“Choose me! Choose me!” When you were a kid, were you ever hoping to get picked for something that came with an incentive? Maybe the teacher asked for a volunteer to erase the blackboard in return for a candy bar. If that reward appealed to you, your hand shot up and you tried to shout above everyone else’s clamor.

As an adult, incentives and rewards take forms far removed from candy bars. Who wouldn’t want to be picked for a promotion? Who wouldn’t want their lottery number to come up? But sometimes, if you’re hoping to avoid something unpleasant that happens to a lot of others, the reward will be relief.

This may well be the situation for guys who participate in routine prostate cancer screening using the PSA blood test. If the result reveals an unusually high number for your age range, or a suspiciously high increase from last year’s test, how many patients get that uh-oh feeling? They fear the doc’s next words, “Let’s get you in for a biopsy.” That’s because two aspects of prostate biopsy can be scary:

1. Being stuck with 12 or more needles
2. The prospect of finding prostate cancer (PCa)

Let’s face it. You’d rather not be included among the one million men sent for a biopsy each year.^[i] How can you be chosen to avoid what seems inevitable? The answer is simple: get more information than what the PSA alone gives. How do you get it before you find yourself lying on a table while being numbed up for the needle gun? Again, a simple answer. Get a multiparametric MRI (mpMRI).

Negative MRI? Hold off on a biopsy

A September 2024 Renal & Urology News item offers reassuring news for men with suspicious PSA results. The report opens, “Omitting biopsy in patients with a negative prostate MRI more than halves the diagnoses of clinically insignificant prostate cancer.” This is another way of saying that conventional 12+ needle biopsies guided by transrectal ultrasound (TRUS) pick up way too much insignificant PCa that does not require immediate treatment. Which is another way of saying that way too many men are biopsied due to insufficient information!

You may wonder, how does a doctor know when a patient’s abnormal PSA means he should be chosen for a biopsy? After all, it could mean anything from having an infection, to bike riding or having sex the day before the blood draw, to cancer.

Here’s where multiparametric MRI (mpMRI) comes in. mpMRI excels at detecting and identifying significant PCa. Thus, if your scan is positive for significant PCa, it means you need an MRI-guided targeted biopsy into the suspicious area. On the other hand (here’s the good news), if your mpMRI scan is negative for significant PCa, it means you can hold off on a biopsy.

The above-mentioned news report described a study published in theNew England Journal of Medicine (NEJM), one of the most prestigious journals due its high criteria for accepting papers. In this case, the study by Hugosson et al. (2024) involved roughly 13,000 men whose screening PSA test results were 3 ng/mL or higher, followed by mpMRI. Half were assigned to conventional TRUS biopsy (12+ systematic but random samples), and the other half to MRI-targeted biopsies if their scans were positive for suspicious lesions. All participants were followed for an average of 4 years during which they were invited to repeat screening (PSA + MRI) at 2-year intervals.

The authors concluded that “… omitting biopsy in patients with negative MRI results eliminated more than half of diagnoses of clinically insignificant prostate cancer” while the risk of being found to have incurable PCa at future screenings was very low.^[ii] In short, a patient with an abnormal PSA result should be referred for mpMRI prior to a biopsy decision. If the mpMRI results are negative for significant PCa, it’s safe to hold off on a biopsy while continuing PSA screening; in this case, future blood tests plus mpMRI will detect any PCa activity that now requires a biopsy.

The point is, if you want to be picked to avoid a biopsy, raise your hand. Simply follow up your PSA test with mpMRI. The possibility of a negative result is an appealing reward.

One final word: the Hugosson study, like numerous previous studies, demonstrated that mpMRI targeted biopsies are more precise than random TRUS biopsies, while reducing the number of needles needed for diagnostic accuracy. To determine if a biopsy is necessary after an atypical PSA, our Center offers state-of-the-art mpMRI on a powerful 3T magnet, with accuracy and efficiency boosted by integrated Artificial Intelligence software. If scan results are negative, no biopsy is needed at that time. However, if the scan is positive for a suspicious lesion, Dr. Sperling and his team of experts provide real time MRI-guided targeted biopsies. Real-time guidance has been shown to be more precise than fusion guidance. Contact the Sperling Prostate Center to learn more.

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] Schmeusser B, Levin B, Lama D, Sidana A. Hundred years of transperineal prostate biopsy. Ther Adv Urol. 2022 May 21;14:17562872221100590.
[ii] Hugosson J, Godtman RA, Wallstrom J, 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.