P Ca Screening – Should MRI be considered as alternate to PSA
We are in an era where MRI is becoming popular even in Prebiopsy situations of P Ca and there are innumerable articles now available addressing this including a Cochrane review published by FJ Drost et al (2019) showing a pooled sensitivity of 91% (95% CI 0.83–0.95). All this recent reports suggest that MRI should be adopted as a screening test for P Ca. Does it mean that all patients over 45 suspicious of P Ca (many could be asymptomatic and some having LUTS) be subjected to MRI. This will lead to ~1 in 6 men in USA to be subjected to MRI.
In India the study by Sujata Pattawardhan et al recently showed that the need for biopsy in India was only for men with a PSA cutoff level of 8.9ng/mL. Similar opinion has been given by Suryaparakash and he has a higher level for cutoff. If these studies are accepted, are we not performing MRI, which is a costly tool, indiscriminately however useful it might be?
It is true that more csP Ca could be detected by performing MRI and the point raised by several workers is that Prostatic biopsies could be minimised. In a study by Veru Kasiviswanathan et al (2018) suggested that by taking the MRI pathway leads to 28% fewer biopsies when used as a triage test. But the question is should we not perform PSA test as a preliminary prior to embarking on performing MRI. Hugosson et al (2019) and others mentioned that PSA screening had no significant benefit on mortality. There are studies indicating that the benefit from screening was not consistent between countries. Studies have also opined that overdiagnosis remains the most serious harmful effect of PSA screening and has been estimated as occurring in 23–42% of prostate cancers detected by screening. All this bring us to the question as to whether MRI should replace PSA as an alternative Screening tool.
David Eldred-Evans, Anwar R Padhani, Hashim U Ahmed* (2020 Published July 21st) have brought out a thought provoking article on ‘Rethinking P Ca Screening: Could MRI be an alternative Screening Test’. The authors have well orchestrated the need for MRI in the Screening of P Ca.
The incidence of P Ca in India is low as has been well documented by many studies. But our pundits in the field are devoted to making P Ca a common disease and are making an all out war at detecting the disease. Though we are detecting P Ca in early stages, it should be realised that even today we see many cases of P Ca in Advanced Stages. This is true in western countries as well inspite of disease being detected in early stages more often. We are in the process of building RP’s and many are performing RP’s even in Locally Advanced cases and more often with additional treatments that need to be offered making the overall treatment costly. But do we not have to ape the West. RT and even Hormonal therapies (Old as well as New are giving satisfactory out comes in such group of patients. It is well explained in NCCN Asian Guidelines for P Ca that the so called side effects of Hormonal therapy is not valid among Orientals and they are able to tolerate Hormonal therapy over a long duration.
Should we not choose a treatment option that could be beneficial for our patients than opting for a treatment that could enhance the financial burden of a patient? Let us try and make treatment for P Ca less costly and as Prof. HS Bhat has rightly mentioned that the treatments we offer should be ‘Low Cost, but Effective’.
I know I have stuck my head out by making such statements but I am willing to be castigated for these comments. I will be happy to have the opinion of our pundits in this regard.
With warm Regards,