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Old 07-13-2010, 02:57 PM   #1
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Question Needle biopsy vs. MRI-S

I'm more confused than ever. If someone has a high PSA, they are usually advised to get an invasive needle biopsy. And more often than not, it turns out to be something other than cancer. Why not get an MRI-S first? If it shows NOTHING, chances are it's not cancer. Wouldn't that save the person from getting a needless biopsy?

An MRI-S may not positively identify cancer but wouldn't it almost certainly indicate the absence of cancer?

Thanks.

Last edited by JohnR41; 07-13-2010 at 02:58 PM. Reason: punctuation

 
Old 07-13-2010, 08:19 PM   #2
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Re: Needle biopsy vs. MRI-S

Quote:
Originally Posted by JohnR41 View Post
If someone has a high PSA, they are usually advised to get an invasive needle biopsy.

Not so fast...

The American Urological Association (AUA), in their free online document titled "Prostate Specific-Antigen Best Practice Statement: 2009 Update" calls on doctors to take several steps in-between so as to minimize needless biopsies. I'll quote:
"...the current policy no longer recommends a single, threshold value of PSA which should prompt prostate biopsy. Rather, the decision to proceed to prostate biopsy should be based primarily on PSA and Digital Rectal Examination (DRE) results, but should take into account multiple factors including free and total PSA, patient age, PSA velocity, PSA density, family history, ethnicity, prior biopsy history and comorbidities."
All of Sub-Section 6 of the document' Early Detection section is dedicated to "When is a prostate biopsy indicated?"

The free and total PSA test is a simple blood test which increases specificity for prostate cancer.

I agree that at that point the MRI-S would give another possible indication that prostate cancer might or might not be present. The free and total PSA test cost would be around $100 (round numbers), and the MRI-S cost might be a couple of thousand dollars. The T3 MRI-S equipment costs around $2-2.5 million, plus the roughly $0.5 million in installation costs. Don't get me wrong, it's got some good uses, but for a doctor who has invested in it, it might be an expensive solution looking for a problem to solve. (looks to me like this is the Wheeler business-model; just an opinion/observation based on how aggressively he is in "sell" mode)

If you are trying to determine whether you have prostate cancer or not, get the free PSA test first, as the AUA recommends. Then, don't be afraid of the biopsy; it's a bit "uncomfortable", but not painful. If you have an endless stream of personal time and money, there is a long list of other tests one could also get which all indicate the possibility of cancer, but they don't confirm it. Could be worthwhile.

-----------------------------------
Added information later on the free PSA test as an edit for the sake of completeness…recognizing that not everyone will be familiar with it.

When someone gets a “PSA test”, the result is the “total PSA” (tPSA) in their bloodstream. The total PSA is, however, made up of two components: the “complex” PSA and the “free” PSA.
• Complex PSA (cPSA) is the amount of PSA in one’s blood that is bound to other proteins. cPSA has no value in measuring risk for prostate cancer.
• Free PSA (fPSA) is the amount of PSA in one’s blood that is freely circulating as a protein and that is not bound in any way to other proteins.
Mathematically, tPSA = cPSA + fPSA

Once both total and free PSA tests are completed (blood draw), a doctor compares the free PSA to the total PSA result to determine the % free PSA.
• The smaller the % free PSA, the more likely the patient is to have prostate cancer. Below 10% is a pretty sure sign of PC.
• Conversely, in men with elevated PSA (total PSA), the greater the % free PSA, the more likely the patient is to have an enlarged prostate or BPH. Above 25% is a pretty sure sign of no PC.

Last edited by kcon; 07-14-2010 at 07:50 AM. Reason: add'l info on free PSA

 
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Old 07-14-2010, 10:17 AM   #3
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Re: Needle biopsy vs. MRI-S

Quote:
Originally Posted by kcon View Post
Not so fast...

The American Urological Association (AUA), in their free online document titled "Prostate Specific-Antigen Best Practice Statement: 2009 Update" calls on doctors to take several steps in-between so as to minimize needless biopsies. I'll quote:
"...the current policy no longer recommends a single, threshold value of PSA which should prompt prostate biopsy. Rather, the decision to proceed to prostate biopsy should be based primarily on PSA and Digital Rectal Examination (DRE) results, but should take into account multiple factors including free and total PSA, patient age, PSA velocity, PSA density, family history, ethnicity, prior biopsy history and comorbidities."
All of Sub-Section 6 of the document' Early Detection section is dedicated to "When is a prostate biopsy indicated?"
How many "needless biopsies" were there with the previous threshold and how many are there now? In other words, what percentage? Have there been any independent studies of this? (I don't think the AUA would be an independent unbiased source.)

Last edited by JohnR41; 07-14-2010 at 10:28 AM.

 
Old 07-14-2010, 10:38 AM   #4
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Re: Needle biopsy vs. MRI-S

Quote:
Originally Posted by JohnR41 View Post
How many "needless biopsies" were there with the previous threshold and how many are there now? In other words, what percentage?
Hi John,

At the moment your question is in the immediately previous post.

There are actually two main thresholds involved, the traditional one at 4.0, and a newer one, strongly pushed by Dr. William Catalona, MD, one of the nation's premier surgeons for prostate cancer and a pioneer in PSA research.

As you might expect, there are more negative biopsies if the lower threshold of 2.5 is used as a trigger for getting a biopsy. Dr. Catalona's research indicated that about 15% more cancers were found at the lower threshold, and of course, they were found earlier. However, only about 15% of that 15% were clinically significant, with the rest appearing to be so small that they would probably pose no risk to the man throughout his life. Well, 15% of 15% is .15 X.15 = 2.25% for significant cancers (pretty low benefit ), caught somewhat earlier than they otherwise would have been.


As far as I know, there has been no study analyzing the added curative success due to catching the cancer somewhat earlier, but, based on great success with the old level (99.4% survival of all white patients at five years, 95% survival of men with challenging cases at ten years, etc.), I'm not seeing much room for improvement. I find I'm looking at the added numbers of biopsies at the 2.5 trigger as well as the cost in peace of mind, earlier burden of care, etc., versus the benefit. Personally, that tradeoff does not look so hot to me, but I've had no enrolled medical education. I'm far from the only one with these concerns, perhaps the reason the AUA declined to endorse a PSA of 2.5 as a trigger point.

I realize this does not answer your specific question, but I thought it might help. I hope you get additional replies.

Take care,

Jim

 
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