Articles on Urological Issues

PROSTATE MRI AND PI-RADS

While CT scans show anatomical pictures of the body such as structures (kidney) or joints (knee, ankle, etc.), Magnetic Resonance Imaging shows a higher detail by imaging at the cellular level. By imaging at a cellular level the images created by MRI are much more detailed and create detailed images of the prostate anatomy whether there is prostatitis, prostate cancer or images of abnormal anatomy.

The magnets in MRIs vary in strength and are rated in Testla (T) units. The strength range is from 0.2T to 3T but the magnet strength used for most health care diagnoses is either 1.5T or 3T. The stronger magnetic field of the 3T provide more detail with less distracting non-pertinent imaging: 3T MRI imaging increases the signal strength and for imaging the prostate the images are more clear.

A prostate MRI is multi-parametric, meaning 4 different imaging techniques are used to evaluate the prostate. The imaging parameters that are used to evaluate the prostate are:

T1 weighted Helpful only in showing areas of hemorrhage from prior biopsies
T2 weighted Defines the different zones of the prostate including the neurovascular bundles. T2 low signal intensity signifies an abnormal area, or “lesion” better stated “Region of interest” (ROI).

In addition to the T1 and T2 images, functional images are needed. There are 2:

DWI Diffusion Weighted Imaging: how quickly water flows through the prostate. With abnormal areas there is restricted diffusion.
DCE Whether or not the ROI takes up the injected medication. If there is contrast enhancement there is increased risk of harboring prostate cancer.

MRI SCORING — PI-RADS
PROSTATE IMAGING REPORTING AND DATA SYSTEM

Radiologists report the findings on prostate MRI using the PI-RADS scoring system. Results are as follows:

PI-RADS SCORERISK OF HAVINGCLINICALLY SIGNIFICANT
PI-RADS 1 Very low 0%
PI-RADS 2 Low 0%
PI-RADS 3 Intermediate 9%
PI-RADS 4 High 23%
PI-RADS 5 Very high 63%

Prostate MRI is an imaging technique that adds much information about the prostate. This allows your urologist to make better informed recommendations when additional evaluation is needed.

The MRI that we recommend is a 3T large bore MRI approximately the size of an average CT. This means that the claustrophobia associated with the older generation MRIs is almost never a problem with the large bore recommended by your urologist. We have our patients MRIs peformed at the only free standing imaging center that has a 3T magnet as well.

PSA—Screening Guidelines and Background

The United States Preventive Services Task Force (USPSTF) changed their PSA screening guidelines from “PSA screening is of no value” (2012) to “PSA screening is of value” (May 8, 2018). This review of PSA screening guidelines is intended to provide insight and clarification.

These guidelines are from the USPSTF and the American Urology Association.

CURRENT PSA SCREENING GUIDELINES

  1. 2018 Men aged 55 to 69 at average risk of developing prostate cancer
  2. Men over age 70 who are expected to live 10 years and have an increased risk of developing prostate cancer
  3. Men aged 45 who have an increased risk of developing prostate cancer: African Americans and those men with one first degree relative with prostate cancer OR who have first degree relatives who have died of cancer of the breast, ovary or pancreas
  4. Men aged 40 with 2 or more first degree relatives with prostate cancer—the highest risk group

RISK FACTORS FOR DEVELOPING PROSTATE CANCER

  1. African Americans: twice the risk of developing prostate cancer.
  2. Men with one first degree relative (father or brother) with prostate cancer: twice the risk of developing prostate cancer. The risk increases with 1 or more family members who died of prostate cancer.
  3. Men who have a first degree relative who died from cancer of the breast, ovary, or pancreas: increased risk of developing prostate cancer.
  4. Men with multiple first degree relatives with prostate cancer—these men are in the highest risk group.

NOTES

  1. The most reliable indicator of prostate cancer is PSA Velocity. The PSA should increase by ~ 0.1 per year. An increase of 0.5 per year is a “Risk Count”. Each time this occurs the risk of developing prostate cancer increases 50%.
  2. Screening intervals can be every two years, especially if the PSA is less than 1.0. “Interval cancers” (cancers detected between screening events) are rare.

BACKGROUND

The first article to prove that PSA was of value in detecting early prostate cancer was published in 1991. This article and FDA approval resulted in PSA screening being widely used in the detection of prostate cancers that would not otherwise be found and detection of prostate cancer at earlier stages.

