231211 ART mpMRI Accuracy Detecting Serious PCa Revised Criteria for Biopsy
I am a big proponent for use of a mpMRI during AS (active surveillance). I also believe it has a place in the routine monitoring of PCa in men who have not been diagnosed with PCa. I had PSA’s well below 4.0 and neither of my two Urologists found an anterior tumor that occupied 33% or one third of my prostate via DRE (digital rectal exam)…it was located on the front part of the gland and you could not feel it via the back side of the prostate…who knew?
Well I do now and my Sons are not going to suffer that error. My URO’s should have done a mpMRI to rule out an anterior tumor when they saw that my PSA kept rising month by month, year by year. They also should have considered family history; my Dad and my Grandfather both had PCa. Based on family history and a steadily rising PSA I should have been scanned at a PSA of 2.0 NOT 4.0.
I have said elsewhere that PSA 4.0 level thresholds are obsolete; its meaningless…it was taken from the original cohort of men in the 1980’s landmark study that established PSA as a marker for PCa and is simply 2 times the standard deviation of the PSA that those men had! Its not based on any science or follow on study…its baffling that URO’s still use PSA of 4.0 as a “safe limit.” Its not; take my word for it. Waiting to scan and treat men and allowing PSA to rise is the #1 cause of lawsuits registered by the Harvard Medical School for its graduate URO’s…but we don’t learn.
Now I see that mpMRI’s have their limitations; their NPV (negative predictive values – chance that they are correct) is closer to 77%, not 90% as previously thought! That means that up to 23% of men scanned with via mpMRI with a NEG outcome may be positive for serious cancer. BUT there is a criteria that is provided for those men…PSA Density! If a man’s PSA density is more than 0.1 AND he has a NEG mpMRI he should proceed to a biopsy!
Take note and don’t make the same mistake that I did. PSA of 4.0 is not safe. A DRE wont find all cancer. A mpMRI can help and if its NEG and your PSA density is high, move to a biopsy. Find, treat and cure this disease while its inside your prostate. Once it gets out it’s a totally different condition, disease and prognosis.
Notes from ART;
1. Multiparametric MRI (mpMRI) of the prostate has a negative predictive value (NPV) of 77% for csPCa, defined as Grade Group 2 or higher cancer. Prior research suggested that mpMRI has an NPV approaching 90%.
2. The study included 857 patients across 26 urology practices who underwent 871 prostate biopsies within 1 year of a negative mpMRI. Of these biopsies, 439 were performed in the biopsy-naïve setting and 432 while on active surveillance (AS).
3. The patients had a mean age of 65 years and a median PSA level of 5.6 ng/dL.
4. On multivariable analysis, a PSA density of 0.1 or higher was significantly associated with 5.1-fold greater odds of finding csPCa following a negative mpMRI.
5. The investigators concluded that this PSA density threshold should be used for pursuing prostate biopsy following a negative mpMRI.