MRI guided prostate biopsy best way of active surveillance for prostate cancer

Prostate cancer is a common type of male cancer which is highly treatable in the early stages. All over the world tens of thousands of men are diagnosed with low-risk prostate cancer. All such patients are asked just to monitor their slow-growing tumours as they need no active treatment.

Magnetic resonance imaging-guided prostate biopsy best way of active surveillance for prostate cancer, find researcher. MRI imaging, let doctors see the majority of prostate tumours and take a biopsy from the exact location of cancer within the prostate.

Doctors relied  on ultrasound to guide a biopsy needle into the prostate in the past. However,  ultrasound doesn't allow the visualisation of prostate tumours, so a biopsy may have missed a tumour. Over the past decade, it's become possible to instead perform a MRI guided biopsy.

Prostate cancer is typically detected with a blood test measuring levels of prostate-specific antigen (PSA). However, elevated PSA levels detect not only aggressive prostate tumours, but also very slow-growing cancers that are unlikely to become life-threatening. Men with higher than usual PSA levels are referred to get a biopsy, in which cells are collected from the prostate reveal more details about a tumour.

We've found that when you use an MRI-guided biopsy to confirm what appears to be a low-risk prostate cancer, you can then tell the patient with pretty good accuracy what the future is going to entail and what his risks are of having a cancer that will require treatment in the future, said the senior author of the study.

If you know exactly where to put the biopsy needle, you've a much better chance of getting answers about a tumour, said a researcher. Earlier this year, his group reported that combining MRI-guided biopsies with a more traditional approach of sampling throughout the prostate detects more cancers than either approach alone. However, he said questions have lingered about the clinical benefit of MRI imaging guided biopsies and exactly when they should be used in the monitoring process.

From 2009-2018, 606 men with prostate cancers of apparent low risk were enrolled in the active surveillance program. For the new study, researchers analysed data on 332 of those men, all of whom received an initial MRI-guided biopsy and at least one follow-up biopsy an average of 3.9 years later.

The researchers found that when a man's prostate tumour had a Gleason Score of 7 at the time of an MRI-guided biopsy, there was a three-and-a-half times greater risk that the man would develop higher-risk cancer compared to men who had a negative biopsy. ( The Gleason Score is a grading system used to determine the aggressiveness of prostate cancer). A score of 6 is generally considered low-risk cancer recommended for active surveillance, while a score of 7 or more may require radiation or surgery.

Moreover, combining an MRI-guided biopsy with the more standard approach of taking a systematic sampling of biopsies from around the prostate boosted the likelihood that a positive initial biopsy result was truly positive.

In the study, the risk of later developing high-grade prostate cancer was less than 8% for men whose biopsies were negative, 11% if the biopsy revealed a Gleason Score of 6, and 23% with a score of 7.

While MRI-guided biopsy is being used, it is still not being very widely used and our results have the potential to establish a new standard for using it in active surveillance, said the researcher.

MRI-guided biopsy can be used to determine which men should receive more frequent follow-up biopsies or even active intervention before a higher-grade tumour develops, he said.

The study also integrated the use of tracked biopsies- in which technology lets physician take a follow-up biopsy from the same location as a previous biopsy to determine how cancer is changing. The team found that the tracked biopsy detected more upward changes in the grading of cancer-- from a low-grade to high-grade tumour-- than non-tracked biopsies. However, more work is needed to study the value of tracked biopsies.

All these new technologies are advancing the field and serving patients better, he said.

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Red meat may increase levels of chemical linked with heart disease

Researchers are working towards developing a non-invasive method to detect prostate cancer through urine sample.

Since cells from the prostate are shed into urine naturally, the new method, which aims to make use of a novel microscope based on a photonic crystal bio-sensor, could offer a more accurate diagnosis. 

"The system we are developing utilises a sensitive bio-sensor, which allows us to distinguish cancer cells from normal cells based on a unique feature of the cells," said a Prof.

"If you can detect a cancer cell, you're starting from a more precise place and you can give a more accurate diagnosis," he added in a statement released.

The new method could significantly improve accuracy compared to the approach used in current clinical practice.

Prostate cancer is the second most prevalent type of cancer, and the third leading cause of cancer-related deaths, in men. Early detection is key to survival, which is why doctors are required to screen all men over the age of 50 for the disease.

To screen patients for prostate cancer, medical professionals take a blood sample and look for prostate-specific antigen (PSA). If a high level of PSA is found, the patient is suspected to have prostate cancer and required to have a prostate biopsy.

Unfortunately, PSA tests are far from providing satisfactory diagnoses and result in a large number of unnecessary prostate biopsies due to a high false-positive rate.

This is because PSA elevation may also occur in men with infection and chronic inflammation or benign prostatic hyperplasia.

