Harvard researchers confirm value of approach to avoid unnecessary biopsies by using MRIs and PSA Density

Ask your urologist whether an MRI and PSAD might avoid need for a biopsy

By Howard Wolinsky

A major meta-analysis—a study combining studies— by researchers at Brigham and Women’s Hospital (BWH) in Boston has shown that an MRI scan combined with prostate-specific antigen density (PSAD) can rule out the need for biopsies 30-50% of the time.

The meta-analysis, which created a dataset of more than 36,000 patients at BWH, found prostate biopsies may be unnecessary for patients with a PI-RADS under 4—PI-RADS is the rating system of MRIs— and a PSAD below 0.10 ng/ml2.

[PI-RADS scores the prostate lesion from 1 (highly unlikely to be clinically significant) to 5 (cancer is highly likely to be clinically significant). PSA density (PSAD) is the PSA blood level divided by the prostate's volume (as determined by MRI).]

The BWH researchers found that using specific PI-RADS and PSAD cutoffs, doctors could confidently skip 50% of biopsies while only missing 5% of clinically significant cancers, or they could skip 30% and only miss 3%.

For more on the study: jamanetwork.com/journals/jamanetworkopen/fullarticle/2816957

"In the workup of men suspected of having prostate cancer, prostate MRI findings combined with PSA density measurement can help doctors decide which patients to biopsy," said senior author Ramin Khorasani, MD, MPH, Radiology Vice Chair for Quality and Safety at Brigham and Women's Hospital and Mass General Brigham and Philip H. Cook Professor of Radiology at Harvard Medical School. "With this new analysis, we looked to see how MRI can help urologists decide which patients to biopsy and which patients may not need aggressive diagnosis and treatment."

(Lead author Ramin Khorasani, MD, MPH.)

The new study builds upon previous findings from a similar study using data only from BWH, that was published in the Journal of the American College of Radiology in 2022. That study found that an analysis using PI-RADS and PSAD cutoffs could pinpoint up to 50% of cases in which a biopsy would be unnecessary.

The new study performed the same analysis on data from 72 previously published studies of men with prostate cancer, including their PI-RADS results, prostate-specific antigen density testing, and determination of clinical significance from a biopsy.

"These data give us the confidence to say that in some cases, we can safely follow men with testing rather than aggressively pursue a biopsy in all cases," said Adam Kibel, MD, chief of Urology at Brigham and Women’s Hospital and Dana-Farber Brigham Cancer Center. "By making this information available to physicians and patients, we can help them make a more informed decision about undergoing a biopsy."

The researchers wrote: “These findings suggest that prostate biopsies may not be necessary for patients with equivocal or negative magnetic resonance imaging results and low PSAD.”

Researchers plan to use their analysis to develop a simple patient-level scoring system that urologists can use to evaluate their patient's need for a biopsy, which can carry the risk for infection but also for potentially disabling and deadly sepsis.

For more on PSAD: