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MRI vs. Biopsy: Which Should Come First? · Intellectual Medicine

• 0:00
  So you've had an elevated PSA and your family doctor has
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  referred you to urology. What comes next?
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  They often are going to recommend a biopsy, but should
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  an MRI be the next test? And why do they do a biopsy
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  anyhow? Is the MRI good enough to make a
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  diagnosis? You're the captain of your ship,
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  folks. You're the one that gets to
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  decide. So you've had an elevated PSA
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  and your family doctor has referred you to urology.
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  What comes next? They often are going to
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  recommend a biopsy, but should an MRI be the next test?
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  And why do they do a biopsy anyhow?
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  Is the MRI good enough to make a diagnosis?
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  Is it good enough to guide therapy?
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  Well, it is nowadays. The Mris have been refined to
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  such a point that it further renders irrelevant and not
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  necessary the biopsy. Now, here's the problem you're
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  going to have, gentlemen. The urologist wants to do the
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  biopsy. It's what he was bred to do.
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  Or she. It's what they were
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  indoctrinated into. The biopsy's the king of the
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  hill. We need tissue.
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  No, we don't. 1990. Maybe we did not.
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  In this era, the Mris are fantastic and you don't need the
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  dye. So what should you do first,
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  Even if your doctor is affirmative toward biopsy, you
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  must do a biopsy. We have to get a biopsy.
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  Pause and just tell them. Let's do an MRI first.
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  Now the MRI can tell the likelihood of cancer being
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  present. It can also tell whether or not
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  the cancer is inside or outside the capsule to a reasonable
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  degree of certainty. You get a good picture.
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  Another thing I like about the MRI first is that you can follow
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  it. So the doctor will tell you, and
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  it's been my experience that no matter what the MRI shows, the
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  urologist is still going to want to do that biopsy.
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  I have to know. The MRI is scored from 1:00 to
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  5:00 and something called the Pyrads A1 means that's pretty
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  normal. No cancer of five means, yeah,
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  it looks like you got cancer. And then there are in betweens.
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  I had a patient with a low, relatively low PSA was in the
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  fives a pyrides of two. And the doc said, OK, let's set
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  you up for the biopsy. And the patient said, well, why?
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  The evidence doesn't point toward cancer.
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  They want the biopsy. They want the tissue.
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  This is what they believe and it's how they get paid, so I'm
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  not implying that they are exclusively focused on
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  reimbursement. But let's be honest folks, it
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  has an influence. Doctors, urologists, and
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  particular surgeons don't get paid very much to chit chat with
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  you. You'll notice the conversations
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  in most cases tend to be rather truncated, so you need to go in
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  there prepared MRI or biopsy. 100% MRI.
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  That comes first. Even if you disagree with me,
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  even if you decide to go forward with a biopsy, it's not wrong as
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  long as you've given it thought and you've gotten good
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  information. Now, here's another fallacy I
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  want to dispel The MRI as a tool to help target where the
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  biopsy's going to go. That, folks, is biologically
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  inconsistent with the way cancer behaves.
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  This is not like an isolated lump.
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  The cancer does not cluster itself into discrete little
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  packets, making it convenient to be biopsied.
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  I mean, if that were the case, tell the urologist, well, they
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  call this a targeted biopsy. By the way.
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  It sounds very sophisticated. You know, we're not going to do
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  the old fashioned way where we're just jamming it with 12
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  different jabs. We're more sophisticated.
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  We're going to do a targeted biopsy.
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  Sounds good. Unproven, More fallacy than
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  fact. So ask him this.
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  If they're affirmatively want to do a biopsy, Dr. With the MRI
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  now targeting the biopsy, how about if you just did one biopsy
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  instead of a dozen or more? Most of the time they're going
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  to buck. Well, you know, the cancer could
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  be elsewhere. Of course it could be elsewhere.
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  Cancer disseminates like a spider's web.
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  It disseminates on a cellular level.
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  So the number one thing we're going to find out from that MRI
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  and be prepared, men, if you have an elevated PSA and you're
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  above age 50, the odds are overwhelmingly likely that your
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  MRI will be abnormal. It's going to have nodules in
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  it. You're going to have a pyrides
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  of 3-4, maybe even 5. This is not a panic moment.
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  This is not a jettison into the biopsy quickly because things
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  may get out of hand. It's a point of information.
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  I've had many men with high PSA with pyrides of four or even 5
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  on their MRI nodules. Looks like cancer.
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  OK let's call it indolent cancer isolated to the gland.
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  These are the cells are to sleeping.
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  So you'll hear the urologist tell you in many cases we need
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  the biopsy to tell how aggressive your cancer is.
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  Another fallacy. You can't tell aggression by one
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  point on a curve. You can tell prognosis.
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  How likely is it that this particular cancer will progress
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  in the future, But it doesn't predict what will happen next.
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  Prognosis is different than aggression or severity of
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  progression. So that one biopsy that they
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  want to get so they can hang the Gleason score on it.
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  Another outdated metric, the Gleason score, this idea that
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  they can get the crystal ball out and tell what's going to
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  happen because the cells look like a Gleason 8 and no, eight.
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  It's, it's a nine. No, no, it's an 8.
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  It's subjective, right? It's the pathologist doing their
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  best job to try to describe what those cells look like, but it
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  does not predict. It just assesses potential
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  prognosis, right? So you have that in your hand.
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  You don't need the biopsy because what are they going to
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  do now? We got a biopsy.
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  Ask your doctor this question, doc.