"False positive diagnoses are very common in prostate cancer tests," he said.

"As a result, a patient may undergo a biopsy he doesn't need, which is painful and could cause an infection. Also, because prostate cancer is highly heterogeneous and even multi-core prostate biopsy only samples a few local areas, it can easily be missed by clinicians," he added.

Since about 70 percent of men who go through the biopsy process are found to be cancer-free, the Prof. wanted to look for a better way.

"We need to use every weapon in our arsenal to attack this disease," he said.

"It's important to think outside the box and use innovation to address these critical issues," he added.

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Focal Therapy For Prostate Cancer Soon In The GCC

Prostate cancer is the most common cancer affecting men and second most cause of cancer related deaths. Prostate cancer is commonly diagnosed through rectal examination and blood test such as Prostate Specific Antigen (PSA). More recently, Magnetic Resonance Imaging has proven to be a valuable adjunct to cancer diagnosis. The natural history of prostate cancer is indolent with majority of men with prostate cancer more likely to die of other age related causes like myocardial infarction, stroke etc. Hence the treatment of prostate cancer is usually one of the two options – Active surveillance and Radical treatment. It is very important to identify the correct patient for appropriate treatment at the diagnosis of prostate cancer.

Over the last 10 years, researchers in Europe and United States have developed a new treatment option for prostate cancer. In this new treatment, the cancer inside the prostate gland is selectively killed while preserving the remaining prostate. The advantage of this treatment is the cancer is destroyed in the body and simultaneously the harmful complications of treatment are avoided. This treatment is offered as an out-patient procedure and the patient can resume work next day. Patient’s normal life in terms of urinary problems and sexual problems are not affected with this treatment. However, this treatment cannot be offered to all the patients with prostate cancer. There is a series of selection process using scans and biopsy before which this treatment can be offered.

Based on our clinical experience, 20-30% of patients who undergo surgery can be effectively treated with this new treatment and surgery can be avoided. Also Focal therapy can be eligible for patients undergoing Active Surveillance who do not want to have the anxiety of cancer left untreated in the body. US-FDA have very recently approved this new treatment and slowly becoming available in many cities in USA. This treatment will be eventually become available around the world. 

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Everything you need to know about prostate cancer screening

Overall, prostate cancer kills as many men as women killed by breast cancer. Both cancers become more common as we get older, although breast cancer has a higher public profile, perhaps because it is more likely to kill women at a relatively young age. Prostate cancer usually affects older men (though last year actor Ben Stiller talked publicly about his diagnosis at the age of 48).
 
Prostate cancer, already the commonest cancer in African-Caribbean men, is likely to be the most commonly diagnosed cancer overall in the UK by 2030. Zephaniah says: “Prostate cancer has always been a bit hush-hush. I’ve started to lose friends to the disease.” So why the silence? And why is there no national screening programme?

Roger Kirby, professor of urology at the University of London, says the problem with a screening programme is that prostate cancer is very unpredictable: “It can be rapidly growing and kill you, intermediate or slow growing and not cause you much harm. 

Screening picks up all three.” The PSA [prostate-specific antigen] blood test is cheap and easy, but isn’t selective, says Kirby. “You can’t differentiate benign (non-cancerous) prostate enlargement from cancer. And you can’t differentiate slow-growing from rapidly growing cancers.” Men often end up having further investigations, such as a biopsy, that can be painful, time-consuming and anxiety-inducing.

But a major new study has found that if men with a raised PSA have an MRI scan first, many unnecessary procedures could be avoided. The study estimates that adding the extra test could help 27% of men avoid an unnecessary biopsy and reduce the number of men who are “over-diagnosed” (diagnosed with a cancer that does not go on to cause any harm during their lifetime) by 5%.

MRI scanning can help to identify which men with a raised PSA have life-threatening disease. Professor Mark Emberton at University College hospital, a prostate cancer specialist, says every man with an abnormally high PSA should have an MRI. If it’s normal, he does not need further investigation or treatment. But if an abnormal area is seen on the MRI, a guided biopsy is taken. In the days before widespread MRI, biopsies were very hit-and-miss. Kirby agrees that MRI-guided biopsies cause less damage and are more likely to yield results; the samples are analysed to find the severity of the cancer.

Kirby, who has been open about his own experience of prostate cancer, advises men to get an annual PSA blood test done by their GP after the age of 50. Emberton adds that men at high risk of prostate cancer, or with worrying symptoms, should be referred for MRI testing even if their PSA is normal. This will avoid missing the 15% of cases with a normal PSA.

