(Editor’s note: Pathology Report columnist Ming Zhou, MD, PhD, has moved to Mount Sinai Health System in New York City. If you have questions for him, please contact him directly at Email: Ming.zhou@mountsinai.org)
How does prostate magnetic resonance imaging (MRI) help detect clinically significant cancer and its pros and cons?
A reader voiced his tremendous frustration over the ambiguous, or uncertain, results of MRI and prostate biopsies. He had many questions. One of them is: Other than aiming the biopsy, does the MRI mean anything? I’d like answer this question from a pathologist’s perspective, particularly, how does MRI help detect clinically significant prostate cancer and what are its pros and cons in using MRI in diagnosing prostate cancer?
Prostate MRI is not a cut-and-dried procedure and requires expertise. Even though MRI has been increasingly integrated in the prostate cancer diagnosis practice, the effectiveness of prostate MRI and MRI-targeted biopsy is variable and influenced by several factors, including imaging quality, MRI protocols, and experience of radiologists. In general, the accuracy and outcomes of these procedures are significantly better with the high-volume centers of excellence.
What is the definition of clinically significant prostate cancer?
For prostate cancer treatment, we aim to treat so-called clinically significant cancer which is defined as cancer that is likely to impact a patient’s health due to its potential to cause symptoms or spread. From pathology perspective, it generally refers to prostate cancer that typically has a Gleason score of 7 or higher (Grade Group 2 or higher) (where Gleason grades 4 and 5 are present), or large tumor volume involving a significant portion of the prostate gland (eg, maximum biopsy core involved by cancer >6mm).
What is PI-RADS (Prostate Imaging Reporting and Data System)?
PI-RADS is a way by which radiologists standardize the study and reporting of prostate lesions based on their their imaging characteristics that predict the likelihood of clinically significant prostate cancer:
PI-RADS 1: Very low likelihood of clinically significant cancer (<5% detection rate).
PI-RADS 2: Low likelihood of clinically significant cancer (~10-15% detection rate).
PI-RADS 3: Intermediate likelihood of clinically significant cancer (~20-30% detection rate).
PI-RADS 4: High likelihood of clinically significant cancer (~50-70% detection rate).
PI-RADS 5: Very high likelihood of clinically significant cancer (>70% detection rate).
Pros of prostate MRI
Prostate MRI enhances the ability to detect clinically significant cancer that might be missed by standard biopsy protocols. Additionally, it reduces the chance of detection of clinically insignificant cancer, which is small, Gleason 6 (Grade Group 1) cancer that is unlikely to impact a patient's health or require aggressive treatment due to its low risk of progression or adverse outcomes.
Cons of prostate MRI
PI-RADS 1-2 lesions are in general considered negative and patients may avoid a biopsy, while PI-RADS 3-5 lesions are considered significant and therefore a biopsy may be warranted.
However, even with the very low risk for clinically significant cancer with PI-RADS 1-2 lesions, the risk is not zero, and can be up to 10-15%. Even for PI-RADS 5 lesions, the cancer may be missed in ~30% of patients.
So the decision to biopsy is not as simple as a the binary PI-RADS score (<2 vs >3). It can be affected by other factors such as whether patients had a prostate biopsy previously and other clinical and laboratory tests. Patients need to have a conversation with their urologists to decide on the biopsy and repeat biopsy.
References:
Fazekas T, et al. Magnetic Resonance Imaging in Prostate Cancer Screening: A Systematic Review and Meta-analysis. JAMA Oncology. 2024.
NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Prostate Cancer Early Detection Version 2.2023 — September 26, 2023.
Ming Zhou, MD, PhD, is a tenured professor and the Vice Chair for Oncological Pathology, Director of Urological Pathology Service and Fellowship Program, Department of Pathology, Molecular and Cell-based Medicine, Mount Sinai Hospital and Icahn School of Medicine in New York City.
