The evolving role of MRI imaging in undiagnosed prostate cancer

As we have been pointing out for a while, the actual and potential roles for the use of multiparametric MRI (mpMRI) scanning in the diagnosis of prostate cancer is changing, and quite fast too.

In England, for example, where pretty much everyone lives within a couple of hours of a high quality MRI center, and the cost of each mpMRI scan is set by the National Health Service, the standard of care is now moving rapidly toward the use of mpMRI scanning prior to any biopsy for presumed risk of localized prostate cancer.

In Canada and the USA, it is currently recommended that any repeat biopsy for a man who has had at least one prior, negative, 12-core, systematic biopsy for risk of prostate cancer should be done after an mpMRI (and ideally a 3-T mpMRI).

The problems associated with wider uptake of early mpMRI scanning prior to an initial biopsy here in the USA are multiple:

  • Many patients may live hundreds of miles from a high quality MRI center that could offer 3-T mpMRI scanning of the prostate.
  • The numbers of available and skilled uroradiologists capable of reading these scans is small.
  • The cost of such MRI scans is high, and varies significantly from region to region (and even from center to center within  a region).
  • The need for such an MRI could significantly delay implementation of a biopsy and initiation of treatment for some of the patients in most need of early treatment.

Despite these problems, a newly published review by Bjurlin et al. in Current Opinion in Urology argues strongly that there are now good data to justify the use of early MRI scanning in all biopsy-naive men who are being evaluated for risk of localized prostate cancer:

  • The combination of mpMRI and targeted biopsies appears to increase detection of clinically significant disease among biopsy-naive men (compared with systematic 12-core biopsy alone).
  • The addition of prostate cancer biomarkers and predictive nomograms along with MRI scanning may further enhance prebiopsy risk assessment.
  • Prostate-specific MRIs prior to biopsy may be able to help in
    • Guiding patient counseling regarding prostate cancer risk
    • Allowing for accurate tumor localization during targeted biopsy
    • Increasing the likelihood of detection of clinically significant cancer, and
    • Limiting the detection of indolent disease.

They further note that that the use of MRI scanning prior to biopsy, in conjunction with the use of biomarkers and predictive nomograms, may allow for deferral or appropriate avoidance of biopsy altogether in carefully selected patients.

The “New” Prostate Cancer InfoLink is of the opinion that the standardized use of MRI scanning prior to any biopsy will be taken up here in the USA (and probably in Canada too) within a matter of a few years. It may not be available to all potential patients (because of distance from an appropriate center) bit we suspect it will be available to most patients by the end of 2020 or thereabouts, and we suspect that Medicare and commercial insurance providers will have worked out why there is a cost-benefit to this particular equation too.

In the meantime, it never hurts to ask whether early MRI scanning is a possibility and whether it would be covered by your insurance provider. Anf of course if you have the personal resources to cover such a cost, you may want to “just do it” anyway, whether it is covered by your insurance provider or not.

One Response

  1. We have to keep in mind that the UK does not have a history of universal PSA screening. In the US, only about a third of men who are sent for a biopsy will be found to be positive, and most of those with low-risk prostate cancer. mpMRIs are much more expensive than biopsies in the US. This will not be a cost-effective decision in the US until we have better/more widely used alternative biochemical markers, and better methods for ruling out benign causes of PSA elevation. I hope we have that done by 2020.

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