Precision Diagnosis in Prostate Cancer: Avoiding Overtreatment with MRI

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• Prostate Cancer Diagnosis Revolution
• Lessons from Other Cancers
• The Problem of Blind Biopsies
• Consequences of Overdiagnosis
• MRI-Guided Precision
• Benefits of Targeted Therapy
• Future of Prostate Cancer Care

Prostate Cancer Diagnosis Revolution

Prostate cancer diagnosis is undergoing a fundamental transformation. Dr. Mark Emberton, MD, describes this shift as a revolution driven by precision medicine. The goal is to move from a one-size-fits-all approach to a highly individualized strategy for each patient.

This new paradigm focuses on obtaining a correct, precise, and complete diagnosis before deciding on a treatment plan.

Lessons from Other Cancers

The evolution of prostate cancer diagnosis mirrors advancements in other oncology fields. Dr. Mark Emberton, MD, highlights the history of kidney cancer. Diagnosis once relied on feeling a lump or seeing blood in the urine.

The advent of ultrasound and CT scanning allowed for earlier detection and a more complex description of tumors. This imaging precision enabled "nephron-sparing" surgery, which removes just the cancer and preserves kidney tissue, helping patients avoid kidney failure and live longer.

The Problem of Blind Biopsies

For decades, the standard method for prostate cancer diagnosis was a blind biopsy. Dr. Mark Emberton, MD, explains that urologists would put needles into the prostate gland without knowing the exact location of potential cancer.

This technique was fundamentally imprecise. Its primary goal was simply to determine if cancer was present or absent, not to map its exact size and location within the prostate.

Consequences of Overdiagnosis

The imprecise nature of blind biopsies led directly to significant overdiagnosis and overtreatment. Dr. Mark Emberton, MD, notes that prostate cancer became the worst offender in this regard. Many men were diagnosed with very low-risk disease that would never have threatened their lives.

Despite this, they often underwent radical treatments like a complete prostatectomy (removal of the prostate gland). This meant many people were treated for prostate cancer while very few actually benefited from the therapy, exposing them to serious side effects unnecessarily.

MRI-Guided Precision

The advent of magnetic resonance imaging (MRI) has been the critical game-changer. Dr. Mark Emberton, MD, emphasizes that MRI uses special sequences to pinpoint the exact location of cancer within the prostate gland. This technology involves no radiation and provides a detailed map for urologists.

Instead of blind sampling, doctors can now guide a biopsy needle directly into the tumor itself. This makes the diagnosis far more meaningful and accurate, forming the foundation for all subsequent treatment decisions.

Benefits of Targeted Therapy

A precise diagnosis opens the door to targeted, minimally invasive treatment options. As Dr. Mark Emberton, MD, explains, when you know exactly where the cancer is, you can treat it optimally. Surgeons can operate differently depending on whether the cancer is on the left or right side.

Radiation oncologists can deliver more radiation to the tumor and less to healthy tissue. There is even the potential to treat just the cancer itself and preserve the entire prostate gland.

Future of Prostate Cancer Care

The ultimate benefit of this precision approach is a dramatic improvement in patient quality of life. Dr. Mark Emberton, MD, concludes that by preserving the prostate gland, patients can maintain urinary continence and erectile function.

These are two very common problems associated with whole-gland treatments like prostatectomy or radiotherapy. This shift represents a move away from unnecessary overtreatment and towards personalized, function-preserving cancer care.

Full Transcript

Dr. Anton Titov, MD: Prostate cancer diagnosis has to be correct, precise, and complete. Can you overdiagnose prostate cancer? Prostate cancer overtreatment. Diagnostic methods for prostate cancer are changing. Precision medicine has now reached prostate cancer.

Prostate cancer is an umbrella term for tumors with different characteristics. Prostate cancer diagnostic tests and treatment strategy are constantly evolving and have become complex. What is the diagnostic path to precise and complete diagnosis of prostate cancer?

Dr. Mark Emberton, MD: So this is a really interesting question. It is one that's changing as we speak. It's interesting to look at other cancers and the way that the cancer diagnosis has evolved.

For instance, the diagnosis of kidney cancer was made clinically by feeling a lump or seeing blood in the urine. It was ultrasound and CT scanning of kidney that allowed us to detect kidney cancer earlier. CT allowed us to have much more complex description of what was present in the kidney.

Indeed, it was CT scanning that allowed us to start to see the cancer within the kidney. We could plan surgery in a way that we could remove just the cancer. We could leave as much kidney tissue preserved. This is "nephron sparing" surgery.

Surgery has resulted in many patients living longer because of an avoidance of kidney failure. I think probably the most talked about example of precision medicine treatment is breast cancer.

So 40 or 50 years ago every woman had a mastectomy. Mastectomy is a removal of the front part of the chest wall. It's a huge operation. But that was first the only operation you could have for breast cancer.

And then with mammography we could identify the cancer within the breast. We could decide whether a smaller operation would be sufficient. Clinical trials supported minimally invasive treatment.

In many women, removing a breast cancer lump is as effective as removing the whole anterior chest wall with all the problems that come with it.

Dr. Anton Titov, MD: Cancer surgery becomes minimally invasive.

Dr. Mark Emberton, MD: Correct! And in prostate cancer, minimally invasive treatment hasn't happened yet! We've been removing the whole prostate gland or irradiating the whole prostate gland. Our target has been the prostate gland itself.

That's why for the last 50 or 60 years we've been putting needles into the prostate in a blind manner. We do not really know where the cancer is. We are trying to identify whether the patient has cancer or doesn't have cancer.

If the patient had cancer, we would remove the prostate gland. If patient didn't have cancer, we would discharge them. And it's been like that for a long time.

That meant that men were misdiagnosed with prostate cancer. We missed a lot of prostate cancers. Men had prostatectomy, removal of the prostate, many times unnecessarily.

They had very low risk prostate cancer disease that wouldn't have killed them had the prostate been left in place. And some of you will have heard, some of listeners will have heard, things about cancer overdiagnosis and cancer overtreatment.

Prostate cancer was the worst offender in overdiagnosis. A lot of people were treated for prostate cancer. Very few people benefited from prostate cancer therapy.

And that's the revolution. The last revolution is in prostate cancer diagnosis. It's really the advent of MRI, magnetic resonance imaging, which doesn't involve any radiation.

And many of the listeners and the people watching this will have had MRI for their knees, hips and maybe even their head. But we are directing MRI technology to the prostate.

We are using a lot of special MRI sequences to tell us where the cancer is within the prostate gland. And once we do MRI, we can diagnose the patients with great precision.

We can put the needle into the prostate cancer itself. That makes for much more meaningful diagnosis. But it also opens up the opportunity to treat the cancer patient in an individual way.

So if all you want to do is remove the prostate, every prostate carcinoma patient gets the same treatment. If what you want to do is to treat the cancer optimally, you might operate differently.

If the cancer is on the left or the right, you might put more radiation where the cancer is and less radiation elsewhere. Or you might even try and just treat the cancer itself and preserve the prostate.

Thereby you can preserve urinary continence and also erectile function. These are two problems that are very, very common when we treat the whole prostate gland for cancer.