Not all prostate MRIs are equal –
The prostate MRI study is considered now to be the best screening tool to detect the 15 percent or so of high-grade potentially deadly prostate cancers. However, not all prostate MRIs are equal as there is extreme variability in study quality and in reliability of image interpretation.
You will recall from the “Unreliable PSA-based Screening Prostate Cancer Hoax Part 1” and the “Unreliable Biopsy & Imaging Reports Prostate Cancer Hoax P2” articles that there are very significant concerns about PSA-based screening and ultrasound-guided prostate biopsies being able to detect the few potentially deadly prostate cancers.
What steps can I take or should have taken to prevent unnecessary evaluation and unneeded risky treatment for prostate cancer? Especially, since many prostate cancers are NOT deadly.
Both the PSA and ultrasound-guided prostate biopsy are highly unreliable.
- First, never get a screening PSA (prostate specific antigen) test as the harm to thousands of men significantly outweighs the possible benefits to a few. Also, the PSA test FAILS to save significant numbers of lives.
- If you did have a PSA test in error or felt the need for the test, never rely on a single result. Steadily upward trending PSAs and or, a PSA density (PSA level is divided by the size of your prostate) greater than 0.16 may indicate the need for an MRI of the prostate with an expert.
- Recall however, that we have no good early warning tests for high-grade prostate cancer and that the PSA especially, is unreliable for indicating possible potentially deadly high-grade cancers as these often produce little or no PSA.
- Despite the hype, there has been no objective evidence that the many other biomarkers available can lead to the early detection of high-grade prostate cancer for curative treatment and survival.
- Do NOT fall for a risky office-based ultrasound-guided prostate needle biopsy sampling randomly only about 0.1 percent of your prostate. Prostate cancer diagnoses based upon a 12-core biopsy are highly unreliable.
MRI imaging of the prostate.
- The prostate MRI is the most reliable screening test for detecting the 15 percent or so of potentially deadly high-grade prostate cancers (close to being foolproof but only in the right hands).
- The MRI evaluates the WHOLE prostate and, based upon imaging details in a properly conducted study, is able to identify reliably with PIRADS 4 and 5 features almost all high-grade cancer anywhere within the prostate and ignore the bogus G6 (Gleason 3+3=6) cancer. Uncommonly, some intermediate-risk cancers may show PIRADS 4 features.
- Because prostate cancers often arise in one to five different areas of the prostate (multifocal) and the MRI scans the WHOLE of the prostate it underscores why the MRI is infinitely better than the unscientific ultrasound-guided needle biopsy sampling randomly 0.1 percent of the prostate.
- If you did have the highly unreliable 12-core needle biopsy, irrespective of what was diagnosed, wait some eight weeks or so before scheduling an MRI to allow inflammatory changes from the needle biopsy trauma to settle and not impact the quality of the images.
- Non-contrast MRIs of the prostate or bp (biparametric) MRIs are standard practice now for prostate cancer screening but only with radiologists skilled in prostate MRIs (should be doing about 1000 per year).
Prostate MRIs with contrast or mp-MRIs.
- If follow up MRI studies are needed after focal therapy, radiation or proton beam treatment, contrast is necessary and these studies are called mp or multi-parametric MRIs.
Prostate MRIs and gadolinium contrast allergy.
- Gadolinium (Gd) is a contrast agent that WAS commonly used during prostate MRIs. However, because of possible toxicity concerns and the knowledge that this agent may not be necessary to detect high-grade prostate cancer its use is now limited. The move towards non-contrast MRIs or bp MRIs has led to cost-savings and reduced side-effects.
- In those with a prior history of contrast allergy or asthma and where contrast administration may still be indicated pretreatment with steroids and antihistamines is an option.
Prostate MRIs and implanted devices. What about hip prostheses, penile implants, defibrillators and pacemakers?
- Despite abundant misinformation regarding MRIs in patients with these devices, MRIs of the prostate are still possible when undertaken by a true expert (personal communication, Joe Busch MD, Buschcenter, Atlanta). Because of device-induced artifact mp-MRIs rather than bp or noncontrast MRIs are ideal. The quality of these studies can vary according to the composition of the device material but usually at least two good MRI sequences are possible. This information along with PSA trends and PSA density can give fairly reliable information as to what is going on in the prostate and whether or not a targeted biopsy is needed.
- Those patients with an implanted device and a contrast allergy can usually still have an mp-MRI as long as they have been pretreated with steroids and antihistamines before the study.
MRIs are NOT all the same.
- Not all prostate MRIs are equal. Although most newer generation MRIs are suitable, many radiologists are not skilled in prostate MRIs (garbage in, garbage out). Additionally, other MRI “detection” options using endorectal coil MRI or, office-based “fusion” techniques are NOT reliable. Regardless of this knowledge, many urologists will have you convinced that their “fusion” study – combining an MRI (likely suboptimal) done somewhere in the past and then “fused” with the trans-rectal ultrasound study done in the office – is reliable. This is not so as the MRI images for your “fusion” study are not in real-time. Of even more concern, many urologists will add a risky, unscientific 12-core biopsy for a 0.1 percent random sampling of your prostate. An irrational process that simply undermines the scientific benefits of a well conducted and well read MRI of the prostate. To underline this point, the highly unscientific random, template or saturation biopsies have NO part in a prostate MRI study.
