Tag: PSA

Could MRI Move the Needle in Prostate Cancer Workup?

Posted on by Virginia Hunt

Traditional systematic biopsy can miss clinically significant prostate cancers and often causes discomfort for patients along the way. While many countries have added MRI to prostate cancer workup protocols to determine which patients really need the needle, pre-biopsy MRI is used in only about one-third of U.S. prostate cancer workups – why?

More organized prostate cancer screening programs are popping up across the world. But a big challenge remains: deciding which patients with elevated PSA tests should undergo biopsy, and which ones can avoid or defer biopsy. That’s where MRI comes in…

  • ​​Australia, Canada, the U.K., and much of Europe have all adopted pre-biopsy MRI scans as the standard of care.
  • Pre-biopsy MRI scans are noninvasive and much more sensitive than traditional systematic biopsies, which typically obtain 10-12 cores to find lesions (93% vs. 50%).
  • The pace of MRI adoption for prostate cancer workup reflects ongoing disparities, with Black patients, people living outside cities, and Medicaid-eligible populations less likely to have access.

So, what’s the holdup in the U.S.? A new STAT article broke it down, finding:

  • Many U.S. urologists haven’t been trained in using MRI findings and/or performing MRI-targeted biopsy.
  • MRI access is still an issue across the country, especially in rural areas.

But something else may factor in: money. 

  • Biopsies can often be done in-house, so each procedure could mean up to $1.5k in reimbursement. 
  • Biopsies can detect low-grade cancers that might never become clinically significant, potentially leading to additional surveillance and repeat biopsies, which also generate revenue. 
  • Greater MRI use could reduce biopsy-related revenue.

Still, some organizations say yes to pre-biopsy scans, including the National Comprehensive Cancer Network, the American Urological Association, and the American Society of Clinical Oncology (albeit conditionally for the latter two).

  • Plus, a 2020 paper won over insurance companies to cover prostate MRI — but not all clinicians know that.
  • MRI scans have also proved helpful in other areas, like staging prostate cancer.

What could move the needle?

  • Training, ideally in urology residency, to overcome the knowledge gap early.
  • Education aimed at urologists and patients about reimbursement options and clinical benefits.
  • Improved access to high-quality MRI across the U.S.
  • Unified, implementation-focused programs like the one trialed in the Czech Republic, which led to a 10-percentage-point increase in pre-biopsy MRI utilization.

The Takeaway

The STAT article shows the U.S. is lagging far behind other countries in using MRI to diagnose and manage prostate cancer with more precision. Even though some major medical organizations are on board, broader implementation of MRI for patient workup requires overcoming limited training, barriers to technology access, and financial incentives that may favor biopsy.

MRI for Prostate Cancer Staging

Posted on by Brian Casey

Digital rectal exams for prostate cancer staging could become a thing of the past thanks to MRI. A new study in JAMA Network Open found that MRI performed as well as digital exams in determining the extent of prostate cancer disease.

Prostate cancer screening is moving closer to becoming a more widely accepted test, and MRI has played a major role in that evolution by enabling more precise workup of men with high PSA levels.

  • But what about other aspects of prostate cancer diagnosis and treatment, such as staging men found to have clinically significant disease? It turns out MRI has a role to play there as well. 

To learn more, researchers from Germany looked at data from 4.4k men with a median age of 66 and median PSA level of 7.4 ng/mL (anything over 3 ng/mL is typically referred for additional workup). All patients were scheduled for radical prostatectomy. 

  • Patients received digital rectal exams to assign clinical T stage and assess characteristics of cancer severity, such as local tumor extent, extracapsular extension, and seminal vesicle invasion. 

This was compared to multiparametric MRI scans on 1.5T or 3T systems, with data reported using the PI-RADS scale. The study’s primary outcome was distant metastasis-free survival. 

Among the patient cohort, researchers found…

  • MRI staging was slightly more accurate than digital exams for predicting biochemical recurrence-free survival (C index = 0.62, with 0.5 representing chance-level prediction and 1 indicating perfect prediction). 
  • And MRI was also better at predicting distant metastasis-free survival (C index = 0.67).
  • But MRI and digital exams were comparable when using four of the major prostate cancer risk classification systems in Europe.

