Topic: Prevention and Screening

Micro Ultrasound and MRI of the Prostate

by Gerald L. Andriole, Jr., MD | Oct 2024

Dr. Gerald L. Andriole, Jr., MD, analyzes the evolving role of micro-ultrasound and MRI in the diagnosis and management of prostate cancer and discusses the advancements in imaging technologies that have significantly improved the accuracy of prostate cancer detection.

In this 13-minute talk, Dr. Andriole begins by examining the limitations of utilizing single imaging techniques, particularly in detecting small, clinically significant prostate tumors. Dr. Andriole explores the complementary role of micro-ultrasound and multiparametric MRI (mpMRI) in prostate cancer imaging. This combination of micro-ultrasound and MRI, he notes, enhances the accuracy of prostate cancer diagnosis.

Dr. Andriole also highlights the clinical implications of these imaging modalities and their potential to reduce the need for unnecessary biopsies and more effectively guide active surveillance strategies. He discusses the ongoing research and developments to integrate these technologies into routine clinical practice.

Transperineal Fusion Biopsy

by Michael A. Gorin, MD | Oct 2023

Michael A. Gorin, MD, discusses transperineal fusion biopsy as a viable alternative to transrectal prostate biopsy and its complications. He emphasizes the gravity of the risk of infection, given the large number of prostate biopsies performed.

Dr. Gorin then displays American Urological Association (AUA) recommendations for infection avoidance, highlighting the strategy of transperineal biopsy. He explains that the European Association of Urology (EAU) recommends transperineal biopsy as the first choice for infection avoidance, citing data from a meta-analysis that show a decrease in complications with transperineal biopsies versus transrectal biopsies by more than half.

Further, he shares data showing improved detection of anterior tumors with transperineal biopsy and explains the positioning of the biopsy cores in transperineal biopsy is superior to that of transrectal biopsy. Dr. Gorin shares further data illustrating improved cancer detection with transperineal biopsy before turning to methods of performing transperineal prostate biopsy.

Dr. Gorin addresses magnetic resonance imaging (MRI) targeting, explaining that as of 2020, the AUA endorses the use of pre-biopsy MRI. He displays data showing improved cancer detection with MRI-targeted biopsy and addresses cognitive fusion and explains that a lack of mapping cores is a drawback but explains that today, there are many options for transperineal MRI/transrectal ultrasound (TRUS) fusion prostate biopsy that include grid, mini-grid, and freehand elements.

Dr. Gorin concludes that transrectal prostate biopsy carries a significant risk of infectious complications and transperineal prostate biopsy reduces these risks and can be performed under local anesthesia. Additionally, multiple systems are available to perform transperineal prostate biopsy with TRUS/MRI fusion.

Optimizing Biopsy Approach Before Precision Prostatectomy

by Arvin George, MD | Sep 2023

Arvin K. George, MD, reviews the strengths and limitations of prostate magnetic resonance imaging (MRI), identifies strategies to optimize the detection of clinically significant prostate cancer, and reviews outcomes of precision prostatectomy. Dr. George begins by addressing the weak predictive value of multiparametric MRI (mpMRI,) calling it imperfect. However, data from the PROMIS study supports mpMRI over transrectal ultrasound (TRUS.)

Dr. George cites data on MRI-targeted, systematic, and combined biopsy for prostate cancer diagnosis, and defines precision prostatectomy as a subtotal prostatectomy that preserves tissue and nerves. Dr. George illustrates two scenarios to support the use of precision prostatectomy in conjunction with a 3D ultrasound to guide treatment—one for biopsy-naive patients and the other for patients with prior biopsy. He then shares data on precision prostatectomy outcomes, in which all patients maintained social continence and 85% of patients maintained potency after one year.

In regards to remission rates, only 6.6% of post-mpMRI biopsy patients presented with clinically significant prostate cancer at 36 months, with over 90% of patients requiring no secondary treatment. Dr. George reiterates that mpMRI is not perfect, but its preservative effects on patients makes it worth further exploration.

About the 26th Annual Southwest Prostate Cancer Symposium:
This conference educated attendees about advances in the management of localized and advanced prostate cancer, with a focus on imaging, technology, and training in the related devices. It included a scientific session, as well as live demonstrations of surgical techniques. You can learn more about the conference here.

