New study finds prebiopsy MRI scans reduce by half the risk of Gleason 6 diagnosis
Join me and Joe Gallo at a special ZERO virtual support group on Feb. 27
By Howard Wolinsky
Avoidance of systematic biopsy in favor of MRI-directed targeted biopsy for screening and early detection in persons with elevated PSA levels reduced the risk of overdiagnosis by half, a new Swedish study found.
But this came at the cost of delaying the detection of intermediate-risk tumors in a small proportion of patients, reported Dr. Jonas Hugosson, of the Department of Urology, Sahlgrenska University Hospital, in Gothenburg, Sweden and colleagues in a study appearing on Dec. 8, 2022 in the New England Journal of Medicine.
Researchers invited 37,887 men aged 50 to 60 years of age to undergo regular prostate-specific antigen (PSA) screening. Participants with a PSA level of 3 ng per milliliter or higher underwent magnetic resonance imaging (MRI) of the prostate.
One-third of the participants were randomly assigned to a reference group that underwent systematic biopsy as well as targeted biopsy of suspicious lesions shown on MRI. The remaining participants were assigned to an experimental group and underwent MRI-targeted biopsy only.
“The primary outcome was clinically insignificant prostate cancer, defined as a Gleason score of 3+3. The secondary outcome was clinically significant prostate cancer, defined as a Gleason score of at least 3+4,” researchers said.
They said the study showed the benefit of a prebiopsy MRI to reduce the risk of detecting Gleason 3+3, which can lead us down a rabbit hole of overdiagnosis and overtreatment.
A Gleason 6 diagnosis on one level is good news since you would be considered unlikely to lead to metastasis and death. But it does lead to biopsies with risks of infection and sepsis, which can potentially be lethal.
MRIs tend to overlook very low-risk cancers. Consider that a feature, not a bug.
Personally, in 2010, I underwent a biopsy based on a rising PSA, just under 4. The biopsy found I had a low-risk Gleason 6 of less than a millimeter in a single core. A urologist tried to rush me into his ER. I got a second opinion and was declared the “poster boy of Active Surveillance.” Urologists said I have one of the “wimpiest cancers” they’ve ever seen.
In fact, doctors tell me that if my rising PSA (around 4) were seen today, I likely would undergo an MRI, no suspicious cores would have been identified, and I would not have been diagnosed with prostate cancer.
My subsequent biopsies--we were asked to undergo annual biopsies in those primitive times--never again showed any sign of cancer. I haven’t had a biopsy in almost seven years.
I was supposed to have a targeted MRI in 2006, while establishing a baseline with my new urologist. But an MRI showed no areas of suspicion--”targets” for a biopsy. I consented to in effect a blind, “random” or systematic biopsy because my new urologist wanted a baseline.
I’m not sorry I did. It paved the way toward that possibly being my last biopsy.
(Remember: Each of us is different. So don’t think you automatically would follow my path.)
A recent study showed that Gleason 3+3 tumors visible on MRIs—no lesions were visible in my last MRI in 2016— have a higher risk of progressing than MRI-negative cancers.
The Swedish researchers said, “Our trial showed that changing the diagnostic algorithm to include prebiopsy MRI in all participants with elevated PSA levels and only targeted biopsy of lesions with a PI-RADS score of 3 to 5, and no biopsy of lesions with PI-RADS scores of 1 to 2 reduced the risk of detecting Gleason 3+3 cancers by half [54%].
“Since the frequent detection of small Gleason 3+3 cancers after PSA screening is regarded as a major contributor to the high incidence of potentially harmful overdiagnosis of prostate cancer, this finding is of importance. This strategy also considerably reduced the percentage of biopsies in participants in the experimental group who had elevated PSA levels. Although the incidence of severe adverse events after prostate biopsy in our trial was low — probably owing to the relatively young age of the participants — prostate biopsy is an unpleasant and potentially risky procedure.”
The study found that 19% fewer clinically significant cancers were detected in the experimental MRI-only group than in the reference group
“Clinically significant cancers in the reference group that were detected by systematic biopsy alone (in 10 participants) were mostly small and all had a Gleason score of 3+4, with a small amount of Gleason pattern 4 detected. Six of the 10 participants had disease that was managed with active surveillance, and 4 underwent radical treatment. Delayed diagnosis in these participants is unlikely to be detrimental, but future follow-up is important.”
Join a virtual AS support group at the ZERO Summit
By Howard Wolinsky
The ZERO Summit is a premier annual event for the prostate cancer community. Each year the community gathers to learn the latest in prostate cancer from medical experts, advocate for research and funding in meetings with legislators, and support each other through shared experience and camaraderie.
The Summit will take place February 26-28, 2023 in person in the Washington D.C. area, and virtually from any location via computer or smartphone.
Register at zerocancer.org/summit
You can meet up with me—an official “ZERO’s Hero” and my personal hero Joe Gallo in a virtual support group for active surveillance for low-risk prostate cancer. on Monday Feb. 27 at 10 a.m. Eastern.
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