Prebiopsy MRIs get strong support in new Scandinavian study
MRIs reduced early detection of 'clinically insignificant cancers' by nearly 60%
(Editor’s note: MRI-first or prebiopsy MRI scans can save many patients from unnecessary diagnosis of low-risk Grade Group 1 prostate cancer. A new Swedish/Norwegian study, reviewed by columnist Antonio Westphalen, MD, a prostate radiology guru at the University of Washington. He told me the new study, which he told me is “probably one of the best studies done to date.”—HW
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Exciting news has emerged for patients and physicians in the field of prostate cancer screening.
A recent (Sept. 25) publication in The New England Journal of Medicine titled "Results after Four Years of Screening for Prostate Cancer with PSA and MRI" (N Engl J Med 2024;391:1083-95. https://www.nejm.org/doi/full/10.1056/NEJMoa24060500 )offers new insights into improving early-detection strategies.
Traditional screening using prostate-specific antigen (PSA) levels was revolutionary in its time but often leads to overdiagnosis and overtreatment of prostate cancers that may not pose significant health risks. To address this challenge, a multidisciplinary team of expert urologists, radiologists, and pathologists from leading institutions in Sweden and Norway conducted a study using data from the GÖTEBORG-2 trial.
The Study at a Glance
In the GÖTEBORG-2 trial, over 38,000 men aged 50 to 60 from Gothenburg, Sweden, were invited to participate in a prostate cancer screening study. Approximately 12,000 men agreed to take part and were randomly assigned to one of two groups:
1. Traditional Screening Group: Men with elevated PSA levels received systematic biopsies to check for cancer.
2. MRI-Guided Screening Group: Men with elevated PSA levels first received a magnetic resonance imaging (MRI) scan; only those with suspicious findings on the MRI proceeded to have targeted biopsies.
By following these men over four years, the researchers aimed to compare the two approaches to see if using MRI could reduce unnecessary biopsies and overdiagnosis while still effectively detecting significant prostate cancers.
Promising Findings
The study's findings are encouraging for improving prostate cancer screening:
• Significant Reduction in Overdiagnosis: By using MRI scans to decide whether a biopsy is necessary, the researchers found they could significantly reduce the detection of low-risk prostate cancers—by 57%. These clinically insignificant cancers typically grow very slowly and may never cause any health problems. Avoiding unnecessary detection spares many men the stress, side effects, and potential complications of treatments they might not have needed.
• No Increase in Missed Serious Cancers: Importantly, the MRI-guided approach did not substantially miss the more serious prostate cancers that require treatment. The rates of detecting clinically significant cancers (those more likely to grow and spread) were similar between the MRI-guided group and the traditional screening group.
• Safety in Skipping Biopsies: Skipping biopsies in men whose MRIs didn't show suspicious lesions did not lead to an increase in advanced or high-risk cancers being detected later. In the short term, it appears safe to delay or avoid biopsies in men with elevated PSA levels but negative MRI results.
Implications for Screening Practices
These results suggest integrating MRI scans into the screening process can significantly improve prostate cancer detection practices. However, several considerations are important:
• Individual Risk Assessment: Healthcare providers should consider individual risk factors when making biopsy decisions, especially for men with elevated PSA levels but negative MRI scans. Factors like family history, age, and overall health can help determine the best course of action.
• Quality of MRI and Expertise: The effectiveness of the MRI-guided approach depends greatly on the quality of the MRI scans and the expertise of the radiologists interpreting them. High-quality imaging and experienced professionals are essential to accurately detect significant cancers and ensure the best outcomes for patients.
Limitations of the Study
While the study provides promising evidence, it's important to consider some limitations:
• Single-Center Design: The study was conducted at a single medical center in Gothenburg, Sweden. This means the results might not apply to other settings with different healthcare systems or patient populations.
• Homogeneous Population: The participant group was quite homogeneous—mostly White men. This underrepresentation of other ethnic groups means the findings might not be applicable to more diverse populations.
• Short Follow-Up Duration: The median follow-up time was 3.9 years, which may not be long enough to assess long-term outcomes like prostate cancer mortality rates.
These factors should be considered when generalizing the results to other men who might benefit from improved prostate cancer screening methods. Therefore, clinicians should always incorporate information about other risk factors into the decision-making process.
Summary
The MRI-targeted biopsy strategy offers a promising advancement in prostate cancer screening by effectively reducing the overdiagnosis of clinically insignificant cancers without substantially increasing the risk of missing significant ones. While the study provides encouraging evidence supporting this approach, some study limitations must be remembered when making decisions about management. By optimizing screening protocols and incorporating individual risk assessments, healthcare providers can improve prostate cancer detection and patient outcomes while minimizing unnecessary interventions.
Prostate cancer screenings are a hot mess—time for a major reform
By Howard Wolinsky
A new report in JAMA Oncology points out a troubling situation—the muddled, conflicting guidelines for prostate cancer.
“Guidelines are clear on when women should get mammograms to screen for breast cancer, but men face conflicting and confusing advice on prostate cancer screening. This is concerning, given that prostate cancer is the most common cancer and the second most common cause of cancer death among men in the US.,” said researchers Sigrid V. Carlsson, MD, PhD, MPH & William K. Oh, MD.
They added: “Randomized clinical trials (RCTs) have shown that regular prostate-specific antigen (PSA) screening can reduce prostate cancer mortality by 30% within 2 decades of follow-up (re-analysis of the European Randomized Study of Screening for Prostate Cancer and the Prostate Lung Colorectal and Ovarian Cancer Screening trial). Yet, recommendations from guideline groups vary widely. In our view, guideline groups must come together to agree on a framework that produces clear and unified recommendations on prostate cancer screening,” they wrote.
The article includes a detailed table laying out the guidelines: View LargeDownload
Guidelines are clear on when women should get mammograms to screen for breast cancer, but men face conflicting and confusing advice on prostate cancer screening.
Researchers note: “Most professional organizations recommend shared decision-making but differ on important aspects such as start age, stop age, and frequency of screening.”
They lay out an approach to developing new guidelines, urging there not be too much reliance on randomized controlled studies, that race and ethnicity be taken into consideration, and that developers avoid a host of statistical problems.
Finally, they note: “PSA screening is here to stay. The question is whether guideline groups can synthesize current knowledge to assist men, their families, and clinicians on deciding how to best balance its benefits and harms. We call for a process that transforms how we think about prostate cancer screening: a consensus conference with stakeholders, integrating the best available evidence—not limited to RCTs but including epidemiologic and modeling studies—and allowing for differences in opinions and interpretations of the available data. Our guidelines must address the context of current clinical practice wherein thousands of PSA tests are being ordered every day and yet more than 35, 000 men are dying of this atrocious and possibly preventable disease in the US every year.”
Kitted out shamelessly with GU Cast PCa swag
By Howard Wolinsky
I spoke recently to the GU CAST podcast by two outstanding Aussie urologists, Declan Murphy and Renu Eapen. We had a good time.
I was making my usual pitch for men avoiding unnecessary treatment and being able to live with low-risk prostate cancer with active surveillance.
I have been on AS since December 2010 so I am still celebrating my pros-mitzvah year.
Declan, Renu and Katie kitted me out with swag. I shamelessly suggested they needed a baseball hat to add to the collection.
My wife Judi is calling me "merch boy." Vive la merch.