Editorial: MRI Promising for Prostate Cancer Screening in the Asymptomatic General Population

The use of prostate-specific antigen (PSA) testing to screen for prostate cancer is notorious for its small prostate-specific survival benefit and risks of unnecessary biopsy, overdiagnosis and overtreatment. In addition, PSA testing can miss clinically significant cancers.

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In a paper published in JAMA Oncology, U.K. researchers recently reported on a multicenter, prospective study that compared biparametric MRI (bpMRI) with PSA testing and ultrasound elastography for prostate cancer screening in the general community. The results suggested that bpMRI might diagnose more men with clinically significant cancer without increasing the number recommended for biopsy or resulting in overdiagnosis.

bpMRI protocols last less than 15 minutes and do not require a gadolinium-based contrast agent.

In an invited editorial, also published in JAMA Oncology, Susanna I. Lee, MD, PhD, chief of Women's Imaging, and Aileen O'Shea, MBBCh, BAO, clinical fallow, both of the Department of Radiology at Massachusetts General Hospital, commend the researchers on the study design, among them the inclusive recruitment methods and the use of different positivity thresholds for testing.

Recruitment

Having noted the poor response rate among racial/ethnic minorities in previous screening studies, investigators in the Imperial Prostate 1 Prostate Cancer Screening Trial Using Imaging (IP1- PROSTAGRAM) study recruited at study sites with high racial/ethnic diversity. They relied on a range of community outreach activities, such as hanging posters and seeking support from community leaders.

Of 2,034 men invited to participate, 20% consented, and the cohort comprised 38% white, 32.4% Black, 23% Asian and 6.6% other-race or mixed-race men. This is important because Black men are diagnosed with prostate cancer more often and at a younger age.

Positivity Thresholds

The participants underwent all three of the screening approaches. If any test was positive, a systematic biopsy was performed with additional targeted biopsies at the sites of imaging abnormalities. 167 men underwent biopsy. Using a threshold of PSA level ≥3 ng/mL and a score of 3 to 5 on the Prostate Imaging–Reporting and Data System version 2, 17 clinically significant cancers were diagnosed (Gleason score of 3+4 or higher).

When the investigators used imaging scores alone:

• A cutoff score of 3 to 5 resulted in 65 MRI-driven biopsies yielding 14 clinically significant cancers (eight PSA-screen negative) and seven clinically insignificant cancers (six PSA-screen negative)
• A cutoff score of 4 or 5 resulted in 38 MRI-driven biopsies yielding 11 clinically significant cancers (five PSA-screen negative) and five clinically insignificant cancers (four PSA-screen negative)

Thus, with either threshold, adding bpMRI to PSA testing for screening will probably increase the rates of both clinically significant and insignificant cancers.

Ultrasound elastography did not perform better than PSA testing alone.

Exciting Potential

Dr. Lee and Dr. O'Shea predict that if prostate MRI continues to be successful in future trials, it will join mammography and low-dose computed tomography of the lung as a screening test that saves lives and improves the general health of the population.

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