The effect:

  1. A decrease in the mortality rate from prostate cancer
  2. Detection of prostate cancers at a much earlier stage—when curable
  3. Detection of some prostate cancers that did not need to be treated due to low volume and low grade

DEVELOPMENTS IN PSA SCREENING RECOMMENDATIONS

In 2012 the USPSTF stated that PSA screening was of no value in the early detection of prostate cancer and was associated with significant harms. They recommended all PSA screening be abandoned.

In 2013 an American Urology Association distinguished panel stated:

  • PSA screening is most beneficial in men age 55 to 70 All men for whom
  • PSA screening is recommended should be counseled about the benefits and the potential risks

In the years between 2012 and 2018 the 20-year decline in prostate cancer mortality plateaued. In addition, there has been a significant increase in men presenting with high volume and metastatic prostate cancer who cannot be cured.

In May 2018 the USPSTF reversed their 2012 recommendation and stated that “PSA screening is of value in the age group 55 to 69”

PSA SCREENING—SHARED DECISION MAKING

Men who are appropriate candidates for PSA screening are informed that PSA screening has potential benefits: an increased cure rate due to earlier detection.

  • An elevated PSA can lead to the recommendation to obtain a prostate biopsy. A prostate biopsy takes about ~ 30 minutes to perform and intravenous sedation is commonly used so that there is no discomfort.

Prostate biopsies have risks that are relatively minor:

  • Infection—The risk of infection has been reduced. The nation-wide risk of infection is approximately 4%. With the use of two antibiotics Roper urologists have decreased this risk to approximately 2%. Currently a study is being done that has shown that the risk of infection can be reduced to 0.03%, a reduction from 2 in 100 biopsies to 1 in 300 biopsies.
  • Bleeding in the urine or in the stool is a risk that is minor and generally resolves in 1-2 days

CAUSES OF AN ELEVATED PSA

PSA can be elevated for several reasons:

  • Prostate cancer
  • Inflammation of the prostate (prostatitis)
  • Prostate size: the PSA level depends on the size of the prostate. Men with larger prostates have PSA levels that are higher than men with smaller prostates

WHAT IS THE RISK OF DEVELOPING PROSTATE CANCER

Prostate cancer is the most common cancer in men (after skin cancer) and the second most common cause of cancer death in US men.

In 2018 approximately 170,000 men will be diagnosed with prostate cancer and approximately 30,000 men will die from prostate cancer. The average risk is 17% in US men or 1 in 6.

These are guidelines. PSA screening remains inexpensive and can be useful in evaluation prostate problems. With the patient’s agreement and after a review of the potential benefits and minor risks, physicians will hopefully be more comfortable be more comfortable discussing PSA screening with their patients.

Prostate Cancer Treatment: A Rebuttal of the Associated Press Article of September 15, 2016

On Thursday, September 15, the Post and Courier published an article from the Associated Press (AP) on a study of prostate cancer treatment options. “10-Year Outcomes after Monitoring, Surgery, or Radiotherapy for Localized Prostate Cancer” was published in the New England Journal of Medicine (NEJM).

The NEJM article reported on a study of 1,643 men who participated in a clinical trial. The study included three groups of approximately 500 men, each assigned either to monitoring (no treatment), surgery to remove the prostate, or radiation therapy to the prostate. The conclusion was that at 10 years prostate cancer mortality was equal regardless of the treatment, with no significant difference among the three treatment options.

The AP article did note that “More men being monitored and not treated saw their cancers worsen”.

A quote from the lead author was “There’s been no evidence that treating the disease early on makes a difference”.

The final quote in the AP article was from another of the authors, Dr. Malcolm Mason who noted, “We need something to allow us to identify men with aggressive disease earlier”.

What was not mentioned in the AP article but was noted in the NEJM article was that in the non-treated group 3 times as many men developed spread of their prostate cancer to the bones as compared to men treated with surgery and men treated with radiation therapy.

Also not mentioned by the AP was in the men monitored 25% required treatment (surgery or radiation) due to prostate cancer progression within 3 years of beginning monitoring and a total of 54.8% required treatment prior to the 10-year end of study date.

Lowcountry Urology Clinics contacted Dr. Malcolm Mason regarding what we perceived were significant deficiencies in the study.

