The National Institute for Health and Care Excellence (NICE) have issued Guideline CG175 stating that men with a raised PSA blood test who require further investigation to diagnose or rule out underlying prostate cancer (PCa) with a view to radical treatment should no longer proceed directly to an invasive prostate biopsy but instead should be offered a multi-parametric MRI scan.
Clinical trials comparing mpMRI with standard ultrasound guided (TRUS) biopsy have shown that mpMRI is much more accurate in detecting PCa and that PCa seen on mpMRI is significant and usually needs treatment. On the other hand when the mpMRI is normal, it is much less likely that a significant PCa is present. Such patients can then safely wait on a closely supervised “Active Surveillance” programme. About a third of patients presenting with a raised PSA but normal-feeling prostate can thus avoid an invasive TRUS biopsy.
There are however still some problems to overcome.
Firstly, GPs cannot order mpMRI scans and not all UK urology departments have appropriate MRI scanners.
Secondly, there is a shortage of radiologists trained to report mpMRI scans and reporting criteria have only just been standardised.
Thirdly, if a scan is normal, there may still be an underlying cancer present as it has been shown that half of such men placed on “Active Surveillance” subsequently develop signs of cancer progression and require active treatment.
Despite these caveats, this is a major step forward which virtually nullifies the argument that PSA screening for PCa leads to “over-diagnosis”. Furthermore, now that Active Surveillance has become the standard UK management of insignificant, non-aggressive PCa, the “over-treatment” argument no longer carries much weight. These historical arguments against screening now have to be weighed against the latest PCa screening evidence showing a 64% fall in PCa mortality in a screening programme involving over 400,000 men just reported from Northern California! ref
Although the UK has no formal screening programme, the Prostate Cancer Risk Management Programme entitles UK men over the age of 50 to have a PSA test. It also flags up those men who are at higher risk of PCa and who should unquestionably be in a screening programme from their 40s until at least their mid 70s: men with a family history of PCa, or breast cancer on their female side, and black men of African or Caribbean heritage.
CHAPS Charity has contributed positively to this NICE guideline updated recommendation which will be published in April 2019.
Reference: Alpert PF. Urology. 2018; 118: 119-126