The prostate gland does not have a voice. If it did, I might tell its owner, “Hey, dude, I just noticed a clump of mutated cells inside me that’s growing. I bet it’s cancer—can you find out ASAP?” It can’t make an announcement. It can, however, quietly send out an alert of suspicious activity. It’s called prostate specific antigen, or PSA. It consists of surface proteins that prostate cells release into the bloodstream where a blood test can measure the amount. The amount released by healthy cells is normally low.

However, a larger quantify of PSA is released when the prostate is stimulated by external or internal activity. Here are things that commonly cause a spike in PSA blood levels:

• Sexual activity
• Riding a bike
• A digital rectal exam (DRE)
• An inflammation or infection of the gland
• Benign prostatic hyperplasia (BPH)
• Prostate cancer (PCa)

Thus, a test result that’s higher than expected, or rising over time, is the prostate’s way of sending an alert. The problem is, without further testing of the presence of other symptoms, it’s not possible to know if PCa is the reason.

How the PSA blood test has led to harm

The PSA blood test in itself is as harmless as sampling blood for other things like blood sugar, cholesterol, kidney function, etc. However, the fact that it MIGHT indicate PCa is a red flag for doctors who don’t want their patients to die of cancer. Out of an abundance of caution, therefore, one million biopsies are done annually in the U.S.—all because of PSA results. And yet, roughly 300,000 men will have biopsy results that are positive for PCa.

Prostate biopsies come with risks: Infection, erectile dysfunction, blood in urine or semen, and pain. What’s worse, the standard TRUS biopsy isn’t as accurate as one going through it might hope. Sometimes it misses PCa, which continues to grow in the gland. Sometimes it picks up PCa that may never turn aggressive, but again out of caution, doctors recommend aggressive whole-gland surgery or radiation. Such overtreatment comes with higher urinary, sexual and bowel side effect rates than focal therapy or Active Surveillance. In short, the pathway looks like this: PSA ? Biopsy ? Treatment ? Side effects. Because of this, new physician guidelines state that an annual PSA test should not be automatically done on a healthy patient who has no known PCa risk factors. Instead, doctor and patient should discuss the benefits vs. harms of a PSA test in order to decide if one is necessary.

This is like throwing the baby out with the bath, because the PSA test is universally available and cheap when compared with other tests. Why not keep it if there is a method to identify the 300,000 men who truly have PCa, while sparing the other 700,000 from an unnecessary biopsy? It would boost benefits (detecting and diagnosing PCa) while greatly reducing the risk of unproductive yet harmful biopsies!

In fact, the Journal of the American Medical Association (JAMA) published an original April 2024 paper saying that such a method already exists. An international team reviewed and synthesized data on over 80,000 patients from 12 studies comparing the usual pathway vs. one that adds an MRI scan before rushing to biopsy. Since multiparametric MRI excels at identifying areas suspicious for clinically significant PCa (requires treatment), men whose MRI was negative for suspicious areas could safely avoid a biopsy. They concluded that their results “suggest that integrating MRI in PCa screening pathways is associated with a reduced number of unnecessary biopsies and overdiagnosis of insignificant PCa while maintaining csPCa detection as compared with PSA-only screening.”^[i]

In their own words, here’s what this means for patients: “The findings of this meta-analysis support the integration of prostate MRI in prostate cancer screening to improve the balance of patient harms and benefits.”^[ii]

Indeed, the ability to increase the accuracy of PCa detection while reducing the number of unnecessary biopsies is the solution to a 700,000-person-per-year problem. Studies have also shown that this rebalancing is an economic benefit as well as a personal one, since the collective cost of biopsies, overtreatment, and managing side effects is a much greater burden on healthcare dollars than the cost of adding MRI. So, let’s implement the wisdom of the 18-person international team members who conducted the study, and integrate MRI into the pathway ASAP.

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.

References

[i] Fazekas T, Shim SR, Basile G, et al. Magnetic Resonance Imaging in Prostate Cancer Screening: A Systematic Review and Meta-Analysis. JAMA Oncol. 2024;10(6):745–754.
[ii] Ibid.