MRI scans twice as effective at spotting prostate cancer as biopsies

ack

VIP/Donor & WBF Founding Member
May 6, 2010
5,538
194
63
Boston, MA
#1

Folsom

VIP/Donor
Oct 26, 2015
3,604
289
83
Eastern WA
#2
I wonder if that's even a good thing, in some ways. Prostates get removed needlessly too often. Tumours on them come and go way more often than people realize.
 

Steve Williams

Site Founder, Site Owner, Administrator
#3
I wonder if that's even a good thing, in some ways. Prostates get removed needlessly too often. Tumours on them come and go way more often than people realize.
They come but they never go
 

WLVCA

Member Sponsor
Nov 2, 2012
2,007
285
83
Tucson
#4
I am at that age when prostate is a concern.

There is so much conflicting information out there that its really confusing.

Biopsy or no biopsy?

MRI or biopsy?

Surgery or high intensity focused ultrasound?

Last time I asked my urologist about HIFU he told me about the groups major investment in surgical treatment.

Is he concerned about my prostate or paying for the groups's investment?

Very confusing for me.
 

Folsom

VIP/Donor
Oct 26, 2015
3,604
289
83
Eastern WA
#5
They come but they never go
Maybe tumor is the wrong word? Because I've been enlightened of something very different from that.

It's not as if the body isn't known for developing cancerous spots and also seeing them leave before they get big and the body cannot deal with them.
 

jazdoc

Member Sponsor
Aug 7, 2010
2,733
64
48
Bellevue
#6
I am a radiologist who reads prostate MRI.

First some background. Prostate cancer is very common and the incidence rises as we, ahem, "mature". I would bet that given the demographics, upwards of 50% of the WBF membership has prostate cancer. Much like thyroid cancer; the vast majority of prostate cancers are biologically indolent and the vast majority of men with prostate cancer will die of something else. Certain demographics (African Americans) do have higher rates and on average, more aggressive prostate cancers.

MRI of the prostate gland is a difficult examination to interpret and the results are most definitely not binary. The current 'gold standard' of MRI interpretation has been developed by the American College of Radiology and is similar to (and based upon) mammographic reporting standards. The only way to actually diagnose prostate cancer is by biopsy. Current recommendations for patients with suspected prostate cancer are first, random biopsies, typically performed in the urologist's office. MRI is reserved for problem solving, i.e. indeterminate or discordant random biopsy results or for persistently elevated or rising PSA blood test in patients with treated prostate cancer for which disease outside of the prostate gland is not demonstrated.
 

Steve Williams

Site Founder, Site Owner, Administrator
#7
The current 'gold standard' of MRI interpretation has been developed by the American College of Radiology and is similar to (and based upon) mammographic reporting standards. The only way to actually diagnose prostate cancer is by biopsy. Current recommendations for patients with suspected prostate cancer are first, random biopsies, typically performed in the urologist's office. MRI is reserved for problem solving, i.e. indeterminate or discordant random biopsy results or for persistently elevated or rising PSA blood test in patients with treated prostate cancer for which disease outside of the prostate gland is not demonstrated.
Thank you for confirming the obvious
 
Apr 3, 2010
15,820
1
0
Seattle, WA
#8
MRI of the prostate gland is a difficult examination to interpret and the results are most definitely not binary. The current 'gold standard' of MRI interpretation has been developed by the American College of Radiology and is similar to (and based upon) mammographic reporting standards. The only way to actually diagnose prostate cancer is by biopsy. Current recommendations for patients with suspected prostate cancer are first, random biopsies, typically performed in the urologist's office. MRI is reserved for problem solving, i.e. indeterminate or discordant random biopsy results or for persistently elevated or rising PSA blood test in patients with treated prostate cancer for which disease outside of the prostate gland is not demonstrated.
The study advocates mp-MRI with specific training. Is that what your experience is based on?

This was a cohort trial with both tests performed on the same patients with elevated PSA so it has very good comparative power. The results show that mp-MRI was far more accurate as a pre-diagnostic than biopsy. The biopsy was better in specificity but not as a screening tool. As a result, the mp-MRI is stated to be a better screening tool and is able to reduce the percentage of biopsies which are needed. Since biopsy can have side effects, that benefit is solidly there.

Have you read the report and disagree with my summary here?
 

jazdoc

Member Sponsor
Aug 7, 2010
2,733
64
48
Bellevue
#10
The study advocates mp-MRI with specific training. Is that what your experience is based on?

This was a cohort trial with both tests performed on the same patients with elevated PSA so it has very good comparative power. The results show that mp-MRI was far more accurate as a pre-diagnostic than biopsy. The biopsy was better in specificity but not as a screening tool. As a result, the mp-MRI is stated to be a better screening tool and is able to reduce the percentage of biopsies which are needed. Since biopsy can have side effects, that benefit is solidly there.

Have you read the report and disagree with my summary here?
I have read the newspaper report but not the journal report (I'll have to wait for access at my hospital.)

PSA is a crappy test, so having better comparative power is the medical equivalent of high jumping a pancake. I would refer you to the Wilson criteria for screening tests:

The Wilson criteria for screening emphasise the important features of any screening program, as follows:

1. the condition should be an important health problem
2. the natural history of the condition should be understood
3. there should be a recognisable latent or early symptomatic stage
4. there should be a test that is easy to perform and interpret, acceptable, accurate, reliable, sensitive and specific
5. there should be an accepted treatment recognised for the disease
6. treatment should be more effective if started early
7. there should be a policy on who should be treated
8. diagnosis and treatment should be cost-effective
9. case-finding should be a continuous process

Using MRI for prostate carcinoma screening fails most of these criteria.
 
Aug 7, 2015
549
1
16
Australia
#12
PSA is a crappy test
I am glad you have said that but you wouldn't believe how some doctor's attitudes to it have not changed over the years - even after the dismal statistics concerning its lack of efficacy and it's indirect potential to cause harm have been widely available.

Three years ago at age 48 I was opportunistically asked if I wanted a PSA test. I had already thoroughly researched it and had decided I would not have one. Infact I was first made aware of the test a decade prior, when the President of the Australian Cancer Council no less publicly stated that he himself would not have the test. There is no male cancer history of any sort in my entire family tree going back 150 years (yes, I have every male listed and what they died from!) and I am completely asymptomatic. The doctor actually wanted to have a good debate / argument about it. I told him that we could either sit there for 8 hours whilst I gave him the evidence or he could simply send me on his way and see his next patient.

Two years later I was vindicated: the Royal Australian College of General Practicioners released a media statement disendorsing the PSA test stating that it was ineffectual and caused more harm than good. They also drew up clinical guidelines that stated doctors are not allowed to broach the subject of a PSA test with a patient unless they are clearly in a high risk prostate cancer category and were pro-actively asking about the test themselves or were symptomatic. The guidelines also require doctors to provide patients with an information sheet on it. Any low-risk patient who still wants to take the test after reading that info sheet is pretty brave (or pretty stupid). Once on the PSA train, it is a pretty hard train to disembark from.

I actually discussed all of this with a urologist last year and we were talking about the new 3T MRI scans. His personal position was that he'd not do a biopsy without at least a 2T MRI (following repeated "positive" PSA tests). Still, for anyone reading this thread and wondering what all this PSA testing debate is all about, it is pretty hard to go past this write-up on it:

http://insidestory.org.au/eleven-grams-of-trouble
 

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