Case Discussion: Early Detection of Prostate Cancer

by Thomas E. Keane, MD | Jun 2023

Thomas E. Keane, MD, leads a discussion with Dr. Kader and Dr. Crawford concerning the case study of a 63-year-old patient presenting with increasing PSA levels. The panel navigates through the various considerations and next steps in patient management, with an emphasis on personalized care in prostate cancer management.

After reiterating the importance of gathering comprehensive medical history and meticulously examining the patient’s PSA history, the panel discusses the range of options available, including ordering further tests such as blood or urine tests, an MRI, or even performing a biopsy. The panel explores the complexities behind treatment decision-making, emphasizing the need to carefully weigh the risks and benefits of each approach.

Drawing upon their vast experience, the panel discusses the significance of risk calculators in evaluating the patient’s condition. While these tools provide valuable insights, the panel underscores their limitations, emphasizing the need for continued research and refinement. Additionally, they explore the emerging role of MRI in detecting high-grade prostate cancer, emphasizing the importance of standardized and high-quality interpretation to ensure accurate diagnoses.

Early Detection of Prostate Cancer: Navigating the Challenges in 2023

by E. David Crawford, MD | Jun 2023

E. David Crawford, MD, Editor-in-Chief of Grand Rounds in Urology and Professor of Urology at the University of California, San Diego, discusses the challenges of early detection of prostate cancer (PCa) and recommends a prostate-specific antigen (PSA) cut-off of 1.5 ng/ml. Because most diagnostic testing is completed by primary care physicians who may not understand the nuances of PSA testing, Dr. Crawford recognizes that they need a simple message from urologists. Dr. Crawford contends that PSA testing should be considered as routine as measuring a patient’s cholesterol, especially since more than 70% of men will have a PSA of less than 1.5 and will not require further screening for another 5 to 10 years.

He states that a PSA of 1.5 ng/ml to 4.0 ng/ml may be in a “danger zone” and require additional testing for benign prostatic hyperplasia (BPH), PCa, and PCa risk. Dr. Crawford concludes by reiterating the importance of simple messaging to move forward with effective screening and early detection of PCa.

PSA Screening in 2023

by Gerald L. Andriole, Jr., MD | Jun 2023

Gerald L. Andriole, Jr., reviews evidence supporting a more comprehensive family history and biomarkers in screening and treating prostate cancer. Andriole underscores the power of a well-taken family history. He suggests doctors counsel patients on their hereditary risk of prostate cancer, emphasizing the importance of one diagnosed high risk family member, to reduce the rate of mortality.

Describing the Germline Mutations in Metastatic PCa, Andriole recommends all patients with prostate cancer who have certain characteristics be encouraged to speak to their physicians about whether they may need genetic testing for an inherited mutation. When looking in detail at polygenic risk scores (GRS,) knowledge of high GRS decreased mortality rate.

Andriole highlights the Prompt Test, the direct to consumer, poly-genomic test in the US. In comparison, the UK Biobank data compares prevalence and hazard ratio to show the frequency is higher, some predict cancer aggressiveness. He expects to hear a lot about the prompt test in future.

Dr. Andriole recommends identifying patients with clinically significant PCa earlier through a lower PSA cutpoint. He suggests using image guided Micro US or MRI, or a transperineal biopsy to show potentially indicative biomarkers.

Prostate Cancer Screening in 2023

by Sigrid V. Carlsson, MD, PhD, MPH | Apr 2023

Sigrid V. Carlsson, MD, PhD, MPH discusses prostate cancer screening, focusing on PSA screening, risk calculators, biomarkers, and MRI.

How the Addition of Multiparametric MRI has Changed a Private Practice Setting in Prostate Screening

by Richard G. Barr, MD, PhD, FACR, FSRU | Feb 2023

Richard G. Barr, MD, PhD, FACR, FSRU, describes how mpMRI has changed prostate cancer screening for a small radiology practice group.

Interviews with Icons – Urology Education and the Future of PCa Screening, Detection, and Management

by Neil H. Baum, MD | Feb 2023

Neil H. Baum, MD, and E. David Crawford, MD, discuss the educational mission of GRU, as well as prostate cancer screening, detection, and treatment.

