From the Guidelines
High PSA levels are indeed an indication for prostate MRI, as it helps to visualize suspicious areas within the prostate that may represent cancer, allowing for more targeted biopsies if needed. When a patient has an elevated prostate-specific antigen (PSA) level, typically above 4.0 ng/mL, a multiparametric MRI of the prostate is often recommended as part of the diagnostic workup 1. This imaging technique is particularly valuable in cases where PSA levels are rising but previous biopsies have been negative, or when deciding if a biopsy is necessary at all. The MRI can detect clinically significant prostate cancers while reducing unnecessary biopsies for indolent disease. Other indications for prostate MRI include abnormal digital rectal examination findings, active surveillance of known prostate cancer, and evaluation of the extent of known prostate cancer.
Some key points to consider:
- PSA is a continuous parameter, with higher levels indicating a greater likelihood of prostate cancer (PCa) 1
- Multiparametric magnetic resonance imaging (mpMRI) is increasingly important for biopsy optimisation, with pooled sensitivity and specificity of 0.91 and 0.37 for ISUP grade 2 cancers, and 0.95 and 0.35 for ISUP grade 3 cancers, respectively 1
- Risk calculators developed from cohort studies may also be useful in reducing further testing, and prostate-specific antigen density (PSA-D) may help predict the presence of clinically significant PCa (csPCa) 1
- The sensitivity of MRI increases with higher PSA levels and higher-grade cancers, making it an effective tool in the diagnostic pathway for men with elevated PSA 1
In terms of guidelines, the European Urology guidelines (2024) recommend the use of mpMRI for biopsy optimisation, and suggest that an MRI-based indication for biopsy after referral leads to lower rates of biopsy, fewer men diagnosed with PCa labelled as insignificant, and more 1. Overall, the use of prostate MRI in patients with high PSA levels is supported by the latest evidence and guidelines.
From the Research
High PSA and MRI Prostate
- High PSA levels can indicate the need for an MRI prostate scan to detect potential prostate cancer [(2,3,4)].
- Studies have shown that multiparametric MRI (mpMRI) can accurately detect clinically significant prostate cancer in men with elevated PSA levels [(2,3,4)].
- The use of PSA density (PSAD) can help stratify patients and determine the need for systematic biopsy or MRI-targeted biopsy alone 2.
PSA Density and MRI Prostate
- PSAD can be used as an adjunctive predictor of clinically significant prostate cancer detection in men undergoing combined biopsy 2.
- A PSAD of > 0.2 ng/mL/cm3 may indicate a low added detection of clinically significant cancer with systematic biopsy, and clinicians may consider omitting systematic biopsy for targeted biopsy of MRI-visible lesions in these patients 2.
Digital Rectal Examination and MRI Prostate
- Digital rectal examination (DRE) can still provide valuable information in the detection of significant prostate cancer, even in the era of MRI [(5,6)].
- DRE findings can be used to improve the effectiveness of opportunistic significant prostate cancer screening programs 6.
MRI Prostate and Prostate Cancer Detection
- MRI prostate scans can help detect clinically significant prostate cancer in men with elevated PSA levels [(2,3,4)].
- The use of MRI prostate scans can help reduce the need for unnecessary prostate biopsies 4.