There are cancers you can personally detect before symptoms appear, and cancers that are hidden until you experience signs that something’s wrong.  

• Obvious cancers you can detect include skin cancers (e.g. change in a mole, sore that doesn’t heal) and lumps you can feel through skin (e.g. in the breast, throat, armpit or groin)
• Cancers you are unlikely to know you have until symptoms appear (e.g. unusual bleeding or discharge, pain, persistent cough or trouble breathing, etc.) or are picked up by a screening test.

The prostate is hidden away where it’s impossible for you to detect if cancer is growing. By the time urinary symptoms or pain occur, it is probably large and/or aggressive. Thankfully, prostate cancer (PCa) is now often picked up early through screening by a PSA blood test and digital rectal exam (DRE).   

Don’t judge a book by its cover

The PSA blood test was heralded as a lifesaver when it was introduced in the 1990s. A simple blood draw could be analyzed for the amount of prostate specific antigen (PSA) it contained. Antigens are proteins shed by many types of cells—including cancer cells—into the bloodstream. They are unique to each type of cell, so they act as a kind of identification badge about their origin. Thus, antigens from prostate cells are able to be recognized in a blood sample because they are “prostate specific.”  

Normally, PSA levels in the blood are low, but more antigens are shed into the blood if the prostate is stimulated in some way: sexual activity, a long bike ride, an infection in the gland, BPH, and even a DRE can spur antigen release. So can tumor growth. Thus, an elevated or rising PSA could mean cancer.

However, a suspicious PSA report is like coming across a book with the attention-getting cover title, “Your Prostate Might Be In Trouble.” Uh oh, right? Well, you can’t judge this book by its cover because the screening PSA test is merely prostate specific, not prostate cancer specific.

Tell me more

If a PSA test is suspicious, the conventional next step used to be a biopsy. I have written about the flaws of the conventional TRUS biopsy approach. True, it gives much more information than PSA: Gleason score (measure of aggression), volume of cancer (number of positive needles, length of needle core positive to cancer) and some idea of location (from which prostate side/area each sample was taken). The question is, is this all the information you can get to equip you for decision-making?

The conventional pathway to decision is simply not up to the decision-making task because it’s missing a key component: accurate visual depiction of the tumor. Remember, there are cancers YOU can easily detect, but not prostate cancer. It’s tucked away in a place where even surgery can’t access it without difficulty. At best, the results of a 12-needle biopsy allow only an educated guess as to the size and location of a tumor, not a complete picture. Instead, seeing the whole picture without invading the body is the best thing to do even before a biopsy. That is the most effective information to target the biopsy needles directly into the suspicious area—something ultrasound can’t give—and therefore the most accurate diagnosis.

Multiparametric MRI: you can get all the information you need

An April, 2019 published study underscores the value of a picture that’s worth a thousand pathology reports. The paper by Raeside, et al.[ii] presents the results of their review of 245 robotic prostatectomy cases in which patients had mpMRI imaging prior to surgery in order to detect the dominant tumor and any possible extracapsular extension (tumor that broke through the outer capsule of the prostate, or Stage T3). The cases were divided into four groups according to the number of MRI parameters used:

1. MRI using only a single parameter (T2-weighted MRI)
2. mpMRI using two parameters (T2-weighted and diffusion weighted MRI)
3. mpMRI using three parameters (T2-weighted, diffusion weighted, and dynamic contrast enhanced MRI)
4. mpMRI with three parameters plus the new PI-RADS vs2, a 5-category rating system that further defines a patient’s imagine information.

The researchers found that adding diffusion-weighted and dynamic contrast parameters improved detection of the dominant tumor, while the accuracy of detecting Stage T3 was “initially very low.” However, when the PI-RADS v2 reporting system registered a 3-category rating (high likelihood of Stage T3), the sensitivity of detecting patients who were not good surgery candidates increased significantly.

Would you choose surgery if you knew…?

Prostate cancer patients who have robotic prostatectomy are relieved afterward when their surgeon says, “Good news, we got it all.” However, hearing that there were “positive margins” means there is a risk that cancer was left behind—not such great news. Many published papers maintain that a TRUS biopsy can “predict” the probability of Stage 3 based on ultrasound showing unusual bulges or asymmetry, plus the clinical factors of Gleason grade, number of positive needle cores, and length of cancer in the core. The difference is, mpMRI + PI-RADS v2 can confirm the presence or absence of Stage T3 disease far more reliably than the conventional pathway. My point is, since you can’t personally see your prostate cancer, only mpMRI and experienced PI-RADS v2 reporting can give you what you need to know before biopsy, and before making a treatment decision.

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] Khan A, Moore CM, Minhaj Siddiqui M. Prostate MRI and image quality: The urologist’s perspective. Eur J Radiol. 2024 Jan;170:111255.
[ii] Raeside M, Low A, Cohen P, Sutherland P, Gormly K. Prostate MRI evolution in clinical practice: Audit of tumour detection and staging versus prostatectomy with staged introduction of multiparametric MRI and Prostate Imaging Reporting and Data System v2 reporting. J Med Imaging Radiat Oncol. 2019 Apr 5.