He graduated summa cum laude from Fudan University Medical School in Shanghai, China. He completed my pathology residency training at the University of Michigan (Go Blue) and had a fellowship in the Urological and Kidney Diseases at the Johns Hopkins Hospital. He has had faculty and administrative roles at Cleveland Clinic, New York University, University of Texas Southwestern Medical Center, and Tufts University School of Medicine, where he served as Chair and Pathologist-in-Chief from 2019 to 2024.
Recognized nationally and internationally as a leading authority in urological pathology, he has authored over 200 peer-reviewed articles and 116 review articles and book chapters, and co-edited five textbooks of urological and prostate pathology He has served the Board of Directors of the United States and Canadian Academy of Pathology as President of the Genitourinary Pathology Society, an international organization for urological pathologists.
Oldest astronaut in history raises awareness about prostate cancer, especially for Black men
By Howard Wolinsky
Back in 1961, President John F. Kennedy named Ed Dwight as America’s first Black astronaut. But Dwight didn’t make it into space in NASA’s program because of the racism of the time.
More than 60 years later, the retired pilot from Denver in May finally made that journey aboard Jeff Bezos’ Blue Origin NS-25 passenger shuttle. Dwight set a record for being the oldest astronaut in history—he was 90 then and now is 91.
"I'm overwhelmed... I thought I really didn't need this in my life. But now I need it in my life. This is fabulous,” Dwight said after the 10-minute suborbital flight.
By a few months, he beat out Star Trek’s William Shatner, who also was 90 when he went into suborbit in 2021.
A year before his space flight, Dwight had been diagnosed with prostate cancer and was treated with radiation, apparently setting a record for treated prostate cancer patients.
Dwight was shocked about being diagnosed with prostate cancer. "I was pretty knocked off my feet," he told CBS News. "Turns out, they caught it early which is a good thing."
He sees increasing awareness about prostate cancer is his mission now.
"Mr. Dwight is unique in a lot of ways… his health and well-being really is different than the average 90-year-old. The decision to treat really made sense for him," Dr. Juan Montoya, a urologist at AdventHealth told CBS. "I think that's really important as we strive to personalize treatment approaches to the individual."
Presumably, Dwight had undergone PSA screening many years earlier.
I hope doctors at AdventHealth will respond to my questions:
--Was Mr. Dwighht on Active Surveillance? If so, for how long?
--How did it happen at age 89 that his cancer was discovered? Is it unusual for a cancer to show up at that age?
--Isn't it unusual for an 89-year-old to undergo aggressive treatment> --What was different about Mr. Dwight? Was he in extraordinary condition? Maybe he is a 91-year-old with condition of a 60-year-old? --Is treatment often offered to men in his age bracket?
--What is the oldest age of a patient who has undergone radiation for PCa? Is surgery ever recommended in that age group?
--Did Mr. Dwight have a family history for prostate cancer?
The Prostate Cancer Foundation recommends that Black men obtain a baseline PSA test between ages 40-45.
One in six Black men will develop prostate cancer in his lifetime—compared to one in eight men overall. Black men are 1.7 times more likely to be diagnosed with—and 2.1 times more likely to die from—prostate cancer than white men.
Don’t miss Dr. Peter Carroll’s presentation to ASPI
Active Surveillance Patients International has posted its September program “Active Surveillance: Past, Present and Future” by pioneering AS researcher Peter Carroll, MD, MPH, of University of California, San Francisco.
Carroll, recipient of ASPI’s Chodak Award, discusses a variety of topics, including AI and its potential impact. The late Gerald Chodak, MD, laid down the fundamental thinking that lead to AS and was ASPI’s first medical advisor,
TheActiveSurveillor.com will be reporting soon on some developments from that session.
Thanks to Fans for the Cure for inviting me to be a speaker.Here’s an item from their newsletter.
Support Group Welcomes Patient Advocate Howard Wolinsky
The Online Men’s Support Group was joined on Thursday, September 19, by one of the world’s most famous and effective advocates for prostate cancer patients, Howard Wolinsky. The lead medical writer of the Chicago Sun-Times for over twenty-five years, Wolinsky told the story of his 2010 diagnosis for a low-risk (Gleason 6, one core) prostate cancer for which his urologist nevertheless was recommending a prostatectomy a few days later. Fortunately, Howard sought out a second opinion, undertook a regimen of Active Surveillance (about 6% of low-risk men chose this option in 2010), and continues to be monitored about once a year – fourteen years later.
