Sperling Prostate Center

Dodging a Bullet: MRI Before Biopsy

Some men will do just about anything to avoid seeing a doctor until a symptom like pain or bleeding suddenly freaks them out. If you’re one of them, you may be contributing to a shorter life. Many cancers, including prostate cancer (PCa), have no early symptoms, yet that’s when they can still be cured. Failing to screen for PCa may be like signing an eventual death warrant.

Women outlive men on average by 5-10 years. One reason is regular health monitoring. More women than men have annual check-ups and screening tests to rule out silent killers. For men, one such screening tool is the PSA blood test. Granted, it’s not perfect. However, men who neglect an annual doctor visit are also likely to skip a PSA blood draw—even though you don’t even need to see a doctor because many local, regional and annual events offer free PSA tests.

Here’s a simple quiz. Which of these excuses is a valid reason for not having an annual PSA test?
a) I’m too busy and don’t have time.
b) There’s no history of PCa in my family, so why bother?
c) I keep meaning to but I forget.
d) I heard it leads to painful tests and risky treatments.

What did you pick? I hate to say it, but if you chose a, b, or c you are living in denial. On the other hand, if you chose d, you’re partly right. Up until very recently, a million men per year whose PSA test was suspiciously high were rushed into a dreaded needle biopsy.

Why the rush? Well, the blood test alone is not 100% reliable, but no responsible doctor can sleep at night believing that one of his patients might have cancer growing in his prostate because the doctor didn’t test further. After all, there was no other confident way to know what the PSA result meant.

And why the dread? Let’s face it. A biopsy gun shooting 12 or more blind needles into a walnut size gland can be painful, with risks of infection, bleeding, and sexual dysfunction. Even if a numbing agent is injected beforehand to eliminate pain, the risks are still there.

Worse yet, not only is the PSA blood test not specific for cancer, the biopsy itself is inaccurate at least 30% of the time. If it misses hitting a tumor—which it tends to do in certain areas of the gland—you’re likely to have at least one future repeat biopsy, which may also miss the tumor again in the same area. Or, if the biopsy results turn out to be positive for a low-risk cancer that doesn’t require immediate treatment and may NEVER become dangerous, your biopsy wasn’t even necessary to begin with! So, if there’s no biopsy, you’ve dodged a bullet that either hits the wrong target, or misses it altogether. But here’s the catch: Without a PSA test you may be that 1 man out of 8 who has a time bomb ticking in your body and doesn’t know it.

A new way to dodge the biopsy bullet

Thankfully, there’s a new example of a way to preserve PSA screening without rushing to a standard 12-core biopsy. Since January 29, 2020, Dutch men have no reason to skip a PSA test because they don’t want a doctor saying, “Get an immediate biopsy.” Our Netherlands radiology colleagues at Radboud Medical Center and a handful of other Dutch centers succeeded in changing the standard diagnostic guidelines of the Dutch Association of Urology (NVU).

The new national guidelines mandate a noninvasive, painless MRI scan to be done in response to an elevated PSA value. According to Radboud’s patient newsletter of Feb. 3, 2020: Prostate MRIs will now be required for men in whom prostate cancer is suspected (e.g. due to elevated PSA values). These guidelines replace the current method, in which a prostate biopsy (with 12 tissue samples) is performed following an elevated PSA value. If a scan does not reveal any abnormalities, the patient can be sent home with confidence, and without tissue samples. If the scan is abnormal, a [MRI-guided targeted] biopsy can be performed, but with 3 needles instead of 12.

The benefits of these guidelines really add up! Each year in The Netherlands, 40,000 men have elevated PSA results. The new guidelines spare 57% of them from biopsies because their MRI scans don’t reveal significant PCa. In turn, 6,400 fewer men are over-diagnosed and over treated. With in-bore MRI guided targeted biopsies for those whose MRI reveals areas that appear cancerous, only 51,600 tissue samples are taken using 3 needles, instead of 480,000 samples using 12 or more needles. As for biopsy risks, only 52 men will experience complications instead of 1200 men who undergo conventional blind biopsies.

As if sparing men weren’t enough, there are bank accounts and tax dollars that are also spared. As measured in Euro dollars, following the MRI-before-biopsy guideline is calculated to save €375 per patient, or a national savings of €15 000 000 annually for the Dutch economy.

To sum it up, leading Dutch radiologist Jelle Barentsz states, “Technological advances are enabling us to discover prostate cancer make care better, faster and more targeted. At the same time, we can reduce pointless and unnecessarily risky treatments and save money.”

Therefore, be sure you participate in annual PSA screening—and if by chance your result is higher than normal, contact The Sperling Prostate Center to discuss an MRI before biopsy.

NOTE: This content is solely for purposes of information and does not substitute for diagnostic or medical advice. Talk to your doctor if you are experiencing pelvic pain, or have any other health concerns or questions of a personal medical nature.

About Dr. Dan Sperling

Dan Sperling, MD, DABR, is a board certified radiologist who is globally recognized as a leader in multiparametric MRI for the detection and diagnosis of a range of disease conditions. As Medical Director of the Sperling Prostate Center, Sperling Medical Group and Sperling Neurosurgery Associates, he and his team are on the leading edge of significant change in medical practice. He is the co-author of the new patient book Redefining Prostate Cancer, and is a contributing author on over 25 published studies. For more information, contact the Sperling Prostate Center.

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