“Send in the reinforcements!” How many vintage Hollywood movies foretold a thrilling end to a worrisome situation with that battle cry? Whether it was a cavalry stockade besieged by hostiles, or a WWII platoon in a tight spot, the audience knew that help was on the way.

It is estimated that upwards of 20-25 million PSA tests are done each year in the U.S. The American Cancer Society recommends, “Screening should be done yearly for men whose PSA level is 2.5 ng/mL or higher.” While it can be anxiety provoking to get an abnormally high or sequentially rising PSA result, 7 out of 8 men will not be diagnosed with prostate cancer (PCa) in their lifetime. And, most of the 13% of men who are indeed found to have PCa will have what some call the “garden variety” that is non-life threatening and is highly treatable. In other words, the majority of men don’t need to fear being trapped in a tough cancer spot.

However, screening is still essential because a small percentage of PCa cell lines are dangerous—but a PSA test offers no clue to such PCa types. As the Centers for Disease Control and Prevention (CDC) points out, “The goal of screening for prostate cancer is to find cancers that may be at high risk for spreading if not treated, and to find them early before they spread.” The trouble is, such cell lines are often sneaky invaders that can elude detection. Two such types are intraductal PCa (IDC pattern) and cribriform PCa (Cr pattern). It is very important to find these tumors early because they are aggressive. Not only can they infiltrate nearby healthy tissue quickly, they tend to spread to other parts of the body.

Hard to find? Send in reinforcements

If a PSA result is abnormally high, waiting a year for the next test would be playing with fire if the patient is carrying an IDC or Cr pattern. Since an abnormal PSA result may be worrisome, reinforcements are needed. Until the advent of prostate MRI, doctors generally referred patients for a conventional randomized TRUS biopsy using 12 or more needles.

Now there’s an intervening step between a suspicious PSA test and a needle biopsy. Multiparametric MRI (mpMRI) is a noninvasive way to decide if a biopsy is necessary, since it is able to identify an area of the prostate containing significant PCa. Many men can thus avoid an unnecessary biopsy altogether. However, conventional TRUS biopsy can easily miss IDC and Cr pattern tumors.

Again, multiparametric MRI (mpMRI) comes to the rescue. When real-time mpMRI is used to target a minimal number of needles into the suspicious area, it is superior to TRUS biopsy. This is particularly so for PI-RADS 3 scores on MRI imaging. A recently published comparison between TRUS and mpMRI targeted biopsies for men with PI-RADS 3 found that the targeted biopsies picked up IDC/Cr patterns in 25% of those whose biopsies were targeted vs. 16% of those who had TRUS biopsies.^[i] In particular, live (real time) mpMRI targeting such as we provide at the Sperling Prostate Center has been shown to be superior to other targeting methods such as fusion or cognitive guidance.

In addition to real time mpMRI targeting, there’s an additional diagnostic reinforcement in the form of genomic testing. Tests based on tissue samples that analyze PCa cells for their DNA or other biomarkers. At the May 2024 annual meeting of the American Urological Association (San Antonio, TX), Dr. Nimrod Barashi gave a presentation of how imaging and genomic results can team up to reinforce accuracy. Based on 760 PCa patients for whom both PI-RADS and genomic analysis were available, he and research team found a strong correlation between imaging and genomic findings.^[ii] Such teamwork between two diagnostic pointers lends a high degree of confidence for determining the clinical strategy most likely to succeed in patients with high-risk cell lines such as IDC and Cr patterns.

The ever-increasing ability to target and accurately diagnose is a huge advantage for doctors and patients alike. As always, the secret ingredient is early detection, and PSA screening is inexpensive and widely available. When an unusual PSA result makes a patient fear sneaky invaders, mpMRI and value added genomic testing (if indicated) are reinforcements to reassure that he and his medical team can defend the lifesaving stockade of good health.

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] Ghai S, Klotz L, Pond GR, Kebabdjian M, Downes MR et al. Comparison of Multiparametric MRI-targeted and Systematic Biopsies for Detection of Cribriform and Intraductal Carcinoma Prostate Cancer. Radiology. 2024 Jul;312(1):e231948.
[ii] https://www.urotoday.com/conference-highlights/aua-2024/aua-2024-prostate-cancer/151831