What to make of the results? MRI didn’t have a huge advantage over digital rectal exams, but it was good enough for the authors to suggest that digital exams could be eliminated in favor of MRI workup instead.

  • That would enable clinicians to avoid many of the digital exam’s shortcomings, such as subjectivity, operator dependency, and restricted ability to assess extracapsular extension or seminal vesicle invasion.

The Takeaway

This week’s study shows that MRI’s role in prostate cancer diagnosis and treatment goes beyond just screening, and the digital rectal exam’s role for patient staging could soon become a thing of the past in all but a few cases. 

Cochrane Pivots on Prostate Screening

Posted on by Brian Casey

Prostate cancer screening is getting new support from an unlikely source – the Cochrane group, which historically has been skeptical of population-based screening. Cochrane researchers last week published a new report supporting prostate screening, a sharp change from the group’s previous guidance. 

Prostate cancer screening hasn’t achieved the generally accepted status of other cancer screening tests like breast, cervical, colorectal, and lung. 

  • One of the main sticking points has been overdiagnosis. Prostate cancer can often be slow-growing, and many men live for years with prostate disease before dying of other causes.

But that dynamic has been changing in recent years, in large measure due to the ability of MRI to differentiate aggressive prostate cancer from more indolent disease. 

  • Clinicians are incorporating MRI into prostate screening protocols, using it to determine which men with elevated PSA levels should be biopsied and which ones can be followed with active surveillance. 

For its part, Cochrane is an international non-profit research consortium that periodically analyzes the peer-reviewed evidence behind new medical exams and technologies. 

  • But Cochrane’s work has occasionally been controversial: The group last month published a negative review of Alzheimer’s drugs that included treatments that never made it to market. Also, a Cochrane research center in Denmark for years was one of the most vociferous opponents of mammography screening. 

So that’s why last week’s statement on prostate screening is so surprising, especially given that Cochrane’s 2013 review found no evidence to support the claim that screening reduced prostate cancer mortality. 

In the new review, Cochrane analyzed data from six clinical trials in Europe and North America that included 800k men, finding that screening with PSA blood tests…

  • Detected 30% more prostate cancers overall, most at an early stage. 
  • Reduced the relative risk of a metastatic prostate cancer diagnosis by 35%.
  • Reduced prostate cancer mortality by 2 deaths for every 1k men screened (for comparison, mammography’s benefit is estimated to be 6-8 deaths). 
  • For every 1-2 deaths prevented, 36 additional cancers were diagnosed – a possible sign of overdiagnosis. 

What changed? Cochrane researchers said that we now have longer-term data that makes it easier to detect screening’s subtle mortality benefit.

  • They also cited the success of technologies like MRI in reducing unnecessary biopsies – and the harms of overdiagnosis.

The Takeaway

Last week’s news suggests that the ground is shifting under prostate cancer screening in favor of broader use of the exam, potentially with MRI follow-ups. If you can convince a screening-skeptical group like Cochrane of prostate screening’s value, you can convince anyone. 

Support for Prostate Cancer Screening Grows

Posted on by Brian Casey

Routine prostate cancer screening currently isn’t supported by clinical guidelines. But that could be changing, especially given research presented this week finding that prostate screening – aided by MRI to reduce unnecessary biopsies – was as effective as mammography screening. 

Prostate cancer is one of the leading causes of cancer death, killing some 360k men worldwide every year. 

  • But efforts to develop effective prostate cancer screening programs have been hampered by the challenges inherent in PSA testing, which often identifies indolent disease that may never pose a health risk to patients – the classic definition of overdiagnosis. 

That could be starting to change, however. Researchers are discovering that using MRI to work up patients with rising PSA levels could help identify men with high-risk disease who should be sent to biopsy, while lower-risk patients are monitored with surveillance.

  • New research presented at the European Association of Urology meeting on Sunday supports this idea, showing that – if done right – prostate cancer screening can be as effective as mammography screening.

Researchers from Germany compared prostate cancer screening data from 39.4k men who got PSA tests as part of the PROBASE trial to over 2.8M women who participated in the country’s national breast cancer screening program. 

