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Rethinking prostate cancer screening: could MRI be an alternative screening test?

Nature Reviews Urology volume 17, pages 526–539 (2020)Cite this article

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Abstract

In the past decade rigorous debate has taken place about population-based screening for prostate cancer. Although screening by serum PSA levels can reduce prostate cancer-specific mortality, it is unclear whether the benefits outweigh the risks of false-positive results and overdiagnosis of insignificant prostate cancer, and it is not recommended for population-based screening. MRI screening for prostate cancer has the potential to be analogous to mammography for breast cancer or low-dose CT for lung cancer. A number of potential barriers and technical challenges need to be overcome in order to implement such a programme. We discuss different approaches to MRI screening that could address these challenges, including abbreviated MRI protocols, targeted MRI screening, longer rescreening intervals and a multi-modal screening pathway. These approaches need further investigation, and we propose a phased stepwise research framework to ensure proper evaluation of the use of a fast MRI examination as a screening test for prostate cancer.

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Fig. 1: Patient with a false-negative PSA test and clinically significant prostate cancer on MRI.
Fig. 2: Patient with a false-positive PSA and a non-suspicious MRI.
Fig. 3: Cost-effectiveness of an MRI screening programme.
Fig. 4: An example of a multi-modal screening pathway that combines a blood-based biomarker with a screening MRI.
Fig. 5: CanTest framework for evaluating diagnostic strategies for the early detection of cancer: research methods and designs.

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Authors and Affiliations

  1. Imperial Prostate, Division of Surgery, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK

    David Eldred-Evans, Mathias Winkler & Hashim U. Ahmed

  2. Department of Urology, Imperial College Healthcare NHS Trust, London, UK

    David Eldred-Evans, Mathias Winkler & Hashim U. Ahmed

  3. Department of Radiology, Imperial College Healthcare NHS Trust, London, UK

    Henry Tam

  4. Paul Strickland Scanner Centre, Mount Vernon Hospital, Northwood, UK

    Heminder Sokhi & Anwar R. Padhani

  5. Department of Radiology, The Hillingdon Hospitals NHS Foundation Trust, Hillingdon, UK

    Heminder Sokhi

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  1. David Eldred-Evans
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The authors contributed equally to all aspects of the article.

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Correspondence to David Eldred-Evans.

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Competing interests

D.E.-E. receives research funding from The Urology Foundation, the BMA Foundation, the Royal College of Surgeons and Imperial Health Charity. M.W. has received a travel grant and a loan of a device from Zicom Biobot. The research of H.U.A. is supported by core funding from the United Kingdom’s National Institute of Health Research (NIHR) Imperial Biomedical Research Centre; he currently receives funding from the Wellcome Trust, Medical Research Council (UK), Prostate Cancer UK, Cancer Research UK, The BMA Foundation, The Urology Foundation, The Imperial Health Charity, Sonacare Inc., Trod Medical and Sophiris Biocorp for trials and studies in prostate cancer; he is a paid medical consultant for Sophiris Biocorp, Sonacare Inc. and BTG/Galil; he is a paid proctor for HIFU, cryotherapy and Rezum water vapour therapy.

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Glossary

Lead-time bias

Lead-time bias provides a false impression of improved survival from a screening test if the test detects a cancer earlier in time but the patient still dies of the disease at the same time.

Length-time bias

Length-time bias occurs if a screening test detects slower-growing cancers with a better prognosis and so appears to increase survival.

Overdiagnosis bias

Overdiagnosis bias is the maximal form of length-time bias where the cancers detected would never have caused symptoms or mortality during the individual’s lifetime.

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Eldred-Evans, D., Tam, H., Sokhi, H. et al. Rethinking prostate cancer screening: could MRI be an alternative screening test?. Nat Rev Urol 17, 526–539 (2020). https://doi.org/10.1038/s41585-020-0356-2

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