Reducing Unnecessary Biopsies, Overdiagnosis in Prostate Cancer Screening

Prostate MRI integration in prostate cancer (PCa) screening pathways was associated with a reduced number of unnecessary biopsies and overdiagnosis of insignificant PCa, according to one study.

Man being scanned by doctor | Image Credi: auremar - stock.adobe.com

This systemic review and metanalysis is published in JAMA Oncology.

To the researchers’ knowledge, this is the first study to assess the performance of MRI in PCa screening.

“Our findings support and potentially strengthen the cumulative evidence suggesting that the use of MRI following initial PSA [prostate-specific antigen] prescreen is associated with decreased detection of insignificant PCa compared with PSA-only approaches,” wrote the researchers of the study. “Thus, MRI may be a useful tool to mitigate the limitations of PSA-based screening, including overdiagnosis of indolent PCa, which can be associated with overtreatment with avoidable complications associated with any therapy.”

In this study, the researchers aimed to evaluate the use of MRI integration with targeted biopsy and its diagnostic value compared with PSA-based screening.

MEDLINE, Embase, Cochrane/Central, Scopus, and Web of Science were searched on May 5, 2023, to identify all studies pertaining to MRI-based screening strategies. Eligible studies were randomized clinical trials and prospective cohort studies that reported data on the diagnosis of prostate MRI in the setting of PCa screening.

The researchers extracted data on the number of screened individuals; biopsy indications; biopsies performed; clinically significant PCa (csPCa); defined as International Society of urological Pathology (ISUP) grade 2 or higher, and insignificant PCas detected.

The primary outcome was csPCa detection rate, and secondary outcomes were clinical insignificant PCa detection rate, biopsy indication rates, and the positive predictive value for the detection of csPCa.

Twelvestudies, including 80,114 men, were included in the analysis. MRI pathway screening was associated with higher odds of csPCa when test results were positive (OR, 4.15; 95% Ci, 2.93-5.88; P ≤ .001) compared with standard PSA-based screening. Additionally, MRI screening was associated with decreased biopsies (OR, 0.28; 95% CI, 0.22-0.36; P ≤ .001) and insignificant cancer detection (OR, 0.34; 95% CI, 0.23-0.49; P = .002) without significant differences in csPCa detection (OR, 1.02; 95% CI, 0.75-1.37; P = .86).

Separate analyses on the timing or MRI and cutoff for biopsy indication revealed that a Prostate Imaging Reporting and Data System (PI-RADS) score of 4 or greater threshold for biopsy selection was associated with increased reduction in detecting insignificant PCa (OR, 0.23; 95% CI, 0.05-0.97; P = .048), as well as biopsies performed (OR, 0.19; 95% CI, 0.09-0.38; P = .01) without differences in PCa detection (OR, 0.85; 95% CI, 0.49-1.45; P = .22).

The researchers acknowledged some limitations to their study, including a small sample size, possible heterogeneity and publication bias, and lack of safety and long-term survival data.

Despite these limitations, the researchers believe the study findings show that integrating prostate MRI with targeted biopsies is effective for the early detection of prostate cancer.

“We found that MRI mitigates pitfalls of standard PSA-based strategies, as it can be associated with fewer unnecessary biopsies and helps to avoid the detection of insignificant cancers while not comprising significant disease detection,” wrote the researchers. “Our results highlight the need to reassess our approach to population-based screening; however, the optimal setup of MRI and biopsy scheme in the screening process requires further evaluation.”

Reference

Fazekas T, Shim SR, Basile G, et al. Magnetic resonance imaging in prostate cancer screening: a systematic review and meta-analysis. JAMA Oncol. Published online April 5, 2024. doi:10.1001/jamaoncol.2024.0734