As a randomised controlled trial, the PRECISION study1 showed a clear benefit of an MRI pathway in terms of improved detected of clinically significant prostate cancers and decreased detection of clinically insignificant prostate cancers. However, it seems that not all urologists are convinced by the data or sufficiently motivated to change clinical practice on the strength of this study. That said, it is accepted that access to prostate MRI due to reimbursement issues could play a role in some jurisdictions.
The 2021 EAU Guidelines2 have clearly spelt out a recommendation that an MRI should be performed prior to prostate biopsy whether it be those men who are biopsy naïve or have previously had a negative prostate biopsy. The strength rating for both recommendations is “strong”. The 2021 NCCN Guidelines3 are a little more guarded in that the recommendation for an MRI prior to prostate biopsy is qualified by the words ‘if available’. Particularly in the US, 3T MRI is widely available but sadly, it is an issue of reimbursement despite the highest level of evidence to support its routine use prior to prostate biopsy.
There have now been many studies that have confirmed the benefit of using magnetic resonance imaging biopsy techniques over transrectal ultrasound guided biopsy of the prostate. This systematic review and meta-analysis4 are timely and follows from the PRECISION study that there the role of MRI prior to prostate biopsy is not a debatable matter. The meta-analysis confirms the superiority of an MRI guided biopsy approach over TRUS biopsy approach in terms of the of clinically significant and clinically insignificant prostate cancer detection. These outcomes are not just driven from the high-profile PRECISION study results but rather from 32 and 30 clinical trials respectively. This represents a wide body of research that tells us that MRI prior to prostate biopsy is best practice and defines a standard of care.
Where debate does exist, is regarding the way MRI targeted biopsies are performed. This analysis was unable to determine a clearly superior approach when comparisons were made between the three approaches of cognitive, software fusion and MRI in bore gantry targeting. Common sense and our own clinical experience tell us that targeting large lesions in a normal sized prostate will not be different with any of these approaches. As targeted lesions either become smaller or are associated with larger gland volume, advantages could potentially be observed, but to date, none of the data is convincing. Another factor often taken for granted is the fact that not all urologists are equal in their targeting skills, particularly for the cognitive approach. This is further impacted upon by whether a transrectal or transperineal approach is undertaken with the later providing a perspective that more closely resembles that of MRI images. The authors are correct in that more study is needed to confirm superiority of one approach over another.
My own personal view is that for each urologist, there will be a lesion size for a given prostate volume where no targeting approach will be superior. However, the threshold for lesion size relative to prostate gland volume is going to vary according to the skill and experience of each urologist. For now, do offer an MRI for all your patients who are to undergo a prostate biopsy and conduct targeting according to your personal preference.
Written by: Henry Woo MBBS, DMedSci, FRACS(Urol), FACS, Professor of Urology, College of Health and Medicine, Australian National University, Director, SAN Prostate Centre of Excellence, Sydney Adventist Hospital.
- Kasivisvanathan V, Rannikko AS, Borghi M, Panebianco V, Mynderse LA, Vaarala MH, Briganti A, Budäus L, Hellawell G, Hindley RG, Roobol MJ, Eggener S, Ghei M, Villers A, Bladou F, Villeirs GM, Virdi J, Boxler S, Robert G, Singh PB, Venderink W, Hadaschik BA, Ruffion A, Hu JC, Margolis D, Crouzet S, Klotz L, Taneja SS, Pinto P, Gill I, Allen C, Giganti F, Freeman A, Morris S, Punwani S, Williams NR, Brew-Graves C, Deeks J, Takwoingi Y, Emberton M, Moore CM; PRECISION Study Group Collaborators. MRI-Targeted or Standard Biopsy for Prostate-Cancer Diagnosis. N Engl J Med. 2018 May 10;378(19):1767-1777. doi: 10.1056/NEJMoa1801993. Epub 2018 Mar 18. PMID: 29552975.
- https://uroweb.org/guideline/prostate-cancer/#5 accessed September 2021
- https://www.nccn.org/professionals/physician_gls/pdf/prostate_detection.pdf Accessed September 2021
- Bass, E.J., Pantovic, A., Connor, M.J. et al. Diagnostic accuracy of magnetic resonance imaging targeted biopsy techniques compared to transrectal ultrasound guided biopsy of the prostate: a systematic review and meta-analysis. Prostate Cancer Prostatic Dis(2021). https://doi.org/10.1038/s41391-021-00449-7