Almost 48,000 men are diagnosed with prostate cancer in the UK every year. But questions are being asked of the tests used to diagnose these men, and how they might be improved.

The tests used today can be painful, invasive, and, unfortunately, not that good at telling doctors for sure which cases need urgent attention, or which can be watched over time. This challenge is most apparent when looking at the results of screening studies in men without prostate cancer symptoms using the PSA blood test.

But it’s an issue that runs right through the process of diagnosing prostate cancer. And one that needs fixing.

“With prostate cancer, we’ve got the problem that some aggressive cancers are being missed, while lots of harmless cancers are being treated unnecessarily,” says Professor Malcom Mason, a Cancer Research UK prostate cancer expert.

There’s clearly room for improvement, but what would a good system look like?

“It’s not about picking up everything,” says Professor Mark Emberton, a prostate cancer specialist from University College London. “It’s about picking up the right cancers—the one’s that will cause harm and need treating. And avoiding the cancers that won’t.”

That’s what researchers are working towards. And they’re starting by improving existing tests that look for prostate cancer.

Specialist MRI—getting up close and personal with prostate cancer

An important step has been getting eyes on the tumor. “For a long time, we diagnosed and treated prostate cancer without ever properly seeing it,” explains Emberton. “This all changed with MRI.”

This is not just any old MRI. The big interest has been in a special type of imaging called multiparametric (or mp) MRI. It combines three or four different scans, which can help radiologists build a clearer picture of what’s going on in the prostate.

And results suggest it can steer diagnosis in the right direction—by ruling out the need for, or helping guide, follow-up biopsies.

In two studies that involved over 1,000 men, scientists found that mpMRI can prevent unnecessary prostate biopsies. The latest results showed that 1 in 4 men with an abnormal PSA test or rectal exam didn’t need a biopsy, as the scan showed no abnormalities.

And for men who did need a biopsy, the scan results helped guide doctors taking these tissue samples. This made it less invasive and more likely to pick up abnormal cells than a standard biopsy.

Specialist MRI scans aren’t a standard part of prostate cancer diagnosis yet. They’re being reviewed by the National Institute for Health and Care Excellence (NICE), which will decide whether or not to recommend the scans as part of standard NHS prostate cancer diagnosis.

And as with any new technique, there’s work to be done to ensure that the way the scans are run and analyzed is consistent across the UK. Prostate Cancer UK is working with NHS England and hospitals to address issues around access to MRI scanners and specialist training. And we’re campaigning so there are enough NHS staff in place to diagnose cancer, including the radiologists who interpret scans.

Putting Gleason grade ‘to the test’

Specialist MRI to guide biopsies looks like a big step forward. But what if it could replace biopsies altogether? That’s what Emberton and his team are aiming to find out, in a new study funded by the Medical Research Council and Cancer Research UK.

They will combine mpMRI with potential new diagnostic tests—such as looking at DNA shed by cancer cells into the blood—to see if they can predict prostate cancer progression better than the current system: Gleason grade.

“Gleason grade has been the mainstay in prostate cancer diagnosis for many decades,” says Emberton. “But the time may have come to challenge it by combining imaging with an understanding of the genetic basis of prostate cancer.”

To do this, they’ll recruit 1,000 men with abnormal results following a specialized prostate MRI scan. As part of the study, the men will have an MRI-guided biopsy, as well as blood and urine analysis. The team will then monitor the men using electronic NHS records until they die.

“We’ll be able to track what treatment men are having, how successful it is, and what happens to their cancer over time,” says Emberton. “And link that back to the information we got during diagnosis.”

At the end of the study, they hope to have a new set of tests that not only diagnose prostate cancer, but also help to guide treatment. This would mean that in the future, men could be diagnosed without the need for an invasive biopsy.

It’s an ambitious study, and it will be a while before we have results. But, according to Professor Mason, the length of the study is what sets it apart.

“Most studies stop when they get a diagnosis of ‘clinically significant prostate cancer,’ but the issue is we don’t know what that actually means. The fact that this project will follow people up and look at survival is a huge strength,” he says.

“We’ll have to wait a while to get answers, but it will be worth the investment.”