mpMRI scans before biopsy, mpMRI-guided biopsies recommended in UK

An article in The Daily Telegraph in the UK this morning addresses a variety of issues related to the difficulties associated with the use of TRUS-guided prostate biopsy to diagnose localized and locally advanced prostate cancer.

The article in question (perhaps misguidedly headed “Half of prostate cancer cases may be missed“) deals with the following specific issues:

  • ” … as many as half of cases where patients have ‘significant’ levels of prostate cancer could be being missed during standard biopsy procedures.”
  • “Thousands more men may be wrongly diagnosed as having cancer which requires major treatment, such as surgery or radiotherapy.”

In other words, it is not as though we are actually “missing” half the cancers that need to be “caught.” Perhaps it would be more accurate to state that “blind”, systematic, TRUS-guided biopsies sample only a small portion of the prostate, and so we really may not know, after a single 12-core systematic biopsy, whether we have or have not been able to identify clinically significant disease that needs treatment in a specific individual. As Mark Emberton (a member of the Advisory Board of the “New” Prostate Cancer InfoLink) is quoted as saying later in the article:

There is no other organ of the body where we carry out random ‘blind’ biopsies without knowing where we are looking.

The article in The Daily Telegraph is apparently based on a presentation given (by Dr. Emberton or one of his colleagues) earlier in the week at the UK National Cancer Intelligence Network (NCIN)’s annual meeting “Cancer Outcomes Conference 2013: Intelligence — the primary driver of cancer outcomes” (where, as we have already noted, the NCIN introduced its new national cancer registry initiative). The presentation was based on the expanding support for the idea that pre-biopsy multiparametric MRI (mpMRI) scans and associated mpMRI-guided biopsies may well be able to help us to:

  • Ensure that we actually biopsy only the men who really need biopsies
  • Actually biopsy only the areas of the prostate that we need to biopsy to establish a diagnosis of prostate cancer (if indeed prostate cancer is present)

We have not, as yet, seen an abstract or any other primary source material for this presentation.

We need to be clear that there is a lot of evidence accumulating to support this use of mpMRI. However, it does come with some problems — starting with the fact that (at least at present) mpMRI-guided biopsies (but not mpMRI scans themselves) usually need to be done under anesthesia to make sure that the patient is fully relaxed and stationary during the procedure.

The presentation apparently included data suggesting that expanding the use of mpMRI would be cost effective in the UK. Whether it would be cost effective in a country like the USA, where MRIs tend to be much more expensive than they are in the rest of the world, is a very different question.

There seems little doubt to The “New” Prostate Cancer InfoLink that better imaging techniques are going to allow major adaptations to the traditional use of TRUS-guided biopsies over the next 5 to 10 years. What we are going to need to be sure about, however, is that (a) this does not simply drive up the costs associated with the diagnosis of prostate cancer and (b) it helps us to ensure that patients who are entirely appropriate for management on active surveillance protocols do indeed get managed in such a manner as and when appropriate (as opposed to getting rushed into treatment with their one or two tiny foci of Gleason 6 disease).

In theory at least, this type of change will be good. In practice, there are going to be all sorts of difficulties to iron out because — at least at present — there are relatively few institutions around the world that have the equipment to conduct mpMRI scans and mpMRI-guided biopsies. Furthermore, and just as importantly, the number of uroradiologists who are experienced and skilled at reading such scans is still very small … and that skill and experience is critical to the accuracy of diagnosis.

For those who are interested, the various “comments” following the article in The Daily Telegraph once again display just how biased people become about diagnosis and treatment of prostate cancer based on their own personal opinions and experiences. It really is high time that most of us had started to understand that what is “right” for one man is not necessarily “right” for the next man in line (and could, indeed, be completely “wrong” for him). So much depends on our personal attitudes to risk and how we assess the relative benefits of quality vs. quantity of life. Every individual patient at risk for prostate cancer needs to be helped to come to a decision that works well for him. “Telling” people what we think they “have to” or even “need to” do or have done is commonly unconstructive and unhelpful. Men need to understand their options and the data that support (or clearly refute) the viability of those options in their particular cases.

Last but perhaps not least … Some readers may be interested in looking at the first video on this link. One of our correspondents in the UK tells us that the company that developed this video is the place where Dr. Emberton sends him and other patients to undergo mpMRI in the UK. (In the case of this particular patient, he goes to have scans to monitor him under active surveillance.)

One Response

  1. I agree with the comment “what is right for one man may not be right for the next.” But I would suggest that comment should not only be subscribed to by patients, but by physicians, who also tend to follow personal/professional biases, some with no apologies.

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