A 64-Year-Old Man with Elevated PSA Levels - Episode 10

Remaining Unmet Needs and Future Directions in Prostate Cancer Screening

Judd W. Moul, MD, FACS, wraps up by discussing remaining unmet needs and potential future improvements in imaging modalities for prostate cancer screening.

Patient Case: A 64-Year-Old Man with Elevated PSA Levels

  • A 64-year-old-man underwent PSA testing during his annual physical with his primary care physician; PSA was 5.6 ng/mL and PSA density was 0.16.
  • He then saw a urologist, who ordered a multiparametric MRI; result was PI-RADS 4.
  • The patient was reluctant to undergo a prostate fusion biopsy, therefore the patient’s urologist recommended that he undergo exosome-based molecular testing to help determine risk of prostate cancer; his test score was 16.3.
  • The patient and urologist remained concerned about his PI-RADS 4 MRI score. The urologist also noted that the PSA density of 0.16 was slightly above the threshold of 0.1.
  • The patient elected to undergo TRUS-guided biopsy, which was negative for prostate cancer.

Judd W. Moul, MD, FACS: The unmet needs in prostate cancer screening, since we’ve been talking mainly about screening and biomarkers, I think the biggest unmet need is trying to encourage the United States Preventive Services Task Force to change their recommendations on screening for prostate cancer. Currently, they have a guideline letter of C, which means that the primary care doctor should mention the PSA [prostate-specific antigen test], but not necessarily recommend the PSA and just talk about it, the pros, and cons, and let the patient ultimately decide if he wants to be screened. But we’ve seen the death rates from prostate cancer go up in light of the lack of screening. I would certainly like to see the guideline change to a B rating, I don’t think they’ll go to an A, but I would like them to change it to a B, where the benefit outweighs the harm.

Beyond that, we have to change men’s behavior. There are still too many men who just don’t go to the doctor no matter what the guideline is, or even if they have an elevated PSA, they don’t show up for their follow-up visit with their urologist or don’t show up for their biopsy. We see that a lot in our practice, sadly. Those are unmet needs. Then for the patient who’s compliant and comes in and gets his PSA test, we need to get more data to fine-tune how we use these secondary tests, where we employ the MRI, and which type of biopsy ultimately is the best type. Another final unmet need is the fact that even if we use MRI, the consistency around the country needs to be improved. The quality assurance continues to need to be improved because the quality of these MRIs does vary depending on whether it’s done in an academic institution or in a more private practice setting. It’s variable, so that needs to get better.

Obviously, MRI has had the biggest impact over the last several years, as far as imaging. I think there are going to be more biomarkers coming to market, potentially other blood markers and urine markers, which will be coming to fruition in the next decade. As far as imaging, there are 2 fields that might change the picture. One is, there are developments with regard to prostate ultrasound, a more accurate ultrasound, which could potentially replace the MRI fusion biopsy in the future, meaning as the prostate ultrasound gets better, it might eliminate the need for an MRI. That’s something that’s on the horizon. Then PET [positron emission tomography] scanning, using tracers to visualize prostate cancer using nuclear medicine technologies, that’s an exploding field. And it’s possible that over the next decade or the next 2 decades, as that technology improves, I could see a day where we can employ PET scanning specifically focused on the prostate, maybe combined with a more accurate ultrasound, or even a more accurate MRI, to further increase the accuracy of that initial prostate biopsy. It’s an exciting time, and we could see further advances that could change the field over the next 10 to 20 years.

Transcript edited for clarity.