- All imaging studies like the MRI are read by a radiologist who has to make a judgment call. However, he or she can make incorrect diagnoses because of inadequate knowledge and/or errors-of-interpretation. These errors may be compounded if the technique undertaken to complete the MRI is also substandard.
- Aside from the bp-MRI being useful for screening and detection of potentially deadly high-grade prostate cancers (especially because some high-grade prostate cancers can produce little or no PSA), it is useful for surveillance. Surveillance or monitoring of the prostate can be important for some low-risk cancers because of the phenomenon of field change effects and future cancer development in some of these areas.
Field change effects.
- Field effects concern a biological process where numbers of cells are affected by carcinogenic change(s). Field effects may occur through genetic or epigenetic changes. This process is common in the prostate (like in the bladder) and is the reason why cancer may be found in more than one area of the prostate or develop in another part of the prostate and be of a different grade at a later date during surveillance. Despite the phenomenon of field effects, there is no data indicating that the G6 or 3+4 itself can evolve into a higher grade cancer.
- Whereas most high-grade cancers are identified at presentation some may develop during surveillance for low-risk cancer. This possibility is more likely when several areas of G6 or low-risk 3+4 cancer are being followed. If several areas of cancer are noted, the prostate is deemed “unstable” (because of field effects) and in this situation the risk of a higher grade cancer developing somewhere adjacent to this area of “instability” appears to be increased (personal communication – Dr. Joe Busch).
- However, the risk of high-grade cancer being detected during MRI surveillance for low-risk cancer and significant enough to impact life is believed to be quite LOW. Nonetheless, periodic MRI surveillance especially in those with several low-risk lesions seems reasonable. MRIs may be undertaken yearly or so and then at increasing intervals if no progression or upgrading is detected.
- Be aware though that although MRI imaging is superior to the PSA for detecting high-grade prostate cancers early, there is no objective data to show that MRI imaging and targeted biopsies leads to early detection of high-grade cancers, treatment and, a saving of lives.
MRI-guided prostate biopsy.
- In-bore MRI-guided TARGETED needle biopsies (there’s no objective evidence that needle biopsies spread cancer) can be undertaken on any PIRADS 4 or 5 areas under real-time for confirmation of the target and the disease. These PIRADS 4 or 5 areas commonly harbor high-grade potentially lethal prostate cancer. Also, for bigger growths several areas as well as adjacent areas may be targeted for needle biopsy according to their ADC values to be sure that the highest grade has been identified. And, despite the expense of the titanium needle, the biopsy is important since granulomatous prostatitis (a benign disease) can mimic prostate cancer on an MRI study.
- However, with software improvements there may come a time soon when the prostate MRI study is reliable enough that biopsies are not needed and MRI-guided focal therapy can be undertaken at the same time as the MRI study and diagnosis.
So now you’ve had an MRI done by a radiologist experienced in prostate MRIs.
- If no PIRADS 4 and or 5 areas were detected you can resume periodic monitoring with an MRI in 12 months or so. Random biopsies are NOT done.
- On the other hand, if the MRI showed area(s) of high-grade disease, the targeted biopsy under real-time MRI confirmed disease and, high-grade pathology was validated by a second opinion then, treatment may be a consideration.
- However, before considering treatment of high-grade prostate cancer we need to be sure that it is localized to the prostate. The PMSA PET/CT scan is considered now to be the standard-of-care test for detecting small-volume lymph node spread while the whole-body MRI is useful for detecting small-volume spread to the bones. The so-called standard pelvic CAT scan and bone scan are much too insensitive and unreliable for detecting small-volume prostate cancer spread.
If these studies are negative, a treatment and ideally, a focal treatment may be considered. You will appreciate however, that when there are treatment “options”, no one has objective evidence to say which treatment is best. Otherwise, we wouldn’t be dealing with “options”.
Recall also from the Part 1 article that the 15 year survival from prostate cancer is estimated to be about 96 percent REGARDLESS of the type of treatment. Even more stunning is the revelation that NO treatment has a similar 10-year survival to someone who did have treatment. Watch out.
Coming soon Part 4 – “Treatment” Deception, Prostate Cancer Hoax P4
Here, the arrogance and rot in the prostate cancer industry’s treatment narrative is exposed. Especially for the so-called robotic prostate cancer treatment. A scam where those made vulnerable by a mostly false cancer label are exploited for profit. The “cutting out” of prostate cancer has never saved significant numbers of lives and only caused a great amount of complications, harm and misery. The deceptive marketing of the dangerous robotic prostatectomy is egregious.
Horan, A., “The Big Scare. The Business of Prostate Cancer”
Ablin, R., and Piana R., “The Great Prostate Hoax”
Barrett, S., and Jarvis, W., “The Health Robbers”
Eban, K., “Bottle Of Lies”
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Bert Vorstman BSc, MD, MS, FAAP, FRACS, FACS