But official NHS policy is that PSA testing is “not accurate enough” to form the basis of a screening programme. The UK National Screening Committee (UK NSC) says: “A raised PSA level can mean a man has prostate cancer, although in some cases it may miss identifying a cancer risk. It can also falsely identify a possible risk of prostate cancer, or find a slow growing cancer. This may result in some men opting to have unnecessary treatments with side effects that can affect daily life.”

However, this policy doesn’t take into account the use of MRI and guided biopsy to fine-tune the result, and find the men harbouring aggressive disease. “We’ve been wrong on cancer screening for 40 years,” says Emberton. But changing the programme to include MRI requires clinical trials, and Kirby says that may take another 10-20 years.

At the moment, official advice to UK GPs says: “The PSA test is available free to any well man aged 50 and over who requests it.” But “GPs should not proactively raise the issue of PSA testing with asymptomatic men”. And “GPs should use their clinical judgment to manage symptomatic men and those aged under 50 who are considered to have higher risk for prostate cancer”.

This woolly advice may account for the confusion that reigns among doctors and patients alike. Symptoms that may suggest prostate cancer include persistent burning, difficulty, frequent, uncontrolled or bloody urination in the absence of any infection.

The main risk factor is age; 80% of all men diagnosed with prostate cancer are over 65 and it remains rare under the age of 50. African-Carribean men have a higher risk of getting fast-growing prostate cancer at a younger age, which is thought to be a result of genetic and environmental factors. Between 5% and 9% of cases occur in men with a strong family history of prostate, breast or ovarian cancer. The environmental factors are unclear but rates of prostate cancer are lower in less urbanised societies and rates rise when people move to a more westernised diet and lifestyle.

There may be two reasons why a GP doesn’t encourage a man to have the test; one is obsolete ideas about the accuracy of testing. Another is out-of-date ideas about the disadvantages of treatment; radical surgery that caused relatively high rates of impotence and incontinence is being superseded by less damaging options with fewer side effects. Treatment of localised prostate cancer which hasn’t spread can also be done by active surveillance (keeping an eye with regular checks), radiotherapy including the less destructive cyberknife, or robotic surgery to remove the prostate gland.

An exciting new treatment, Vascular-Targeted Photodynamic therapy (VTP), has been developed in Israel. This involves injecting a light-sensitive drug into the bloodstream and then activating it with a laser to destroy tumour tissue in the prostate – 49% of patients treated with VTP went into complete remission, compared with 13.5% in a control group. But further trials are needed and it may be several years until it is widely available.

The landscape around prostate cancer is changing rapidly; more rapidly than many GPs may be aware of. The only way you will get tested is if you ask – and the price of keeping quiet may be the difference between an early, avoidable death and peace of mind.

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Family History Important Factor for Prostate Cancer

Research in Sweden published on Monday found family history an important factor in men developing various types of   prostate cancer.

"Men with brothers who have had prostate cancer run twice as high a risk of being diagnosed themselves in comparison to the general population," the study by Umea University and Lund University said.

"It's well known that men with prostate cancer in the family have a higher risk of the disease," said Par Stattin, researcher at the Department of Surgical and Perioperative Sciences and principal investigator of Prostate Cancer data Base Sweden (PCBaSe) , which was the basis for the study. "Prostate cancer is often a rather indolent disease with favourable prognosis that often doesn't require treatment but there are also aggressive types that can be mortal. The ability to differ between these types is therefore important. Up until now, there has been no knowledge about the absolute magnitudes of these risks," Stattin said.

Based on studies there are over 50,000 men in Sweden whose brothers and fathers had prostate cancer. The results show men with one brother with prostate cancer had a 30 per cent risk of being diagnosed themselves before the age of 75. This compares with 13 per cent among other men without a family history of the disease. The group also had a 9 per cent risk of an aggressive form compared with 5 per cent among other men. The results also show men with both a father and a brother with prostate cancer had a threefold risk of prostate cancer themselves: a 48 per cent risk of any form of prostate cancer (compared with 13 per cent among other men) and 14 per cent for aggressive cancer (compared with 5 per cent among other men). Additionally, the risk of an aggressive prostate cancer was typically as high in those whose brothers or fathers had the mildest form as those who had an aggressive prostate cancer in the family.

Swedish National Guidelines for prostate cancer states that men with two or more close relatives with prostate cancer should be recommended for prostate screenings between 40 and 50 years of age.

The check-ups involve regular prostrate-specific antigen (PSA) testing and potentially also examinations of the prostate gland.

The study has been published in the Journal of the National Cancer Institute.

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New urine test improves prostate cancer detection

A new urine-based test has improved prostate cancer detection compared to traditional methods, says a study.

The test, developed at the University of Michigan Comprehensive Cancer Center in the US, is called Mi-Prostate Score, or MIPS. While traditional prostate cancer detection models are based on prostate serum antigen, or PSA, levels, the new method combines PSA with two markers for prostate cancer, both of which can be detected through a urine sample.

