“I can’t get no satisfaction,” declared Mick Jagger and the Rolling Stones, having recorded their original song in 1965. As I see it, satisfaction is one of those human experiences that must be earned. Whether the occasion is small or momentous, we get the same feeling of achievement and completion. When we strive to accomplish a challenging task, when we stand up to injustice and come out on top, when the new recipe comes out perfectly—the sense of satisfaction is its own reward. Sometimes, it can take years of trial and error accompanied by persistence and conviction to get our hoped-for results. When they emerge, it’s gotta be darn satisfying!

This is what I imagine the authors of a Sep. 2024 paper in the New England Journal of Medicine (NEJM) must have felt after demonstrating the value of adding MRI into the screening pathway for prostate cancer (PCa). And when I say value, I mean both the clinical value to patients, and the healthcare dollars saved when biopsies and over-treatment can be avoided.

The Study: Combining PSA and MRI Screening

The study out of Europe is titled “Results after Four Years of Screening for Prostate Cancer with PSA and MRI” by Hugosson, et al.^[i] It reports results of a trial that began in 2015 involving over 6500 men who participated in PSA screening. We know that PSA alone is not an accurate method for detecting PCa because other conditions can cause a rise in PSA. Due to this situation, doctors err to the side of caution and send men who have a suspicious PSA result for a prostate biopsy.

In turn, conventional TRUS-guided systematic biopsies are not always the best medical expense. If a man’s biopsy is negative for PCa, it can still cause side effects like infection that require treatment. On the other hand, if it’s positive, it comes with a dual margin of error: conventional biopsy tends to overdetect insignificant PCa (grade group 1) and underdetect significant PCa (grade group 2 and above). This means that many men with grade group 1 undergo surgery or radiation, with their risks of side effects (more expense!) and diminished quality of life—when perhaps they were candidates for holding off on treatment and maybe end up never needing it.

Therefore, the study investigators set out to test whether adding MRI to PSA screening before biopsy would help correct the patients’ harms and added expense of unnecessary biopsies (and by implication, better use of Active Surveillance and/or less aggressive treatments).

How the Trial Worked

To conduct the trial, any participant whose PSA was 3.0 or higher was followed by MRI of the prostate. They were then randomly assigned to either Group A, having a conventional systematic biopsy (plus a targeted biopsy if their imaging revealed a suspicious lesion), or to Group B, having an MRI-targeted biopsy only if a suspicious lesion was seen on imaging. Keep in mind that prostate MRI selects for significant PCa, which shows up with high accuracy, while insignificant PCa is unlikely to show up.

Not surprisingly, then, the systematic-plus-targeted biopsy method was much more likely to diagnose insignificant PCa as well as significant PCa, while the MRI-targeted biopsy population had a lower rate of diagnosing insignificant PCa but a higher rate of diagnosing significant PCa. The authors concluded, “In this trial, omitting biopsy in patients with negative MRI results eliminated more than half of diagnoses of clinically insignificant prostate cancer…”

The Big Question

At the heart of the study was a big 2-part question: After an abnormal or suspicious PSA, is there a way before rushing into a biopsy to tell if a) significant PCa is present, and b) if not, can we safely hold off on a biopsy to avoid procedural risks and conserve healthcare dollars? According to the results of this study, the answer to both parts of the question is YES, thanks to MRI.

I can only imagine how satisfying it was for the study authors to find that their data supported their work to show how adding MRI to PSA screening is in the best interests of all concerned. They have earned the right to pat themselves on the back. In fact, many European urology/radiology centers are leading the way in implementing this new pathway. As they continue to contribute to published data, I hope the U.S. will soon follow suit.

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

References

[i] Hugosson J, Godtman RA, Wallstrom J, Axcrona U et al. Results after Four Years of Screening for Prostate Cancer with PSA and MRI. N Engl J Med. 2024 Sep 26;391(12):1083-1095.