Prostate cancer detection has undergone a revolution in recent years and Australia has led the world down this path. Most people know about the use of the PSA blood test and rectal examination in diagnosing prostate cancer. However, we also know that whilst these tests are invaluable, they are imperfect.
Australia has pioneered the use of multiparametric MRI (mpMRI) scanning when looking for prostate cancer. This new tool has helped us avoid biopsies in people who don’t need them, as well as given us a target to aim for when we do perform a biopsy. We are no longer shooting in the dark, but aiming for a target.
Also, the adoption of transperineal prostate biopsy instead of transrectal biopsy, has dramatically improved cancer detection and almost eliminated the risk of life threatening infection.
PSMA PET scaning has also significantly helped in determining the extent of the disease, which can significantly affect our treatment choices.
PSA is a chemical made by the prostate. It is a normal product and is not dangerous. It is simply a marker of prostate activity. The commonenst reason for it to increase, is the non-cancerous enlargement (BPH) of the prostate that men get as they age. It can also go up with urinary infections. It can also rise with prostate cancer. It is one of the most improtant tests we do when looking for prostate cancer. However, as discussed, other things can cause it’s elevation, so we can’t rely on it exclusively. There are even some types of aggressive prostate cancer that don’t cause PSA elevation at all. This is why rectal examination and mpMRI can be so helpful.
This is the passage of finger into the rectum to palpate the back surface of the prostate. People often wonder why it is necessary when we have the PSA blood test. It is improtant to remember that some prostate cancers don’t cause an elevation of the PSA and a DRE is the only way the cancer can be detected. These are often the most aggressive prostate cancers.
Australia has led the world in the develpoment of this technology to help diagnose and treat prostate cancer. It is important to remember that this scan does not give a yes or no answer. It will look at the prostate and try and identify areas within it that are at risk of being a cancer. It still requires a biopsy to confirm the diagnosis. It is also improtant to remember that 1 in 5 prostate cancers are invisible on MRI. This is why that it is only used as part of the assessment process, by an experienced specialist.
PSMA PET has been used in Australia since 2016. There is strong evidence to show that PSMA PET is more sensitive at detecting prostate cancer that has spread than the standard tests of CT and bone scan. PSMA PET scanning is used in patients considered to have high risk disease or recurrent disease. It helps in localising and quantifying the extent of disease and therfore help in tailoring treatment.
Taking prostate biopsies through the perineum (area of skin between the scrotum and rectum), rather than through the rectal wall, has led to significant advances in prostate cancer detection and treatment. It has also led to the virtual elimination of life threatenting infections from transrectal biopsies.
It allows the fusion of MRI and ultrasound images to enable the targeting of specific lesions. It also allows acces to the anterior (front) zone of the prostate. It helps ensure that we are not missing significant cancer. An accurate estimation of the amount and grade of the cancer, translates into the best choices of treatment being utilised.
Diagram of MRI/US fusion