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  If the biopsy came back negative, no sign of cancer, are
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  we done? Would you believe it?
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  You have a high PSA and abnormal prostate MRI.
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  They're not going to believe it. They're going to want to do
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  another biopsy. Suppose a biopsy comes back and
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  it shows what they would call a cancer.
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  That doesn't seem to be very much at risk.
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  A low Gleason score is what they like to do.
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  They may put you into what's called active surveillance or,
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  as one of my patients described it to me, a urologist annuity
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  'cause now you're coming back for more biopsies so they could
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  just see what that cancer is doing.
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  This is the height of silliness in my view, because we're
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  traumatizing men. We're traumatizing the tissue,
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  potentially spreading cancer, absolutely putting at risk
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  infection, erectile and urinary difficulty, not to mention
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  bloody urine. It's an awful experience.
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  Nobody ever said, you know that prostate biopsy was really cool.
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  No 0%. Furthermore, we do not need it.
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  Now, the MRI totally sufficient if you choose to do what's
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  called active surveillance. Not a bad choice, men.
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  Then you should insist that it be done without a biopsy.
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  With Mr. is done. PIPSA is done periodically.
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  Now, the next step. We've already decided you don't
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  you should not get a biopsy. So using the MRI as a
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  springboard to a biopsy is the wrong approach.
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  You should use the MRI as a metric of change in most cases.
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  You can watch it, see what goes on.
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  What about the future of this? How do you know the MRI is good
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  enough? Well, a study published in the
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  Journal of the American Medical Association, JAMA, 2025 looked
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  at Mris in particular. They looked at Mris done without
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  contrast. Now this is where we should be
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  right now. They will insist we must do
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  contrast. Intravenous contrast with a
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  heavy metal called gadolinium is utilized to help better define
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  the picture. That's all.
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  They can see the picture a little bit better.
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  It turns out that that degree of clarity is not needed.
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  The study in JAMA looked at men who had traditional gadolinium
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  MRI and compare them to men who had what they call biparametric
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  non contrast MRI. The conclusion, It was done over
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  22 centers, over 12 different countries.
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  So this was a big study looking at a bunch of men, a bunch of
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  Mris, and they concluded that the non contrast was the same in
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  its ability to diagnose and assess as the contrast.
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  In other words, it was not inferior, it was dead equal,
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  which means it's actually better because you don't get
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  gadolinium, there's a risk of allergic reaction.
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  Gadolinium can strain the kidneys and it accumulates in
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  the body 100%. This is settled science if you
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  will. It accumulates in the body and
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  in the brain. So this is bad.
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  You don't want heavy metal in you.
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  Furthermore, if we're going to use this for sequential
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  monitoring, we do not want cumulative amounts of
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  gadolinium. And then to top it all off, it's
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  cheaper and faster. A non contrast MRI is going to
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  take maybe 15 or 20 minutes. You're in and out.
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  No IV, no risk of the IV. This is a quantum leap forward.
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  Now that you're educated about it, you should insist you're the
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  captain of your ship, folks. You're the one that gets to
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  decide what you're going to do next, especially in the space of
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  prostate cancer, where conventional treatment is
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  guaranteed to cause harm and has dubious, if any, benefit
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  preventing death. Now, this is a tough sell for
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  the urologist, so you may want to transfer the responsibility
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  to your family doctor. Now family docs, I know I'm one.
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  A board certified family physician spent a lot of time,
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  as you can tell, studying and treating men with prostate
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  cancer and other forms of cancers.
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  Most family doctors are deferential to the urologist
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  because this is their turf. It shouldn't be.
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  A family doctor is fully capable of doing active surveillance
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  with you. What you will need to do is
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  simply tell your family doc, I don't want to see the urologist
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  doc, I trust you. I understand that this is going
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  against medical advice. If they want you to sign a form,
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  go ahead and sign it and then just ask him.
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  Look, can we just do APSA like every three months?
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  And how about repeating the MRI? If you're, if you'd like, you
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  can be done at a three month interval.
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  I do not recommend it any sooner than that.
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  It's too quick. You want to track things, right?
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  Suppose APSA is 7 and three months later it's 7.5 and three
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  months later it's eight or six. Those are all the same.
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  Suppose your MRI is a pyrides of four and six months later it's a
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  pyrides of four stability. Your active surveillance is
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  validating that you have an indolent form of cancer that is
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  not moving. This is fabulous, an advance in
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  our ability to keep men healthy and not impose harm upon them.
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  So I think it's time. The question about biopsy versus
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  MRI, it's MRI, 100% biopsy. I advocate never, but it's
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  difficult to convince, maybe impossible to convince.
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  We're all to good people. They do what they were trained
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  to do and they were trained to biopsy.
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  So you need to move it out of that arena.
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  You know, get consultative input with an empathic family
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  physician, a good nurse practitioner with experience and
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  temperance on top of it all. Most men with prostate cancer
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  die of heart attacks anyhow. You got to look at the big
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  picture all the time then. And when you look at MRI versus
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  versus biopsy, now you're prepared.
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  Now you're prepared to have a conversation with your urologist
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  explaining why no biopsy for you or doc.
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  Before you consider the biopsy, let's do that MRI.
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  And oh, by the way, I want to film without contrast.
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  If you're insistent, you can get your way.
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  Here we go, keeping you educated, master of your ship.
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  You don't need to be a doctor to be a smart consumer of your
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  healthcare needs. Bye guys, until next time,
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  thanks for following. We'll see you then.