Almost 48,000 men are diagnosed with prostate cancer each year in the UK. But questions are asked about the tests that will be used to diagnose these men and how they could be improved.
The tests used today can be painful, invasive, and unfortunately not good enough to tell doctors which cases require urgent attention or which can be monitored over time. This challenge is most evident when looking at the results of screening studies in men without prostate cancer symptoms using the PSA blood test.
But it's a problem as it runs right through the process of diagnosing prostate cancer. And one that needs to be repaired.
"In prostate cancer, we have the problem of overlooking some aggressive cancers while unnecessarily treating many benign cancers," says Professor Malcom Mason, a prostate cancer at Cancer Research UK expert.
There is obviously room for improvement, but what would a good system look like?
"It's not about canceling everything," says Professor Mark Emberton, a prostate cancer specialist from University College London. "It's about finding the right types of cancer ̵
The researchers are working on that. And they are beginning to improve existing tests looking for prostate cancer.
Special MRI – Experience Prostate Cancer Close Up
One important step was to examine the tumor. "We diagnosed and treated prostate cancer for a long time without ever really seeing it," says Emberton. "It all changed with MRI."
This is not some old MRI. The great interest was in a special kind of imaging, multiparametric (or mp) MRI. It combines three or four different scans that can help radiologists get a clearer picture of what's going on in the prostate.
And the findings suggest that it can steer the diagnosis in the right direction – by eliminating the need or helping to follow-up biopsies
In two studies involving over 1000 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 a rectal exam did not need biopsy because the scan had no abnormalities.
And for men who needed a biopsy, the scan results helped doctors take these tissue samples. This made it less invasive and more likely to detect abnormal cells than a standard biopsy.
Specialist MRI scans are not yet a standard part of prostate cancer diagnosis. They will be reviewed by the National Institute for Health and Care Excellent (NICE), which will decide whether or not to recommend the scans as part of the standard NHS prostate cancer diagnosis.
And as with any new technique, there is work to be done to ensure that the way the scans are executed and analyzed is uniform across the UK. Prostate Cancer UK is working with NHS England and hospitals to address issues related to access to MRI scanners and specialist training. And we're running campaigns so there's enough NHS staff to diagnose cancer, including the radiologists who interpret scans.
Put Gleason Class to the Test
Special MRI to guide biopsies as a big step forward. But what if biopsies could be completely replaced? Emberton and his team want to find this out in a new study funded by the Medical Research Council and Cancer Research UK.
You will combine mpMRI with potential new diagnostic tests – for example, DNA delivered by cancer cells into the cell's blood – to see if they can predict the progression of prostate cancer better than the current system: Gleason grade ,
"The Gleason degree has been the mainstay in the diagnosis of prostate cancer for many decades," says Emberton. "But the time might have come to challenge by combining imaging with an understanding of the genetic foundations of prostate cancer."
To do this, they will recruit 1,000 men with abnormal results following a specialized MRI scan of the prostate gland. As part of the study, the men will receive an MRI-guided biopsy and a blood and urine analysis. The team will then monitor the men who use electronic NHS records until they die.
"We can track what treatment men have, how successful it is, and what happens to their cancer over time," says Emberton. "And link that back to the information we received during the 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 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 get results. But according to Professor Mason, the length of the study is what sets it apart.
"Most studies cease when they get the diagnosis of 'clinically significant prostate cancer,' but the problem is, we do not know what it actually is The fact that this project will follow people and look for survival, is a huge strength, "he says.
"We have to wait awhile to get answers, but it will be worth it."  What else is there?
MRI is not the only focus in the diagnosis of prostate cancer; scientists are also testing an ultrasound process called shear wave elastography. This sci-fi technique measures how elastic tissue is. And because tumors are stiffer (or less elastic) than normal prostate tissue, it could provide a way to get information about prostate cancer.
Scientists have tested the technique on 200 men who were due to undergo prostate cancer. They found that the test was able to detect prostate tumors and the results were largely consistent with the Gleason scores. You now need to test shear wave elastography in men who have not yet been diagnosed.
Scientists are not only working to improve the diagnosis, but are also working to identify men who may be at higher risk of contracting prostate cancer. And then think about what you should do with this information. Research shows that black men and men with errors in the genes called BRCA are more likely to develop prostate cancer. But Mason thinks there is more to learn.
"We have some clues as to who might be more likely to develop prostate cancer, but we need to further refine it, looking for more detailed genetic signatures and markers that could help us detect risk."
For Professor Rosalind Eeles of London Institute of Cancer Research means focusing on faulty genes. Eeles has launched an international collaboration to enable researchers around the world access to genetic samples from men with prostate cancer. It could help scientists identify faulty genes more quickly, which not only helps predict who might be at risk, it could also open the door to new treatments.
Diagnosing correctly is a major hurdle in increasing the survival of prostate cancer. But without effective treatments, it would all be in vain.
Fortunately, progress is also being made here.
We support a trial to test drug combinations for men with advanced prostate cancer. STAMPEDE, led by Professor Nick James at the University of Birmingham, has been running for 13 years and has already changed how advanced prostate cancer is treated. It continues to test new drug combinations, with recent results showing that the addition of the targeted drug abiraterone (Zytiga) to standard hormone treatment improves survival by 40%
and for men with prostate cancer who have not spread incremental improvements through use Radiotherapy can reduce side effects and the number of hospital visits.
Experimental treatments, such as high-intensity focal ultrasound (HIFU), could also make waves in the treatment of prostate cancer. The ultrasound technique aims to kill cancer cells with high-intensity sound waves and initial test results suggest that it may work just as well as surgery or radiotherapy. Scientists measure the long-term benefits of the treatment.
Scientists are also testing if experimental laser treatment can help. The futuristic approach called vascular-targeted photodynamic therapy proved safe in early studies. But more research is needed before we know if the treatment can help save lives.
The goal is clear: make prostate cancer diagnosis smarter and more reliable.  There is no quick fix, but with new techniques to get a clearer picture of how prostate cancer progresses, that's what scientists seek. And if they can predict how prostate cancer behaves, it could make the treatment more personal.
"We are working on a system that will allow us to predict how prostate cancer will develop and to choose the right treatment for each person." says Emberton.
Researchers are studying screening for prostate cancer using MRI – they may replace the PSA test