In a wide-ranging discussion that ran 15-20 minutes into overtime, Howard spoke of his journey to writing about his experience in MedPage and Medscape, founding The Active Surveillor newsletter and becoming the co-founder of Active Surveillance Patients International (ASPI). The final 50 minutes or so of the discussion took the form of a Q&A about Active Surveillance, side effects, and the rewards and challenges of a life spent advocating for men’s health.
As if his writing and panel appearances were not enough, Howard (age 77) is a student in the Masters of Public Health Program at the University of Illinois – Chicago.
Physician guests are being finalized for meetings in November and December. For more information about the Online Men’s Support Group, please click on that blue button below.
There's little doubt that the MRI is a better screening tool for high-grade prostate cancer.
However, like pathology interpretations, imaging interpretations are also prone to observer error. As well, there's no irrefutable and reproducible evidence that prostate MRIs save significant numbers of lives.
And although it's very much business as usual in the prostate cancer arena there are some very pesky facts that just can't be ignored.
> PSA testing/screening fails to save significant numbers of lives.
> For the grade 3/Gleason 6 disease - it's biological pathways for cancer development and for cancer spread are INACTIVE so the Gleason 6 FAILS to behave as cancerous.
> Studies show that at 10 and 15 years NO treatment had similar survival rates to those who had surgery or radiation but without all the complications.
So with this background it's abundantly clear that - we need to stop harming men with predatory medicine and, we need a much better marker and a much better treatment for the 10-15% potentially deadly high-grade prostate cancers.
There's little doubt that the MRI is a better screening tool for high-grade prostate cancer.
However, like pathology interpretations, imaging interpretations are also prone to observer error. As well, there's no irrefutable and reproducible evidence that prostate MRIs save significant numbers of lives.
And although it's very much business as usual in the prostate cancer arena there are some very pesky facts that just can't be ignored.
> PSA testing/screening fails to save significant numbers of lives.
> For the grade 3/Gleason 6 disease - it's biological pathways for cancer development and for cancer spread are INACTIVE so the Gleason 6 FAILS to behave as cancerous.
> Studies show that at 10 and 15 years NO treatment had similar survival rates to those who had surgery or radiation but without all the complications.
So with this background it's abundantly clear that - we need to stop harming men with predatory medicine and, we need a much better marker and a much better treatment for the 10-15% potentially deadly high-grade prostate cancers.
Links
PSA has 78% false-positive rate
https://www.medscape.com/viewarticle/828854_3
PSA testing fails to save significant numbers of lives
https://www.nejm.org/doi/full/10.1056/NEJMoa0810696
The Gleason 6 is a bogus cancer - see Table 1
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4708232/
https://ascopost.com/issues/december-25-2016/a-gleason-6-tumor-is-it-cancer-and-should-it-be-treated/
12-core prostate needle biopsy samples 0.1% of the prostate
https://www.medscape.com/viewarticle/945928#vp_2
Prostate cancer surgery fails to save lives
https://www.nejm.org/doi/full/10.1056/NEJMoa1113162
Surgery, radiation or NO treatment have same 15 year survival
https://www.nejm.org/doi/full/10.1056/NEJMoa2214122?query=featured_home
The case against prostate checks and screening - multiple embedded links
https://howardwolinsky.substack.com/p/part-2-up-yours-the-case-again-dres
Most prostate cancer claims are exaggerations and misrepresentations
https://lundberginstitute.org/the-sordid-truth-about-prostate-cancer/
Most published research is false
https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.0020124
Only 11% of medical treatments are of known benefit
https://theincidentaleconomist.com/wordpress/half-of-medical-treatments-of-unknown-effectiveness/
Books
The Great Prostate Hoax by R. Ablin PhD and R. Piana
The Rise and Fall of the Prostate Cancer Scam by Anthony H. Horan MD