Evaluation of selective bone scan staging in prostate cancer – external validation of current strategies and decision-curve analysis

Mrunal D. Hiwase, Alex Jay, Norma Bulamu, Johnathan Teh, Felix Paterson, Ganessan Kichenadasse, Andrew D. Vincent, Michael O’Callaghan, South Australian Prostate Cancer Clinical Outcomes Collaborative (SA-PCCOC)

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Background: Recommendations for staging newly diagnosed prostate cancer patients vary between guidelines and literature. Methods: Our objective was to validate and compare prediction models selecting newly diagnosed prostate cancer patients for bone scan staging. To achieve this, we validated eleven models in a population-based cohort of 10,721 patients diagnosed with prostate cancer between 2005 and 2019. The primary outcome was net-benefit. This was assessed at different balances of conservatism and tolerance, represented by preference ratio and number-willing-to-test (NWT). Secondary outcomes included calibration slope, calibration-in-the-large (intercept), and discrimination measured by Area-under-the-receiver-operator-characteristics curve (AUC). Results: For preference ratios less than 1:39 (NWT greater than 40), scanning everyone provided greater net-benefit than selective staging. For preference ratios 1:39 to 3:97 (NWT 33–40), the European Association of Urology (EAU) 2020 guideline recommendation was the best approach. For preference ratios 3:97–7:93 (NWT 14–33), scanning EAU high-risk patients only was preferable. For preference ratios 7:93–1:9 (NWT 10–13), scanning only Gnanapragasam Group 5 patients was best. All models had similar fair discrimination (AUCs 0.68–0.80), but most had poor calibration. Conclusions: We identified three selective staging strategies that outperformed all other approaches but did so over different ranges of conservatism and tolerance. Scanning only EAU high-risk patients provided the greatest net-benefit over the greatest range of preference ratios and scenarios, but other options may be preferable depending upon the local healthcare system’s degree of conservatism and tolerance.

Original languageEnglish
Pages (from-to)336-343
Number of pages8
Issue number2
Early online date14 Mar 2022
Publication statusPublished - Jun 2022


  • prostate cancer
  • bone scan staging
  • AUC
  • selective staging strategies


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