Expert urologist Boris Gershman, MD shares his approach to prostate cancer diagnosis, staging, and risk stratification, highlighting the increasing use of advanced imaging modalities in recent years.
Dr. Boris Gershman: The question of which tests we use for prostate cancer diagnosis and how these tests have evolved over time is actually a really interesting question. The traditional approach to screening for prostate cancer has been with prostate-specific antigen screening, or PSA screening. And that has remained the standard of care over several decades. And there have been a couple of randomized trials to examine PSA-based screening for prostate cancer, which generated quite a bit of controversy, in terms of health policy, when they were published. The RSPC and PLCO trials. Because they suggested there was a substantial rate of over-screening, over-diagnosis, and the overall mortality benefits of PSA screening were not as great as initially anticipated. And so this has led, in the last decade, to quite a substantial change in the paradigm of screening for prostate cancer and a lot of efforts to improve biomarker-based screening for prostate cancer. To this then, there is a number of different biomarkers, whether blood- or urine-based biomarkers, to try and improve the detection of clinically significant cancer while reducing the detection of clinically insignificant cancer and potentially avoiding unnecessary biopsies in men who do not have prostate cancer. And perhaps the most important development in the last decade, in my opinion, in this regard, is the innovation in terms of multi-parametric prostate MRI. In many other screening- cancer screening paradigms, for instance, breast cancer screening, imaging plays a very prominent role in terms of the screening paradigm. Biomarker-based testing is rarely used as a single mode for screening. So the multi-parametric prostate MRI, in my opinion, represents a similar innovation, in terms of screening for prostate cancer with imaging-based screening. And the introduction of multi-parametric prostate MRI in the last ten years, with increasing empirical evidence and randomized trials suggesting its utility and benefit in terms of reducing detection of clinically insignificant disease, avoiding unnecessary biopsies in men at low risk for prostate cancer, and improving the detection of clinically significant disease, have really changed the cross-benefit analysis, in terms of prostate cancer screening, and have really established multi-parametric prostate MRI as a standard-of-care, ancillary test in this respect.