MSK researchers offer primer on PSA, provide steps before rushing in for biopsies

Researchers from Memorial Sloan-Kettering Cancer in NYC note that secondary testing with biomarkers and MRIs can help 40-50% of us avoid biopsies.

By Howard Wolinsky

(First off, sorry. I had a technical issue with my reader survey. I’ll have to try again. Meanwhile, How about this instead? HW)

Biostatistician Andrew Vickers, PhD, of MSK, and Hans Lilja, MD, PhD, an expert on looking for disease in bodily fluids from MSK and Department of Translational Medicine, Lund University, Malmö, Sweden, just published a primer on PSA that includes strategies for avoding biopsies, which carry risks for overdiagnosis and overtreatment of prostate cancer and also transrectal biopsies that can pose risks for sepsis and other infections. The article appeared in the Asian Journal of Urology.

AnCan Foundation’s take on transperineal biopsies: https://ancan.org/transperineal-prostate-biopsies/

Vickers and Lilja describe the problems starting in the 1990s with PSA that led to overdiagnosis and overtreatment and side-effects impacting quality of life. They also describe secondary tests tests to help sort out who should have a biopsy and should be done before recommending MRIs,

(Andrew Vickers, PhD)

When I started on AS in 2010, we focused on avoiding treatment. Big first step. These days, patients and doctors are trying to go upstream to avoid biopsies that lead to unnecessary diagnosis that can cause emotional distress and financial toxicities such as being denied insurance because you have Gleason 6 “cancer.” The secrets for many biopsy avoiders are biomarker testing and MRIs.

“Starting around 2010, concerns about overdiagnosis and overtreatment lead researchers to look at other approaches, leading to the development of numerous blood [2], urine [2], and imaging [3] markers to be used as secondary diagnostic tests. The principle is that although PSA is extremely sensitive for aggressive prostate cancer—“natural history” study has shown extremely low rates of prostate cancer specific mortality after 20–25-year follow-up in men with PSA levels below the median [4]—it has poor specificity, as most men with elevated PSA do not have high-grade disease on biopsy [1],” Vickers and Lilja wrote.

“Accordingly, a more specific test is given after an elevated PSA so that the overall pathway has good diagnostic properties. Examples of such tests include the free-to-total PSA ratio, prostate health index (PHI), 4Kscore, prostate cancer antigen 3, and MRI.”

They argue that secondary testing is essential before undergoing a biopsy. And they say biomarkers like PHI and 4K should precede MRIs.

Following the strategies outlined by the authors, biopsies (and overdiagnosis and overtreatment) can be ducked in 40-50% of cases. “More widespread use of these tests would help shift the ratio of benefit to harm for PSA screening,” the authors said.

They note: “The results of molecular markers and MRI can be combined to assess the need for biopsy, but it makes more sense to use the marker first to determine eligibility for MRI.”

Vickers and Lilja caution: “The data on MRI are clear: MRI is an excellent prostate cancer diagnostic test on average, with only a small proportion of men with negative MRI having high-grade prostate cancer; however, accuracy varies widely between different centers, with some centers reporting performance characteristics for MRI that are highly unfavorable.”

Here’s an additional caution:

“Indeed, radiologists even within the same institution can vary widely as to how they call imaging results (i.e., interobserver variability) [9]. This is naturally far less of a problem for molecular markers which can be objectively measured in the laboratory.”

The next step is artificial intelligence, AI is starting to play a role in improving MRI reads. In fact, AI recently beat radiologists in a bake-off.

The authors are patent holders on the 4Kscore.

To learn more about the myths of PSA and prostate cancer screening, check out Vickers at https://www.mskcc.org/news/myths-about-psa-tests-and-prostate-cancer-screening

Still time to share your opinions about AI and prostate cancer through Sept. 1

By Howard Wolinsky

Tick-tock, Less than one month to share your opinions on an important issue for urology patients—the growing use of artificial intelligence (AI) in diagnosing and making tumor management choices for prostate cancer,

Around 300 or so of you have sounded off. Let’s shoot for 500. It takes about 15 minutes.

Peter Evancho, an attorney and second-year medical student at the University of Maryland, Baltimore, is conducting a policy analysis about AI and urology and is asking for our help.

Can you take a few minutes and answer Evancho’s survey and share your thoughts about AI and urology care? Survey link: https://rs.igs.umaryland.edu/surveys/?s=3R37KJMPERYEWMH9

Evancho is a second-year medical student at the University of Maryland School of Medicine. He is conducting the survey In conjunction with the Department of Surgery and the Division of Urology at the University of Maryland Medical Center and Principal Investigator Minhaj Siddiqui, MD,

The survey is designed to be completely anonymous. Participation is voluntary.

The University of Maryland, Baltimore’s Institutional Review Board has approved this study under HP-00109759

PCRI in-person is back, baby

The Prostate Cancer Research Institute’s 2024 Prostate Cancer Patients & Caregivers In-Person will be held in-person for the first time since 2019.

The popular p[atient-oriented meeting switched to virtual because of the COVID-19 pandemic. But it’s back in person, Sept. 7-8 at the Westin Los Angeles Airport.

Details to come.

Register here.

Who’s got short shorts? ASPI does.

Active Surveillance Patients International has carved up episodes of the popular AS 101 series, co-sponsored by ASPI, AnCan Foundation, the Walnut Foundation, and Canada’s Nationwide AS Support Group under the auspices of Prostate Cancer Foundation Canada.

Check out the bite-sized videos edited and compiled by ASPI Executive Director Bill Manning from the Active Surveillance 101 series: https://aspatients.org/a-s-101/ To see the full videos covering PSAs, second opinions, genomics, exercise, and more, go to: https://aspatients.org/a-s-101/

Unsolicited testimonial

Jerry Spiotto: "72-years-old, on AS for over a year. Hope to be on it indefinitely. Spoke with Bill Manning (from ASPI) on the phone shortly after my initial diagnosis. He was very comforting and understanding. I find your newsletters interesting and informative. Keep up the good work. Hope my donation helps your cause.”

Thanks, Jerry. Your subscription is helping me stay afloat. It’s our cause I hope. Viva la causa. HW