General introduction and thesis outline 13 advances in preventing over-detection and reducing over-treatment by implementing active surveillance strategies in patients with low-risk prostate cancer.19,25,26 Historically, physical examination in the form of digital rectal examination (DRE) was the most important tool clinicians had to diagnose prostate cancer. Still, current guidelines suggest performing DRE to establish the clinical tumour stage (T-stage).27,28 Four main prostate cancer Tstages are distinguished (Figure 2).27 Nowadays, diagnostic imaging plays an important role in the diagnosis and accurate staging of prostate cancer.29 The last years, diagnostic imaging has vastly improved with the introduction of multiparametric magnetic resonance imaging (mp-MRI) and prostate-specific membrane antigen (PSMA) positron emission tomography (PET) computed tomography (CT) imaging (PSMA-PET/CT). mp-MRI has emerged as an important diagnostic tool in early diagnosis of clinically significant prostate cancer by facilitating targeted prostate biopsies.30 Pre-biopsy use of MRI can reduce the number of unnecessary biopsies, minimise over-diagnosis of clinically insignificant prostate cancer, and improve risk stratification of patients, warranted that high-quality MRI scans are used and radiologists are adequately trained to deliver reliable reports.31,32 Whereas PSMA-PET/CT is already widely applied in case of (suspected) recurrent prostate cancer, its role in primary prostate cancer diagnosis and risk classification is still partly undetermined. Further research is required and currently underway, but there may be a role for PSMA-PET/CT in characterising tumour biology, complementing mp-MRI diagnostics, and identifying lymph node metastases in high-risk prostate cancer patients.33,34 Figure 2 – Four main prostate cancer tumour stages. 1
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