Racial Justice and Prostate Cancer

by Christopher J. Kane, MD, FACS | Jul 2022

Christopher J. Kane, MD, FACS, the Dean of Clinical Affairs at the University of California San Diego School of Medicine, and the CEO of the UC San Diego Health Physician Group, discusses the role of race in prostate cancer mortality among Black men. Dr. Kane presents data showing that both the incidence and rate of death from prostate cancer are significantly higher in Black men, and that this ratio has remained consistent over time. Referencing the SEER database, Dr. Kane notes that Black men were twice as likely to die of prostate cancer. While there are claims that biologic differences between Black and White men are to blame for the rate of death, Dr. Kane points out that the genetic differences between Black men are similar to the genetic difference between White men. He further adds that inheritance patterns of Black Americans are highly variable and cannot be considered a homogenous biological construct. Beyond genetic factors, Dr. Kane mentions other possible causes for the disparity including environmental factors, care dynamics, care quality, and availability. He then reviews a study that analyzed three cohorts to determine whether Black race was associated with inferior prostate cancer outcomes if patients had similar access to care and standardized treatment. The results indicate that Black men were not at higher risk of prostate cancer mortality when they had access to better healthcare. He concludes that physicians can save nearly 4,000 Black men who would otherwise die of prostate cancer each year. Regardless of potential factors impacting disease risk and progression in Black men, Dr. Kane maintains that providing superb screening, detection, and treatment can reduce the observed racial difference in prostate cancer outcomes.

Highlights from the 5th Global Summit on Precision Diagnosis and Treatment of Prostate Cancer

by Faina Shtern, MD | Jun 2022

Faina Shtern, MD, President and CEO of the AdMeTech Foundation, presents key highlights from the 5th Global Summit on Precision Diagnosis and Treatment of Prostate Cancer, a virtual event organized by the AdMeTech Foundation and held from September 23 through September 25, 2021. After introducing the AdMeTech Foundation, Dr. Shtern goes over the rationale for the annual summit and brain trust, explaining that the goal is for multi-disciplinary key opinion leaders to address fundamental challenges in patient care by: developing accurate diagnostic tools; integrating anatomic, biologic, and histologic diagnostics; and integrating precision diagnosis with precision treatment. She discusses the AdMeTech Foundation’s approach, which includes reaching consensus on the best emerging clinical practices, identifying clinical needs and related research priorities, educating the medical community and general public, and expediting the transfer of promising diagnostics and therapeutics to patients. Dr. Shtern then considers the 5th Global Summit specifically, noting that it focused on integrating precision diagnostics and therapies and addressing fundamental problems in prostate cancer care. She summarizes key points from the four meeting sessions, which focused on: the population of men prior to diagnosis with prostate cancer (Session I); the population of men with newly diagnosed localized disease (Session II); precision oncology of advanced prostate cancer (Session III); and image-targeted, minimally-invasive focal procedures. Dr. Shtern concludes by summarizing the key findings of the 2021 meeting’s Panel on Health Disparities and Panel on Bioinformatics, Machine & Deep Learning, and Artificial Intelligence.

Overview of the State of Genetic Testing and Future Applications in Prostate Cancer

by Brian T. Helfand, MD, PhD | Apr 2022

Brian T. Helfand, MD, PhD, Chief of the Division of Urology and the Ronald L. Chez Family and Richard Melman Family Endowed Chair at NorthShore University HealthSystem in Evanston, Illinois, discusses current and potential future applications of genetic testing in prostate cancer screening and treatment. He explains that genetic testing has applications throughout the patient journey. At the prevention and screening stage, genetic testing can determine which men will benefit from screening. At the diagnosis stage, it can determine which men will benefit from biopsy. During early-stage disease, genetic testing can help identify which men will benefit from definitive treatment. Finally, during late-stage disease, genetic testing can identify the men that will benefit from advanced therapies. Dr. Helfand notes that there are two kinds of genetic testing, germline and somatic, and not all tests are relevant at all stages of the patient journey. He then gives an overview of germline genetic testing’s role in screening, arguing that because family history, rare pathogenic mutations (RPMs), and genetic risk score (GRS) all measure risk independently, a comprehensive inherited risk assessment should include all three tools. Dr. Helfand particularly focuses on GRS, defining it as a number calculated based on the cumulative variation across multiple single nucleotide polymorphisms (SNPs), which is then used to provide an estimate of disease risk. He notes that GRS is simple to interpret and more informative than family history. Dr. Helfand also observes that GRS is correlated with number and laterality of tumor cores. GRS, he argues, is useful for risk stratification for both screening and active surveillance. He notes that RPMs can help with stratification in terms of disease aggressiveness. Dr. Helfand concludes by arguing that genetic testing for prostate cancer will be pivotal in the future and should be included in guidelines for both prevention and screening.

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