As part of my virtual AUA conference experiment this year, I purchased the On-Demand Course Pass. I knew that I wouldn't have the chance to attend many, if any, of the instructional courses and given how much I learned from them the last time around, I figured that the $197 investment was worth it.
And really, $197? What a steal—my hotel room in Boston was more than that.
My conclusion? With the exception that it took longer than I expected for the AUA to get the videos posted and available, they were great. Almost too great. Unless I need the CME credit for some reason (you don't get credit for watching videos of the courses from the comfort of your own home), I don't think I'll purchase the in-person course pass again. Why spend time listening live if I can watch the videos at home at 2x speed?
More from Dr. Rosevear: Burnout, biopsy, BPH, and more: Post-AUA review
The other problem I have with the On-Demand course is that there are so many great lectures that I can't possibly do them all justice (even given the unlimited word count my editor gives me for this online blog). Instead, I want to highlight the two courses I found most useful.
The first course was “Prostate Cancer Diagnostics: Biomarkers, MRI, and Biopsy Techniques,” directed by Daniel Barocas, MD.
I found this course helpful since Dr. Barocas not only talked about current prostate cancer biomarkers, but he gave a great overview of the current state of prostate MRI. He started by stating that prostate MRI should not (yet) be used to avoid a systematic biopsy in a man with a suspicious lesion. It should also not be used to avoid doing a prostate biopsy in a highly suspicious man with a normal prostate MRI. I'll admit that I was doing the opposite in both of those situations.
I was also thrilled to see that he pointed out that it is a NCCN guideline that all men with a rising PSA after a negative biopsy receive an MRI; this factoid will help me defend my ordering practices the next time I have to go head to head with some insurance peer-review lackey. Interestingly, he also pointed out that the NCCN guideline’s fine print says "emerging data" suggests that MRI before initial biopsy is helpful; I look forward to that becoming standard of care.
Dr. Barocas also addressed one of my key questions at AUA 2017; do I need to buy a $250,000 MRI-US fusion device?
He said: "There are some studies here at the AUA showing that freehand cognitive fusion may be just as good in many cases.” Interestingly, he also stated that the positive predictive value (PPV) of MRI is 60% for PI-RADS 3, 90% for PI-RADS 4, and 96% for PI-RADS 5. I think this stresses the importance of a quality assurance system in any group that routinely uses this technology, as a quick review of my own last 10 cases does not correlate with these data, meaning that either I or my radiologist is not doing something right.
So to partially answer my question, it appears that MRI technology is ready for prime time, and all small-town urologists should start incorporating prostate MRIs in our diagnostic algorithms. On the other hand, the value that the $250,000 MRI-US fusion technology adds is less clear. I believe that if a group can match the published data regarding PPV using cognitive fusion biopsies, than the need for the machine is probably minimal.