  • Under the PROBASE protocol, men with confirmed PSA levels ≥ 3 ng/mL underwent MRI and biopsy, while those with lower PSA levels got repeat PSA testing in an effort to keep biopsy rates lower.

Major findings of the study included…

  • Both breast and prostate screening detected a high rate of clinically significant, invasive cancers (73% for mammography vs. 69% for 45-year-old men and 74% for 50-year-old men).
  • False-positive rates were much lower for breast screening (10% vs. 42% and 37%).
  • And fewer indolent cancers were detected with mammography (22% vs. 31% and 26%). 
  • But biopsy rates were comparable (1.1% vs. 0.8% and 2.4%), as the study’s active surveillance protocol limited over-treatment.

While the PROBASE study didn’t use AI as part of its protocol, other research has found that AI analysis of MRI scans can make the modality even more precise, with the PI-CAI study just one worth noting.

The Takeaway

Is it finally time for prostate cancer screening to join breast, colorectal, cervical, and lung among the major population-based cancer screening tests? Results from the PROBASE study at EAU 2026 suggest the time may finally be right.

MRI Reduces Prostate Biopsies

Posted on by Brian Casey

New research provides additional support for MRI’s role in making prostate screening more effective. In a new study in NEJM, researchers found that MRI can help reduce unnecessary biopsies more than 50%, with a very low chance of missing high-risk disease. 

As we’ve discussed in previous newsletters, prostate cancer screening based on PSA levels is an imprecise test. 

  • Many men with suspiciously high PSA (typically 3-4 ng/mL or higher) undergo biopsies that detect clinically insignificant disease that would never present a health risk during their lifetimes – the classic definition of overdiagnosis. 

Adding MRI can help make prostate screening more precise by directing biopsy-based workup to only those men with clinically significant cancer – but questions still abound about exactly when it should be used. 

In new results from the GÖTEBORG-2 trial in Sweden, researchers compared prostate screening protocols in men with PSA levels 3 ng/mL and higher who got MRI scans:

  • One group automatically got systemic biopsy and then MRI-targeted biopsy based on MRI results.
  • The other group only got MRI-targeted biopsy if they had a suspicious MRI scan.

In 13.2k men who were followed up for a median of four years, researchers found that those in whom systemic biopsy was omitted …

  • Had 57% lower risk of clinically insignificant cancers.
  • Had lower relative risk of clinically insignificant cancers in subsequent screening rounds (RR=0.25 vs. 0.49).
  • Had 16% lower risk of detecting clinically significant cancers.
  • Had 35% lower risk of advanced or high-risk cancers.

On the down side, the protocol eliminating systemic biopsy could lead to later diagnoses for higher-risk disease for 3 in 1k men – but given the slow-growing nature of prostate cancer it’s not clear how significant this is. 

  • Also, the data indicate that “most prostate cancers become visible on MRI” before they are incurable, which increases the likelihood that they would at least be detected on subsequent screening rounds and could be treated effectively.

The Takeaway

The new findings should help clinicians hone in on the best prostate screening protocols for maximizing detection of clinically significant cancer while minimizing unnecessary workup. Hopefully, the addition of new technologies like AI can move this process along.

Better Prostate MRI with AI

Posted on by Brian Casey

A homegrown AI algorithm was able to detect clinically significant prostate cancer on MRI scans with the same accuracy as experienced radiologists. In a new study in Radiology, researchers say the algorithm could improve radiologists’ ability to detect prostate cancer on MRI, with fewer false positives.

In past issues of The Imaging Wire, we’ve discussed the need to improve on existing tools like PSA tests to make prostate cancer screening more precise with fewer false positives and less need for patient work-up.

  • Adding MRI to prostate screening protocols is a step forward, but MRI is an expensive technology that requires experienced radiologists to interpret.

Could AI help? In the new study, researchers tested a deep learning algorithm developed at the Mayo Clinic to detect clinically significant prostate cancer on multiparametric (mpMRI) scans.

  • In an interesting wrinkle, the Mayo algorithm does not indicate tumor location, so a second algorithm – called Grad-CAM – was employed to localize tumors.

