Prostate cancer usually does not cause any noticeable symptoms in its early stages.

The digital rectal examination of the prostate, which was previously recommended from the age of 50, is unfortunately not very reliable and is no longer officially recommended. The current version of the guideline on prostate cancer therefore now recommends a PSA test at the age of 45 (baseline value), which then determines the interval between further recommended laboratory tests.

If your PSA level is 3.0 ng/mL or higher, you should get an MRI of your prostate to rule out cancer, after talking with your urologist.

The reason: around 30% of men over the age of 50 and up to 70% of men over the age of 80 with elevated PSA levels have asymptomatic prostate cancer – often hidden among benign nodules. However, in more than half of cases, PSA levels are elevated due to benign and harmless prostate conditions.

Indications: Investigation of elevated PSA levels
The mostly non-targeted biopsy (up to 18 samples) achieves a hit rate of only 30 to 40%. This procedure is therefore far from ideal. If no tumor cells are found during the biopsy, this does not rule out the presence of a tumor. If necessary, the biopsy must then be repeated. If a tumor is detected, however, it often remains unclear how extensive and aggressive it is.

Magnetic resonance imaging is clearly superior to other imaging techniques when it comes to diagnosing prostate cancer. Thanks to the possibility of functional MRI diagnostics, it is currently the best imaging technique for visualizing the prostate and provides important information about the exact location and spread of a tumor as well as its aggressiveness—without having to invade the body. 

Suspicious areas can be identified by MRI even before a planned biopsy (tissue sampling), and the probability of hitting the tumor increases significantly. If a biopsy is necessary, the image data obtained during the MRI examination can be transferred directly to the urologist's ultrasound images, thus marking the tumor (which is usually invisible on ultrasound) for biopsy (known as MRI fusion biopsy).

Conversely, if no tumor is detected in the prostate MRI, the examination can help prevent unnecessary diagnostic and therapeutic interventions. This is because an unremarkable MRI rules out aggressive tumor growth in 85-90% of cases. 

Suspicious areas in the prostate must be biopsied for accurate classification and to confirm the diagnosis. MRT fusion biopsy is a novel procedure in which combining MRT images with ultrasound during the biopsy allows even small and unfavorably located tumor foci to be targeted with significantly greater accuracy (up to 85%) (compared to approx. 30-40% with untargeted "blind biopsy").

A fusion biopsy consists of four steps:

1. MRI of the prostate
2. Marking of the area suspected of containing a tumor
3. Superimposing the ultrasound image on the marked MRI image (fusion)
4. Targeted tissue sampling by the urologist

Good results in fusion biopsy require many years of experience and close cooperation between radiologists and urologists.

If a tumor has been detected (including in a biopsy), MRI can provide valuable information for further treatment planning: for example, whether surgery or radiation therapy is more appropriate, or whether it is possible to wait and see (known as active surveillance). This is because not all tumors grow so aggressively that immediate treatment is absolutely necessary.

Patient safety is significantly improved by prostate MRI as part of active surveillance, as regular MRI checks can detect aggressive tumor growth at an early stage.

Since magnetic resonance imaging does not use X-rays, it is also ideal for follow-up examinations in cases of unclear findings. However, when searching for a so-called local recurrence (a renewed increase in PSA after therapy as an indication of renewed tumor growth), an examination using PSMA-PET/CT is preferable. 

1. High-resolution imaging

High-resolution MRI images of the prostate and surrounding area show the exact anatomy and suspicious areas (arrow in image 1: small prostate carcinoma). 

2. Diffusion-weighted imaging (DWI)

Another innovation in prostate imaging that we offer in our practice is diffusion-weighted imaging (Figure 2), which examines the diffusion (movement) of water molecules and displays it graphically. This makes it easier to detect aggressive prostate cancers in particular, as water diffusion is restricted in these cases due to the increased cell density in the tumor. 

3. Perfusion imaging (dynamic MRI)

Perfusion imaging examines the behavior of contrast agents in the prostate over time as an indicator of blood flow. Tumors require nutrients to grow and therefore usually have increased blood flow, which distinguishes them from normal prostate tissue.

1. Tissue sample:

If an area suspected of being a tumor is found during the MRI examination, it should be investigated further. MRI helps to perform a targeted tissue sample (=biopsy) in the abnormal area. For this purpose, the urologist uses the MRI data set during sonographically guided tissue removal (=fusion biopsy).

2. Examination of the rest of the body (staging)

If a tumor has been detected in the tissue sample (=histology), further examination of the rest of the body is necessary in order to plan the further treatment strategy on an individual basis.
This usually requires a CT scan and a skeletal scintigraphy. In the case of more advanced or aggressive tumors, however, an examination using PSMA-PET/CT should be performed.

3. Treatment decision

Only when all important information about the tumor (size, aggressiveness) and possible spread in the body is available can your urologist make a decision about treatment together with you (e.g., surgery, radiation, watchful waiting (active surveillance)). 

Private health insurance providers in Germany usually reimburse the full screening examination costs. Patients insured under state/government insurance plans in Germany can have prostate MRI performed as a self-payer service. Unfortunately, cost coverage is currently not provided for this elaborate examination by compulsory health insurance funds.