Preventing Overdiagnosis of Prostate Cancer with Improved Diagnostic Accuracy

by Dato’ Setia Dr Tan Hui Meng, Consultant Urologist, Subang Jaya Medical Centre (SJMC)

Prostate cancer is currently the third most common cancer among Malaysian men, following colorectal and lung cancers. Despite its rising prevalence, prostate cancer screening remains a topic of debate among medical professionals and the public.

In many cases, early prostate cancer is localised and slow-growing. It may stay confined to the prostate gland for years without causing any health issues. For these patients, immediate prostate cancer treatment may not be necessary.

The Debate Around PSA Screening for Prostate Cancer

The United States Preventive Services Task Force has issued a Grade C recommendation for PSA screening for prostate cancer, suggesting that men should only screen if they have concerns and after discussing it with their physicians. This was done to reduce overdiagnosis and overtreatment.

However, this cautious approach has also resulted in rising cases of late-stage prostate cancer, leading to increased mortality and suffering. The goal should be to screen the right population and detect clinically significant cancers while avoiding unnecessary treatment for indolent cases.

Multiparametric MRI: A Game Changer in Prostate Cancer Diagnosis

For decades, limited progress was made in the diagnosis and management of prostate cancer. The traditional TRUS biopsy, or transrectal ultrasound-guided biopsy, has been the standard approach but suffers from low accuracy. It often misses at least 50 per cent of clinically important cancers, making it a less reliable biopsy test for prostate cancer.

The introduction of multiparametric MRI of the prostate has revolutionised the landscape. mpMRI, used as a triage tool, can prevent many men from undergoing unnecessary biopsies and help detect aggressive cancers with greater precision.

Studies have shown that mpMRI prostate scans identify more than 90 per cent of men with clinically significant cancers, compared to only 48 percent detected through TRUS. Moreover, mpMRI leads to 54 percent fewer diagnoses of clinically unimportant cancers, reducing the risk of overtreatment.

In summary, multiparametric MRI reduces the chance of overdiagnosis and improves the accuracy of identifying life-threatening prostate cancer.

Should Men in Malaysia Be Screened for Prostate Cancer?

Screening remains controversial, but long-term studies support its value. While some men may not benefit immediately from treatment, consistent follow-up shows real benefits over time.

For example, the Goteborg Randomised Prostate Cancer Screening Trial in Sweden revealed that men who underwent regular PSA screening for over 14 years had a 66 percent lower chance of developing advanced prostate cancer and a 56 percent reduction in mortality. These findings support PSA screening in Malaysia for men with longer life expectancies.

Targeted Screening and Personalised Treatment is the Way Forward

To reduce overdiagnosis, the key is to screen selectively and treat only those with clinically significant disease. Men with non-aggressive cancers, such as low-grade tumours, may not require immediate treatment. Instead, they can undergo active surveillance with follow-up mpMRI scans and, if necessary, a repeat biopsy.

For men diagnosed with intermediate risk prostate cancer (ISUP 2) or large volume low-grade cancers, close monitoring combined with expert clinical judgement is vital. Again, the use of multiparametric MRI plays a major role in guiding decisions.

Treatment Options for Localised Prostate Cancer

Men diagnosed with localised and aggressive prostate cancer may need ablative treatment options, including surgery, radiotherapy, or brachytherapy. Counselling is essential, especially regarding potential side effects such as erectile dysfunction or urinary issues.

Advances in surgical technology, particularly robotic systems, have improved precision and outcomes for prostate cancer treatment in Malaysia. For eligible patients, transperineal mpMRI ultrasound fusion biopsy offers a more accurate and safer alternative to traditional TRUS biopsy.

The Role of Focal Therapy in Prostate Cancer Management

Emerging focal therapies such as high-intensity focused ultrasound (HIFU), irreversible electroporation, and targeted ablation techniques are gaining traction, especially for patients with favourable intermediate or large volume low-grade cancers.

These methods offer the potential for effective prostate cancer treatment while minimising side effects and preserving quality of life. As the field evolves, better genomics will help predict outcomes and guide more personalised approaches.

Looking Ahead: A Clearer Future for Prostate Cancer Care

With modern tools like mpMRI, targeted biopsy, and focal therapies, both doctors and patients now have more confidence in making informed decisions. Early detection, accurate diagnosis, and customised treatment can significantly reduce suffering and improve survival.

Source: New Straits Times