Is Likert better than PI-RADS at predicting prostate cancer on MRI and can a mathematical algorithm achieve similar results?

BACKGROUND: Prostate Imaging Reporting & Data System (PI-RADS) is an internationally recognized system to quantify risk of prostate cancer on magnetic resonance imaging (MRI). However, studies have suggested methods to improve predictive accuracy. PURPOSE: To assess two different methods that aim to improve the accuracy of PI-RADS scores: a subjective Likert score given by experienced reporters, and an objective Calculated Adjustment of PI-RADS Equivocal Score (CAPES). MATERIAL AND METHODS: Five experienced reporters in a quaternary referral unit used a standardized reporting template to prospectively collect PI-RADS and Likert scores for 1467 multiparametric MRI (mpMRI) scans between January 2021 and June 2022. Histology results were recorded for patients who underwent trans-perineal biopsy. The CAPES tool was retrospectively applied to the cases scoring PI-RADS 3. A theoretical standardized biopsy protocol (assuming all patients scoring ≥3 were referred for biopsy) was used to compare the three scoring systems for sensitivity, specificity, and positive predictive value (PPV). RESULTS: Across all reporters, significantly fewer equivocal "3" scores were given using Likert (15.7%) or CAPES (2.2%) compared to PI-RADS (24.1%). Assuming a protocol where all patients scoring ≥3 were biopsied, Likert had a higher specificity (69.0% vs. 54.4%), sensitivity (98.3% vs. 97.7%), and PPV (49.9% vs. 40.3%) than PI-RADS for identifying ISUP ≥2 cancer. The CAPES tool had an even higher specificity (81.4%) and PPV (61.2%) with only a slightly lower sensitivity (93.4%) resulting in 37.1% (n = 316) fewer biopsies than PI-RADS, and 22.4% (n = 155) fewer biopsies than Likert across 1467 patients. CONCLUSIONS: Compared to PI-RADS scoring, Likert scoring or CAPES can result in fewer equivocal scores, greater PPV, and fewer unnecessary biopsies.