Our points:

  1. The study was only a 10-year study. This may seem like a long time but with prostate cancer it is not. SEER (Surveillance, Epidemiology and End Results) data from the US indicate that most men with prostate cancer not treated will live 10 years. What is not mentioned in the AP article or the NEJM article is the quality of life in the final 3-4 years of life with prostate cancer that has progressed: spread of the cancer to bones, inability to urinate, bleeding from the prostate and obstruction of the kidneys.
  2. The study showed a 3 times higher incidence of spread of prostate cancer to the bones in the monitored group compared to the two groups who were treated.
  3. In the group of men monitored, over 50% had experienced progression of disease and required treatment prior to the end of the study.

Dr. Mason’s Response: (shortened for space consideration)

  1. “These are 10-year results in a population in which we really need 15 and 20-year followup. This has to be one of the caveats around the results at this stage – including the relatively low mortality rate of prostate cancer”.
  2. “We have certainly gained tremendously in understanding as you say…we need to discuss the data on disease progression and metastasis rates with our patients”.
  3. “I guess that for men with high risk, localized disease the discussion is somewhat different…yes, the threshold for treatment is lower”.

The Bottom Line:

  1. A 10-year study of treatment options for prostate cancer is not sufficient. At least 15 years and preferably 20 years of follow up is needed in order to make valid conclusions.
  2. In all patients with prostate cancer the grade and extent of the cancer as well as the patient’s age and associated medical conditions need to be considered before the patient and the urologist reach a decision regarding the best treatment.
  3. Many men with untreated prostate cancer will live 10 years. However, this does not consider the significantly impaired quality of life during the last 3-4 years of life in those patients with prostate cancer progression.
  4. Every patient and every prostate cancer is different. There is no “one size fits all” option for treating this complex disease.

The Take-away:

Consult your Lowcountry Urology Clinics Urologist prior to making a decision about the treatment of YOUR prostate cancer.

The History Of Prostate Cancer Diagnosis

Prostate cancer is the most common cancer in the United States for men, and the second most common cause of cancer death in men. In 2016 over 230,000 men will be diagnosed with prostate cancer and over 35,000 men will die of prostate cancer. 

Over the past 25 years the diagnosis of prostate cancer has progressed through 3 stages. The first method of diagnosing prostate cancer dates to the beginning of the last century. Diagnosis of prostate cancer required detection of an abnormal area in the prostate noted by prostate examination and the finding of a hard area within the prostate. 

The second method of diagnosing prostate cancer began in the early 1990s with the discovery of PSA (Prostate Specific Antigen), an indication or marker for the possible existence of prostate cancer. Urologists began evaluating the prostate for the existence of prostate cancer with prostate ultrasound-guided biopsy. In this procedure, urologists use an ultrasound scanner to view the prostate on a monitor in real time. With ultrasound guidance, a needle is guided into the prostate to remove a “core” or small sliver of prostate tissue that can be examined. We use a map or “template” to sample key areas in the prostate where prostate cancers are usually found. In most cases, 10 to 12 cores of tissue are removed and sent to a pathology lab to be analyzed for the presence or absence of cancer. This technique was a major advancement in the early detection of prostate cancer. Currently over one million prostate biopsies are performed annually in the United States using ultrasound guidance. It is a common procedure and our group performs over 500 prostate biopsies per year. 

Although ultrasound-guided prostate biopsy was a major advance in our detection of prostate cancer, ultrasound imaging has limitations. A standard first-time biopsy will miss up to 35% of prostate cancers. 

Urologists have known for many years that prostate cancers can be visualized utilizing MRI (Magnetic Resonance Imaging). With research and evaluation, MRI reliability has significantly improved. The current technology allows sharp and detailed images of the prostate. The combination of imaging techniques is known as Multi-Parametric MRI. This is best performed utilizing powerful MRI imaging. Most MRIs are 1.5T. “T” means Tesla or the strength of the magnet. A 3T magnet increases the ability to visualize the abnormalities that need to be identified in order to find a prostate cancer. 

We needed a 3T magnet due to the imaging advantage over the 1.5T magnets in Charleston. The only group with a 3T MRI in the area that agreed to help us bring this technology to South Carolina was Imaging Specialists. They provided significant intellectual support and also made the financial commitment to purchase the software that will enable this procedure to be performed in Charleston. As a result, Lowcountry Urology now offers Prostate Cancer Diagnosis using MRI Fusion Targeted Biopsy using the UroNav ssytem by Invivo.