The Mayo algorithm was trained on a population of 5k patients with a cancer prevalence similar to a screening population, then tested in an external test set of 204 patients, finding …

  • No statistically significant difference in performance between the Mayo algorithm and radiologists based on AUC (0.86 vs. 0.84, p=0.68)
  • The highest AUC was with the combination of AI and radiologists (0.89, p<0.001)
  • The Grad-CAM algorithm was accurate in localizing 56 of 58 true-positive exams

An editorial noted that the study employed the Mayo algorithm on multiparametric MRI exams.

  • Prostate cancer imaging is moving from mpMRI toward biparametric MRI (bpMRI) due to its faster scan times and lack of contrast, and if validated on bpMRI, AI’s impact could be even more dramatic.

The Takeaway
The current study illustrates the exciting developments underway to make prostate imaging more accurate and easier to perform. They also support the technology evolution that could one day make prostate cancer screening a more widely accepted test.

Better Prostate MRI Tools

Posted on by Brian Casey

In past issues of The Imaging Wire, we’ve discussed some of the challenges to prostate cancer screening that have limited its wider adoption. But researchers continue to develop new tools for prostate imaging – particularly with MRI – that could flip the script. 

Three new studies were published in just the last week focusing on prostate MRI, two involving AI image analysis.

In a new study in The Lancet Oncology, researchers presented results from AI algorithms developed for the Prostate Imaging—Cancer Artificial Intelligence (PI-CAI) Challenge.

  • PI-CAI pitted teams from around the world in a competition to develop the best prostate AI algorithms, with results presented at recent RSNA and ECR conferences. 

Researchers measured the ensemble performance of top-performing PI-CAI algorithms for detecting clinically significant prostate cancer against 62 radiologists who used the PI-RADS system in a population of 400 cases, finding that AI …

  • Had performance superior to radiologists (AUROC=0.91 vs. 0.86)
  • Generated 50% fewer false-positive results
  • Detected 20% fewer low-grade cases 

Broader use of prostate AI could reduce inter-reader variability and need for experienced radiologists to diagnose prostate cancer.

In the next study, in the Journal of Urology, researchers tested Avenda Health’s Unfold AI cancer mapping algorithm to measure the extent of tumors by analyzing their margins on MRI scans, finding that compared to physicians, AI … 

  • Had higher accuracy for defining tumor margins compared to two manual methods (85% vs. 67% and 76%)
  • Reduced underestimations of cancer extent with a significantly higher negative margin rate (73% vs. 1.6%)

AI wasn’t used in the final study, but this one could be the most important of the three due to its potential economic impact on prostate MRI.

  • Canadian researchers in Radiology tested a biparametric prostate MRI protocol that avoids the use of gadolinium contrast against multiparametric contrast-based MRI for guiding prostate biopsy. 

They compared the protocols in 1.5k patients with prostate lesions undergoing biopsy, finding…

  • No statistically significant difference in PPV between bpMRI and mpMRI for all prostate cancer (55% vs. 56%, p=0.61) 
  • No difference for clinically significant prostate cancer (34% vs. 34%, p=0.97). 

They concluded that bpMRI offers lower costs and could improve access to prostate MRI by making the scans easier to perform.

The Takeaway

The advances in AI and MRI protocols shown in the new studies could easily be applied to prostate cancer screening, making it more economical, accessible, and clinically effective.  

MRI Makes Prostate Screening More Precise

Posted on by Brian Casey

Prostate cancer screening isn’t a guideline-directed screening test yet, but this could change with the use of MRI and other tools. A series of papers published in several JAMA journals late last week indicates the progress that’s being made. 

As we’ve discussed in previous issues, prostate screening with PSA tests hasn’t met the threshold for clinical benefit achieved by other population-based screening exams.

  • PSA-based screening has been characterized by lower mortality benefits and relatively high rates of overdiagnosis and complications from follow-up procedures. 

But some researchers believe that PSA screening could be made more effective by using additional diagnostic tools like imaging and blood tests to focus on potentially high-risk disease for biopsy while active surveillance is used for less threatening prostate lesions. 

