MRI, myths, and precision: Stacy Loeb, MD, discusses modern prostate cancer screening

In this interview, which took place at the 2025 LUGPA Annual Meeting, Stacy Loeb, MD, MSc, PhD (Hon), discussed major updates and insights on prostate cancer screening. A key highlight was the change in American Urological Association (AUA) guidelines, which now recommend a baseline PSA test between ages 45 and 50, aligning with National Comprehensive Cancer Network (NCCN) recommendations. Loeb emphasized that a baseline prostate-specific antigen (PSA) in the 40s can predict long-term prostate cancer risk, especially for men without known risk factors. Elevated baseline PSA levels (above 1 ng/mL under age 60) warrant closer monitoring. She underscored the growing trend toward risk-adapted screening, using factors like family history, genetic mutations (ie, BRCA), race, and PSA levels to tailor screening intervals.

Loeb noted that shared decision-making is a unifying principle across guidelines, ensuring patients understand the risks and benefits before testing. Differences persist, such as the biopsy approach—European guidelines favor transperineal methods, whereas guidelines remain flexible—and the varying strength of recommendations for MRI use, which she described as a transformative tool for detection and targeting.

Discussing the 23-year European Study of Prostate Cancer Screening (ERSPC) study, Loeb highlighted its finding that screening significantly reduces prostate cancer mortality, with only 12 diagnoses needed to save one life.¹ She emphasized optimizing screening to maximize benefits while minimizing harms through MRI, biomarkers, targeted biopsies, and greater adoption of active surveillance.

Addressing misinformation, Loeb debunked myths such as biopsies spreading cancer or prostate cancer having early symptoms. She urged clinicians to provide patients with reliable, evidence-based resources—an “information prescription”—and to engage publicly to counter misinformation.

Finally, Loeb emphasized lifestyle factors in prevention, recommending reduced red meat and dairy intake, more plant-based foods, regular exercise, and good sleep. Looking ahead, she predicted that precision prevention and genetic-based personalized screening will shape the future of prostate cancer care.

Urology Times: You are at this year's LUGPA Annual Meeting to give a talk titled, "Current State of Prostate Cancer Screening." Could you summarize the key points from this presentation?

Loeb: One key point is that the AUA guidelines changed. They used to say to start screening for average-risk men at age 55, and now they have aligned with the NCCN [to recommend] a baseline screening between 45 and 50. It's very important to make sure everybody knows that that changed. I believe very strongly in baseline PSAs in the 40s as a very important indicator of the future risk of ever developing a clinically significant prostate cancer. This can be especially helpful for people without known risk factors for prostate cancer, because then we don't really know who is at higher risk in that group. So this is just one added value. And if you have someone with a PSA level that's above 1 [ng/mL] who is under age 60, that is a higher risk for ever developing a clinically significant prostate cancer, and that's somebody who needs to be watched more closely. And now all the guidelines are really recommending more of this risk-adapted screening concept of tailoring the interval between screenings based on somebody's individual risk. That includes some of the traditional risk factors that we think of, like African ancestry, any kind of family history of prostate cancer, or of any kind of genetic variant that is associated with higher risk, such as BRCA. But also, [there is] this concept of using the PSA value as a risk factor, and if somebody's got a higher baseline PSA, doing screening more regularly.

In terms of the AUA and NCCN guidelines on screening, what are the greatest areas of alignment and divergence?

Loeb: I think the strongest alignment these days is on shared decision-making. All the guidelines across the board emphasize the importance of making sure that there is a conversation about the risks and the benefits of screening before doing the test, as opposed to just having it done at a screening fair or as part of a large lab profile without any discussion. That is a pretty common element to all the guidelines. Where there are some differences that are interesting, for example, is on biopsy technique. The US-based guidelines still discuss selection between transperineal and transrectal, whereas the European guidelines now recommend the transperineal method for prostate biopsy. That's one of the main differences. There are also a few differences with respect to how strongly MRI is recommended, whether it should be done or it should be considered. Personally, I think MRI has really been perhaps the most transformative development in the realm of prostate cancer screening since I came into the field, because having this test that provides not only risk stratification, but also localization, and allowing us to do a better biopsy has really made a huge difference.

A major recent headline in prostate cancer screening was the publication of the 23-year ERSPC data. Could you summarize some of the key findings from this study?

