Originally published 1/18/2014
Beyond doubt, PSA screening for prostate cancer (PCa) has saved hundreds of thousands of lives since the blood test was introduced in the mid-1990s. However, the classical screening strategy involved a pathway from a suspiciously high or rising PSA directly to conventional 12-needle (or more) TRUS biopsy. Since this, in turn, led to countless men suffering the urinary, sexual and bowel side effects of overtreatment, it is clear that the system is dysfunctional. Since 2012, there has been ongoing controversy about the merits of the PSA test.
The blog below made the case for resolving the controversy by following a suspicious PSA with multiparametric MRI (mpMRI) before proceeding to biopsy. This would filter out men who do not need a biopsy. It was good thinking in early 2014 when we posted it, and it’s still valid seven years later.
Many urologists would protest that MRI is too expensive to be used in this way. Not so, finds a Dutch study published In May, 2021. A research team calculated the cost effectiveness of a model that would incorporate mpMRI into a population-based screening strategy that starts with PSA; in this model, a suspicious PSA would be followed by mpMRI, which could then lead to an MRI-targeted biopsy if indicated. Their analytic projection took into account test sensitivity parameters for the mpMRI and MRI guided biopsy, grade misclassification rates, utility estimates, and the unit costs of different interventions.
Compared with the classical PSA pathway, their model would improve both years of life and quality of life. In adding up the probabilistic costs of the classical vs. MRI pathways, they concluded that the MRI screening pathway has “about 84% chance to be more cost-effective than the classical screening pathway.” To sum it up, not only would MRI resolve the PSA controversy described below, it would save healthcare dollars while improving patient lives.
In early October, the U.S. Preventive Services Task Force made front page news by recommending that healthy men of all ages avoid routine PSA screening for prostate cancer. After decades of raising awareness and encouraging men over 40 to have an annual blood test, both patients and their doctors now face a burning medical controversy: To screen, or not to screen?
Since the early 1990s, the death rate from prostate cancer has fallen due to PSA (Prostate Specific Antigen) testing and improved treatments. Now, several new studies have produced data suggesting that PSA screening is not worthwhile, except for cases with known risk factors. Why? These studies call into question the claim that wide screening adds a lifesaving advantage. An elevated PSA can even result in more unnecessary testing and treatments that can rob patients of continence and/or potency.
Still, many physicians and all prostate cancer advocacy groups maintain that early detection saves lives. However, there is not one universal line of prostate cancer cells. In many cases, it is slow-growing, especially among older patients, so active surveillance may be a better strategy than treatment.
Perhaps the question is not whether we measure PSA but what happens once a concerning PSA is found. Currently a patient is moved quickly into a conventional transrectal ultrasound-guided (TRUS) biopsy. As I see it, there are three problems with recommending a biopsy on the heels of an elevated PSA:
- The elevation may be due to something else besides cancer, so rushing to biopsy is costly and raises anxiety.all for nothing.
- The conventional TRUS biopsy.which obtains 10-14 core tissue samples.may result in false negatives or false positives, since ultrasound guidance alone lacks sufficient fidelity to locate small tumors and target biopsy needles into them.
- Without sophisticated analysis of cancer cells (if found) to distinguish the slow-growing from the aggressive, a radical (whole gland) treatment may be overkill, with damaging side effects.
At the Sperling Prostate Center we offer an alternative that takes the guesswork out of an elevated PSA: a highly accurate MRI imaging process that provides high diagnostic confidence with minimum invasiveness. In other words, let’s stop the either/or debate (to screen or not to screen) and instead ask how we can confirm if biopsy is necessary, and how to reduce the number of biopsy needles if it is.
Furthermore, if a tissue sample is positive for prostate cancer, let’s analyze it with the most sophisticated tools so we know whether to recommend active surveillance vs. treatment. Finally, having accomplished those goals, if treatment is warranted let’s tailor it in terms of disease and lifestyle, to achieve the highest degree of cancer destruction while retaining the highest quality of life.
Our medical team at Sperling Prostate Center is trained in state-of-the-art outpatient, targeted tumor ablation (destruction) using minimal-to-noninvasive MRI-guided technologies. Depending on the size and location of a tumor that requires treatment, the ability to target the disease can spare both continence and potency while keeping all future options open should cancer recur. By clearly visualizing potential problems and selectively targeting the biopsy into those areas, we affirm the value of early detection followed by individualized, lifestyle-sparing treatments. End of controversy.