between 2014 and 2017 in two nonacademic teaching hospitals and an academic hospital. Intervention: All patients underwent 3-T mpMRI evaluated with Prostate Imaging Reporting and Data System (PIRADS) version 2. If imaging demonstrated PIRADS ≥3 lesions, patients were randomised 1:1:1 for one TB technique: MRI-transrectal ultrasound (TRUS) fusion TB (FUS-TB), cognitive registration TRUS TB (COG-TB), or in-bore MRI TB (MRI-TB). Outcome measurements and statistical analysis: Primary (overall PCa detection) and secondary (csPCa detection [Gleason score ≥3 + 4]) outcomes were compared using Pearson chi-square test. Results and limitations: On mpMRI, 234/665 (35%) patients had PIRADS ≥3 lesions and underwent TB. There were no significant differences in the detection rates of overall PCa (FUS-TB 49%, COG-TB 44%, MRI-TB 55%, p = 0.4). PCa detection rate differences were −5% between FUS-TB and MRI-TB (p = 0.5, 95% confidence interval [CI] −21% to 11%), 6% between FUS-TB and COG-TB (p = 0.5, 95% CI −10% to 21%), and −11% between COG-TB and MRI-TB (p = 0.17, 95% CI −26% to 5%). There were no significant differences in the detection rates of csPCa (FUS-TB 34%, COG-TB 33%, MRI-TB 33%, p > 0.9). Differences in csPCa detection rates were 2% between FUS-TB and MRI-TB (p = 0.8, 95% CI −13% to 16%), 1% between FUS-TB and COG-TB (p > 0.9, 95% CI −14% to 16%), and 1% between COG-TB and MRI-TB (p > 0.9, 95% CI −14% to 16%). The main study limitation was a low rate of PIRADS ≥3 lesions on mpMRI, causing underpowering for primary outcome. Conclusions: We found no significant differences in the detection rates of (cs)PCa among the three MRI-based TB techniques. Patient summary: In this study, we compared the detection rates of (aggressive) prostate cancer among men with prior negative biopsies and a persistent suspicion of cancer using three different techniques of targeted biopsy based on magnetic resonance imaging. We found no significant differences in the detection rates of (aggressive) prostate cancer among the three techniques. In a repeat biopsy setting, multiparametric magnetic resonance imaging (mpMRI)-based targeted biopsy has a high detection rate of (clinically significant) prostate cancer. There were no significant differences in the detection rates of (clinically significant) prostate cancer among three techniques of mpMRI-based targeted biopsy.