Loeb: [This is a] very exciting new report just out from the ERSPC in the New England Journal of Medicine, where they had their 23-year follow-up data showing a significant reduction in prostate cancer death with screening compared to the control arm. One of the important take-home messages was the number needed to diagnose. At this 23-year follow-up, you only needed to diagnose 12 patients with prostate cancer to save a life.¹ That's really exciting to see. It really calls out the benefits of prostate cancer screening and why it is so important that we preserve it. The whole idea is to optimize the benefits and minimize the downstream harms by being more judicious about patient selection for screening using better screening methods, such as the incorporation of MRI and markers, targeted biopsies, and then minimizing the downstream harms with overdiagnosis and overtreatment. That's really been happening already with so much of an increase in the uptake of active surveillance.

Urology Times: There are still some myths circulating among patients, like the idea that prostate biopsies can spread cancer. How do you address these misconceptions with patients.

Loeb: Great question. We've actually just published 2 new papers about online misinformation about prostate cancer that is circulating in social networks, and it is really concerning.^2,3 One of the common myths is that biopsies spread cancer. We really need to be preemptive about these things and make sure that patients know biopsies do not spread cancer. One of the other most common myths that is very concerning in the context of screening is that prostate cancer has symptoms. There are so many posts online that say, "early warning signs of prostate cancer: bone pain, blood in the urine, decreased stream." No, these are not early warning signs of prostate cancer. They can be signs of other things, like BPH, but something like bone pain is a very late-stage symptom of prostate cancer. These kinds of myths are very concerning because somebody may not have any of those symptoms, and then they think, "Oh, I'm fine. I don't need to worry about prostate cancer. I don't have bone pain, I don't have blood in the urine." But that's not the case at all. The whole case is that prostate cancer doesn't have any symptoms at an early stage, and that's why screening is so important. I'm worried about it that way, and I'm also worried about people who may have symptoms like lower urinary tract symptoms - maybe they have a decreased force of their stream, and then they might become terrified that they have cancer, when it's very likely that that's just due to prostate enlargement or a benign cause. We really have to be prescriptive with our patients. What I recommend is an "information prescription." Our job is not just prescribe drugs or surgical procedures, but also to be directive and to give our patients recommended sources for additional information, so that they are not left to this online Wild West that is out there. The other thing is participating in public media. Get out there, do videos, social media, radio, whatever network or modality you prefer. As clinicians, we can really help with this issue by getting out there in whatever way we're comfortable, out in the community and online to share evidence-based information.

Urology Times: What are some of the lifestyle recommendations that urologists can share with their patients in order to reduce prostate cancer risk or progression?

Loeb: This is a very important question, because we have people who are coming in and getting screened for prostate cancer, and they're very worried about their risk, and they often want to know, is there anything that I can do to reduce my risk? And there definitely is, and we should be very clear about that with patients. We should tell them, for example, that red meat and dairy are associated with a higher risk of prostate cancer and that consuming more healthy, plant-based food is associated with a lower risk of developing an aggressive prostate cancer. We should emphasize to our patients the importance of physical activity and other lifestyle factors. It doesn't get discussed a lot, but there's actually a significant relationship between sleep disturbances and prostate cancer risk. These are very common issues that people can actually modify, and so I think it's a really wonderful opportunity to help our patients with lifestyle.

Urology Times: Where do you think the next big advance in screening will come from?

Loeb: It's an exciting time. I think everything is going to become more personalized over time. Already, we're starting to do a lot more genetic testing in the realm of prostate cancer, and I think this is only the tip of the iceberg. There has been a lot more emphasis on precision therapies and taking into consideration genetic factors for patients with advanced prostate cancer. I think that if I had a crystal ball, that in the future, we'll be doing a lot more precision prevention and precision screening as we continue to learn more about each individual's genetic background, and maybe there are specific factors that are influencing their risk of cancer that could be changed.

REFERENCES

1. Roobol MJ, I de Vos I, Månsson, M, et al. European Study of Prostate Cancer Screening - 23-year follow-up. N Engl J Med. 2025;393(17):1669-1680. doi:10.1056/NEJMoa2503223

2. Loeb S, Rangel Camacho M, Sanchez Nolasco T, et al. Downstream impact of social media use and variable quality of online information about prostate cancer. Eur Urol Oncol. 2025 Oct 16:S2588-9311(25)00240-8. doi:10.1016/j.euo.2025.09.004

3. Loeb S, Rangel Camacho M, Sanchez Nolasco T, et al. Classification of inaccurate information about prostate cancer on social media in English and Spanish. Eur Urol Oncol. 2025 Oct 30:S2588-9311(25)00260-3. doi:10.1016/j.euo.2025.10.006