MRI a Valuable Tool in Prostate Cancer Diagnosis

UH Urology Institute - Fall 2017

Lee E. Ponsky, MD

While Lee Ponsky, MD, Director, Urologic Oncology Center at UH Cleveland Medical Center and Professor of Urology, Case Western Reserve University School of Medicine, is involved in research that is trailblazing, it centers around a technology that was first used on humans 40 years ago – magnetic resonance imaging. Dr. Ponsky studies the coupling of MRI with active surveillance, an emerging management strategy for patients with indolent prostate cancer, to more effectively diagnose and manage the disease.

Two encounters spawned Dr. Ponsky’s interest in MRI. First, he met Anant Madabhushi, PhD, a biomedical engineering professor and researcher at Case Western Reserve University who utilizes computational diagnostics to extract as much value as possible from imaging data to facilitate patient management and treatment. The two collaborated on a grant from the Department of Defense to further research the technology. Then in 2013, Dr. Ponsky worked with a preeminent Australian urologist on MRI of the prostate.

“I became very convinced that MRI absolutely needed to have a role in the evaluation and management of prostate cancer,” says Dr. Ponsky. Although the PSA blood test is the de facto screening tool, it’s controversial. Patients often have an elevated PSA, but not from cancer. Those patients then undergo a biopsy of the prostate in a general location, rather than a targeted area. “So we have a screening test that’s not great, but it’s the best we have, then we do a sampling of the prostate that’s random,” says Dr. Ponsky.

MRI hasn’t been used in years to detect prostate cancer because it doesn’t reliably detect all lesions on the prostate, although it’s very good at showing aggressive tumors. However, Dr. Ponsky says recent findings on low-risk prostate cancer and active surveillance warrant a second look at imaging as a screening tool.

Low-risk prostate cancer is often slow growing and may or may not progress. Rather than over treat patients, physicians have begun to recommend active surveillance – encouraging health lifestyle habits while closely monitoring for an increase in tumor growth or cancer cell aggressiveness. This allows physicians to intervene with curative treatments if and when necessary. Dr. Ponsky cites data published in 2015 indicating that 75 percent of patients placed on active surveillance were still being watched five years later, 63 percent were being watched 10 years later and 55 percent 15 years later.

Dr. Ponsky’s research now incorporates MRI into patient evaluations. “We’ve come to understand that low-risk prostate cancer may not need to be treated, so maybe we don’t care if MRI misses some low-risk disease,” he says. “We don’t want to miss the high-risk tumors that patients die from. And MRI is very good at picking up aggressive disease.”

Now patients with an elevated PSA can have an MRI. If it detects a lesion or abnormality, then physicians can target that lesion through biopsy and make a diagnosis. Dr. Ponsky continues to work with Madabhushi on computer-assisted diagnostics, which aid in better predicting the aggressiveness of prostate cancer and, consequently, personalizing treatment for patients. The two also team with Vikas Gulani, MD, Ph.D., a radiologist, and Greg MacLennan, MD, a pathologist, both at University Hospitals.

“This work is amazing! We didn’t discover new genes or some new protein. We just figured out how to use existing technologies and understand the disease better,” says Dr. Ponsky. “To me, this has been the single greatest change in the way we manage prostate cancer over the last 15 years.”