In the ProScreen trial in Finland, researchers tested the combination of PSA, a kallikrein four-panel blood test, and MRI in selecting patients for biopsy. 

  • Patients were sent to MRI if they had PSA scores of 3.0 ng/mL or higher and kallikrein scores of 7.5% or higher; those with abnormal MRI scans got targeted biopsy. 

The researchers tested the ProScreen protocol in a study of 61.2k men, with 15.3k invited to screening and 7.7k getting screened. Over a preliminary three-year follow-up period, researchers found …

  • 9.7% of men met the PSA threshold for a suspicious lesion; this fell to 6.8% after the kallikrein test and 2.7% after MRI, illustrating the protocol’s ability to reduce biopsies
  • Biopsy yield for high-grade cancer was 1.7%, which an editorial called a “remarkably high yield”
  • Overdetection of low-grade disease was 0.4%, compared to 3.2% in a comparable previous study

In a second study, this one in JAMA Oncology, researchers performed a meta-analysis of 80.1k men from 12 studies in which MRI was used to direct patients to prostate biopsy after PSA testing, finding that MRI-directed protocols had …

  • Higher odds of detecting clinically significant prostate cancer (OR=4.15) compared to PSA screening alone
  • Lower odds ratio for biopsy (OR=0.28)
  • Lower odds ratio for detecting clinically insignificant cancer (OR=0.34)

Finally, a secondary analysis in JAMA of a large UK trial illustrates the challenges of prostate screening without MRI guidance. Researchers reviewed 15-year outcomes of the Cluster Randomized Trial of PSA Testing for Prostate Cancer (CAP), a study of 415k men,196k of whom were screened from 2002 to 2009 without the use of MRI, finding … 

  • PSA screening increased detection of low-grade cancer (2.2% vs. 1.6%) but not intermediate or high-grade disease
  • Screening reduced prostate cancer mortality by a small amount (0.69% vs. 0.78%)

The Takeaway

Taken together, new studies offer a roadmap toward making MRI an integral part of prostate screening, such that perhaps in years to come it can join other cancer tests as a population-based screening tool.

MRI’s Value for Prostate Screening

Posted on by Brian Casey

Among cancer screening tests, prostate screening could be the most problematic. But a new study published this week in JAMA Network Open offers guidance on the role that MRI can play in making prostate screening more effective – and opening the door to population-based screening.

The problem with prostate screening is that PSA tests often discover disease that’s either indolent or slow-growing. 

  • This can lead to a cascade of interventions that are expensive and have harms of their own. 

But prostate cancer remains a common – and deadly – cancer, with 1.5M cases globally in 2022, and it’s the second most commonly occurring cancer in men after lung cancer.

  • Given these statistics, there has to be a way to perform prostate screening more effectively.

MRI offers one such alternative, and a clinical consensus has emerged that performing a single MRI scan after a positive PSA result can help stratify men before biopsy. 

  • In this scenario, men might not be referred to biopsy if their MRI scan is negative, and adoption of this protocol has helped reduce prostate biopsies in PSA-positive men while still detecting clinically significant cancer.   

But if one MRI scan is good, are repeat MRI scans even better? In the new study, Swedish researchers investigated this question in a secondary analysis of the STHLM3-MRI trial, which involved repeat screening of 1.5k men 2-3 years after an original prostate screening.

Of the group who got repeat PSA and MRI screening, 667 men had PSA levels of 3 ng/mL or higher, the threshold for MRI testing, with the repeat scans finding … 

  • 51 men (7.6%) had equivocal lesions (PI-RADS score of 3)
  • 33 men (4.9%) had suspicious lesions (PI-RADS score of 4)
  • Only 10 men (1.5%) had lesions with PI-RADS scores of 4 or greater

The findings led the authors to conclude that cancer detection was “limited” in the second round of PSA and MRI prostate screening, and detection of low-grade tumors was low.

The Takeaway

At first blush, STHLM3-MRI may seem like a negative study, but it actually helps frame the debate over prostate cancer screening and MRI’s role by omitting the need for multiple repeat scans. The results also give clinicians confidence that it’s safe to omit prostate biopsies in men who have a single negative MRI result – a key finding in reducing the downstream costs of any population-based screening program.

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