Professor Mark Emberton, from University College in London, Great Britain, provided his insights on how mpMRI of the prostate has become a “game changer” in the last several years as part of the prostate cancer plenary session at the 2019 European Association of Urology (EAU) annual meeting in Barcelona, Spain. He specifically focused on the use of pre-biopsy MRI to aid in the diagnosis of prostate cancer. He began his discussion by exploring the history of prostate MRI, which began in the early 1980’s, but did not find much clinical application until the mid-2000’s, when the technology advanced to the point of being able to provide clearer pictures of the gland. With current technologies, we can often obtain very clear and more easily-interpretable images of the prostate gland that can aide in diagnosis, when interpreted by a well-trained radiologist. He reviewed the data from the last 8 years which showed mixed, but largely positive results regarding the use of mpMRI to aide in prostate cancer diagnosis. He noted that practice guidelines often lag behind evidence, and it has only recently been that some European guidelines have changed to state that mpMRI should be offered as a first line investigation for men with suspected prostate cancer prior to biopsy.
Emberton believes that MRI is the single most important test in 2019 for the risk-stratification of localized prostate cancer. He believes that it helps alleviate some of the inconsistencies associated with PSA levels and prostate biopsy. He notes that by utilizing MRI prior to biopsy in men with suspected prostate cancer, the data suggests that there are several potential benefits. First, fewer clinically significant prostate cancers will be missed. Also, importantly, less insignificantly cancers will be diagnosed, thereby minimizing overtreatment of disease. It also leads to fewer unnecessary biopsies, fewer needle deployments, more representative pathology, and less adverse effects. He presented data from the PRECISION trial which showed that men who only underwent mpMRI targeted biopsy, as opposed to standard biopsy, had less hematuria, fevers, hematochezia, erectile dysfunction, and pain.
He next went on the argue that utilizing mpMRI as a risk-stratification tool to determine who requires biopsy also leads to cost reductions across healthcare systems. He showed cost analyses which suggested that mpMRI utilization results in an improved cost/benefit ratio when compared to standard prostate biopsy algorithms. He also stated that use of mpMRI in prostate cancer diagnosis can help with enhanced risk-stratification in men on active surveillance (AS) protocols for low-risk prostate cancer, and can sometimes supplant repeat biopsies in men on AS.
He concluded that pre-biopsy mpMRI in the diagnosis of prostate cancer is necessary, effective, and sustainable in terms of cost-effectiveness. He believes that while the guidelines are finally catching up to the data, to not utilize this proven technology, when available, is sub-standard care.
Presented by: Mark Emberton, MD FRCS Urology, University College London, UCL, Division of Surgery and Interventional Science, London, Great Britain
Written by: Brian Kadow, MD. Society of Urologic Oncology Fellow, Fox Chase Cancer Center at the 34th European Association of Urology (EAU 2019) #EAU19 conference in Barcelona Spain, March 15-19, 2019.