"Around 50 percent of men who undergo a prostate biopsy will not have cancer. We need better ways to manage elevated PSA and determine who really needs to have a biopsy. MIPS gives men and their doctors better information to help make those decisions," said lead study author Scott Tomlins, assistant professor at University of Michigan Medical School.

The study looked at around 2,000 men who were undergoing prostate biopsy because of elevated PSA levels. Using urine samples, the researchers conducted MIPS testing and compared results.

"MIPS gives men a more individualised risk assessment for prostate cancer, so that men concerned about their serum PSA levels can have a more informed conversation with their doctor about next steps in their care," Tomlins said.

The test has been available clinically since September 2013. The findings appeared in the journal European Urology.      

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Dental care cuts prostate symptoms

Treating gum disease can offer relief to men suffering from a prostate condition that makes urination difficult, new research has found.

Gum disease treatment reduces symptoms of prostate inflammation, called prostatitis, a disease that inflames the gland that produces semen, the findings showed.

"This study shows that if we treat the gum disease, it can improve the symptoms of prostatitis and the quality of life for those who have the disease," said corresponding author Nabil Bissada from Case Western Reserve University School of Dental Medicine.

Bissada explained that gum disease not only affects the mouth, but is a system-wide condition that can cause inflammation in various parts of the body.

The researchers studied 27 men, 21 years old and older. Each had had a needle biopsy within the past year that confirmed inflammation of the prostate gland, and a blood test that showed elevated prostate specific antigen (PSA) levels--possible signs of inflammation and cancer.

Researchers found 21 of the 27 participants had no or mild inflammation, but 15 had biopsy-confirmed malignancies. Two had both inflammation and a malignancy.

All the men had moderate to severe gum disease, for which they received treatment. They were tested again for periodontal disease four to eight weeks later and showed significant improvement.

During the periodontal care, the men received no treatment for their prostate conditions. But even without prostate treatment, 21 of the 27 men showed decreased levels of PSA.

Those with the highest levels of inflammation benefited the most from the periodontal treatment. Six participants showed no changes.

Bissada hopes to make periodontal treatment a standard part of treating prostate disease, much like cardiac patients are often encouraged to visit their dentist before undergoing heart procedures and a dental checkup is advised for women who are pregnant or considering pregnancy.

The findings appeared in the journal Dentistry.

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Electronic nose to sniff out prostate cancer

An electronic nose can sniff out prostate cancer - the second most common cancer in males - using urine samples, a new study has found.

Researchers in Finland have demonstrated that the eNose can successfully discriminate between prostate cancer and benign prostatic hyperplasia (BPH) by "sniffing" urine headspace (the space directly above the urine sample).

Prostate cancer is one of the leading causes of cancer death. The heterogeneity of prostate cancer makes it difficult to diagnose and predict tumour progression.

Both of the current cornerstones of diagnosis, ie digital rectal examination (DRE) and prostate specific antigen (PSA) have limitations, while ultrasound guided biopsies are costly, uncomfortable for the patient, and have a risk of infection.

Additionally, significant numbers of diagnosed prostate cancers are of low grade and will not cause symptoms or disease-specific mortality.

The eNose used in the new study is a device that consists of a cluster of nonspecific sensors. When the device is exposed to the sample, it produces a profile or a "smell print", researchers said.

"eNoses have been studied in various medical applications, including early detection of cancer, especially from exhaled air," said lead investigator Niku KJ Oksala, of the Department of Surgery, School of Medicine, University of Tampere and Department of Vascular Surgery, Tampere University Hospital, Finland.

"However, exhaled air is a problematic sample material since it requires good cooperation and technique from the patient and immediate analysis, while urine is simple to attain and store, and is therefore more feasible in clinical practice.

"Preliminary data suggested that detection of urologic malignancies from urine headspace was possible. Our own preliminary results on prostate cancer cells encouraged us to launch this prospective clinical study," Oksala said.

The eNose developed by Environics Inc, Mikkeli, Finland was tested on 50 patients who had been diagnosed with prostate cancer confirmed by biopsy, and 15 patients with BPH.

Both groups were scheduled for surgery. The patients provided urine samples before surgery and those with benign disease also provided samples three months after surgery to be used as a pooled control sample population.

Patients with prostate cancer underwent robotic assisted laparoscopic radical prostatectomy, while the benign disease group underwent trans-urethral resection of prostate.

Results with the eNose confirmed that using urine headspace, the eNose is able to discriminate prostate cancer from BPH. The eNose achieved a sensitivity of 78 per cent and specificity of 67 per cent.

The study was published in the Journal of Urology.

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