We are in the middle of a series on prostate cancer.

For this series I am going through a series of guideline statements put out by the American Urological Association and Society of Urologic Oncologists. The Early Detection of Prostate Cancer guidelines can be found HERE

In this episode we are going to cover guidelines 12-16.

Guideline 12. A biopsy of the prostate may identify a cancer with a sufficiently low risk of mortality that could safely be monitored with active surveillance (AS) rather than treated.

This is true. When a prostate biopsy is done it may find a slow-growing, small-volume prostate cancer. We can overtreat prostate cancers. Treatment options all have risk. The goal of identifying prostate cancer is to find those cancers that need treatment and to carefully monitor the rest.

Guideline 13. Clinicians may use magnetic resonance imaging (MRI) prior to initial biopsy to increase the detection of Grade Group (GG) 2+ prostate cancer.

A prostate MRI (Magnetic Resonance Imaging) is a non-invasive imaging technique used to obtain detailed images of the prostate gland and surrounding tissues.

The MRI will be interpreted by a radiologist.

Guideline 14. Radiologists should utilize PI-RADS in the reporting of multi-parametric MRI (mpMRI) imaging.

PI-RADS stands for Prostate Imaging Reporting and Data System. It's a universally applied way of reporting the MRI findings and a way of quantifying risk of cancer.

A higher PiRADS score means that prostate cancer is more likely, but it doesn't confirm a diagnosis. We still need tissue from the prostate to confirm cancer.

Guidelines 15. For biopsy-naïve patients who have a suspicious lesion on MRI, clinicians should perform targeted biopsies of the suspicious lesion and may also perform a systematic template biopsy.

Both the targeted biopsy and the systematic sampling are important. Cancer may be detected only in the target sample or both in the target and the systematic biopsies. The cancer may only be seen in the systematic biopsies and not in the target biopsy.

Guidelines 16 suggest that for patients with both an absence of suspicious findings on MRI and an elevated risk for GG2+ prostate cancer, clinicians should proceed with a systematic biopsy.

This is a guideline guys don’t want to hear. For most patients with a negative MRI who have never had a prostate biopsy the current standard of care is to advise that man to still have a systematic routine biopsy of the tissue.

We are talking again about prostate cancer. We are at the beginning of our journey with men getting screened for prostate cancer using PSA testing and other validated measures to determine if a prostate biopsy should be performed.

For the purposes of this episode, I am going to be referring to the current AUA guidelines on Early Detection of Prostate Cancer updated in 2023. I covered the first 7 guidelines in the last episode. This episode will cover guidelines 8-11. Reference: https://www.auanet.org/guidelines-and-quality/guidelines/early-detection-of-prostate-cancer-guidelines#x18448

Guideline 8: “Clinicians may use digital rectal exam (DRE) alongside PSA to establish risk of clinically significant prostate cancer.”

Guideline 9: "for men undergoing prostate cancer screening, clinicians should not use PSA velocity as the sole indication for a secondary biomarker, imaging, or biopsy."

Guideline 10: “Clinicians and patients may use validated risk calculators to inform the SDM process regarding prostate biopsy.”

Guidleline 11: “When the risk of clinically significant prostate cancer is sufficiently low based on available clinical, laboratory, and imaging data, clinicians and patients may forgo near-term prostate biopsy.”

LINKS to Shared Decision Making Tools

https://www.prostatecancer-riskcalculator.com

https://riskcalc.org

This is the second in our prostate cancer series of podcast episodes.

The quick summary of the episode, the action items are:

1. Talk with your doctor and decide if PSA blood tests are right for you.
2. If your PSA test is elevated, get a second test.
3. If your test is persistently elevated find a good urologist.

Here is the link to the AUA guidelines on Early Detection of Prostate Cancer. https://www.auanet.org/guidelines-and-quality/guidelines/early-detection-of-prostate-cancer-guidelines

Here are the guidelines discussed in this episode.

1. Clinicians should engage in shared decision-making with people for whom prostate cancer screening would be appropriate and proceed based on a person’s values and preferences.
2. When screening for prostate cancer, clinicians should use PSA as the first screening test.
3. For people with a newly elevated PSA, clinicians should repeat the PSA prior to a secondary biomarker, imaging, or biopsy.
4. Clinicians may begin prostate cancer screening and offer a baseline PSA test to people between ages 45 to 50 years.
5. Clinicians should offer prostate cancer screening beginning at age 40 to 45 years for people at increased risk of developing prostate cancer based on the following factors: Black ancestry, germline mutations, strong family history of prostate cancer.
6. Clinicians should offer regular prostate cancer screening every 2 to 4 years to people aged 50 to 69 years.
7. Clinicians may personalize the re-screening interval, or decide to discontinue screening, based on patient preference, age, PSA, prostate cancer risk, life expectancy, and general health following SDM.
8. Clinicians may use digital rectal exam (DRE) alongside PSA to establish risk of clinically significant prostate cancer.

Find more episodes at soundsurological.com or more of what I am working on at tburology.com.

Dr Brandt begins a conversation about prostate cancer. The introduction briefly overviews prostate cancer. Dr Brandt discusses PSA screening

Find more episodes at sounds urological.com and more information at tburology.com.

A brief summary of this episode

Do we have to be crazy to change the world? Maybe. Here’s to the crazy ones who think they can.

Dr. Todd Brandt interviews Tom Bergman, a physician assistant who helps patients prevent kidney stones.

This interview was originally done in March 2023 for the Urological podcast