P Ca Screening – Should MRI be considered as alternate to PSA

• 01 Aug 2020 10:35:27 AM
• |Onco Urology

Dear All,

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 21^st) 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.

 https://www.nature.com/articles/s41585-020-0356-2.pdf

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,

Venu

Comments(2)

• 

  Venugopal P

  01 Aug 2020 10:41:51 AM

  Dear All,

  As the link is not opening to my satisfaction, I am providing the full article

  Venu

  View Document

• 

  Pankaj N Maheshwari

  04 Aug 2020 07:12:31 AM

  Sir,

  Thanks for sharing the articles. As usual it was a very enlightening reading.

  Few facts:

  ·      CaP in India is not as common as the West but with changing life-style, it is increasing.

  ·      Our incidence of Chronic prostatitis is high that falsely raises the PSA and also causes some changes in DRE

  ·      We need to be selective in our biopsies with the aim to reduce unnecessary ones without missing significant CaP

  
  

  We cannot take 9.7 PSA as a cut-off as:

  ·      One reading is not important. Repeating PSA one month after a course of antibiotics may help. 

  ·      Test should be from a proper lab as this is a kit dependent test. 

  ·      At 9.7 we would miss some malignancies. 

  
  

  We cannot take MRI as a screening tool as 

  ·      We do not have adequate good quality MRI units 

  ·      We do not have adequate well-trained professionals for correct reporting.

  ·      The cost would be prohibitive

  
  

  So, we are forced to join these two as is advised in most recent publications. 

  PSA & DRE, if positive or suspicious: Free/total PSA, If suspicious: MRI, If suggestive biopsy.

  If Free/total or MRI is not suggestive: Follow-up while explaining to the patient that we may still miss some non-significant CaP

  Very soon we will have genetic tests like Mi-Prostate score, SelectMDx and ExoDx that will further help us in taking this decision.