MRI-targeted biopsy: What your colleagues are saying

Urology Times reached out to four urologists (selected randomly) and asked them each the following question: Will the results of the PRECISION study change the way you diagnose prostate cancer?

“I started using MRIs 4 years ago. I don’t know that it’s a game changer, but it certainly helps. MRIs are used differently here than in the United Kingdom. In the U.S., MRIs are used more for active surveillance in the repeat biopsies realm-not to avoid biopsies. Most American urologists don’t decide to biopsy a patient based on MRI results-the most powerful predictors are still the PSA and rectal exam.

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I’ve used it mostly in patients who had a prior negative biopsy, but their PSA is still rising. If they’ve had a previous PI-RADS 4 or higher lesion, I would probably target that for biopsy. If their PSA is rising slowly and their MRI is negative in the prior biopsy, I’m more likely to watch that person.

If the PRECISION study results hold up in future research, any time you can avoid an invasive procedure with risks, obviously that’s good for patients.”

Michael Darson, MD

Scottsdale, AZ

Next:"We’re in a very high Medicaid population, so there are not a lot of extra resources."“Yes and no. From a patient standpoint, there is increasing evidence that MRI fusion targeted biopsies can be more specific so it could potentially reduce the number of biopsies-not necessarily the frequency with which people may biopsy.

Related: PRECISION data lend validation to utility of multiparametric MRI

At USC, we used it a lot. We started using it for patients to determine whether they needed repeat biopsies or not. If it were available for patients who were an intermediate risk, a gray-zone PSA, I think it would be helpful. The challenge, for those of us in rural situations, is the availability. We have MRI machines, but it takes special software to do the MRI and fuse those images with our ultrasound equipment.

The literature shows there can be an advantage to it, but will that resource be available for rural practicing urologists is the question.

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We talked about trying to get it in our practice-my former partner really pushed the hospital to obtain the software-but it hasn’t come to ground yet. We’re in a very high Medicaid population, so there are not a lot of extra resources. Conceptually, I am a proponent, but it is a challenge.”

Charles Best, MD

Aberdeen, WA

Next:"The study certainly raises the question of whether we should be doing fewer biopsies on patients with normal MRIs."“MRI targeted biopsies are a lot of my practice.

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The study certainly raises the question of whether we should be doing fewer biopsies on patients with normal MRIs. AUA guidelines say that unless your institution has its own internal data showing you can either avoid a biopsy or, specifically, not do a systematic biopsy, the change shouldn’t be made. The study doesn’t specifically contradict the AUA. Those guidelines say if you’re only doing a targeted biopsy, your institution should confirm its accuracy.

At the University of Oklahoma, over time, our radiologists have become more proficient in making the right call-not missing something, or over-calling.

It won’t change my management of diagnosis without the knowledge that we can target an area and not miss something. It’s very provocative and will certainly make us rethink how we do our biopsies, but we’re not quite there yet. The PRECISION numbers are good, but because prostate cancer is such a long malignancy, I don’t feel the follow-up was long enough to determine that nothing would happen.

If a patient already had one negative biopsy and an elevated PSA and they want me to tell them what’s wrong with their prostate, I would probably do the entire biopsy, fusion-guided by the MRI, so I could say with certainty they had no cancer. Right now, the current recommendations for a new patient with an elevated PSA and no biopsy history is to have the standard 12-core biopsy. I think my incorporation of the MRI is another reason my practice would not change; I already get an MRI on every patient that comes in the door wanting a biopsy.

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I’ll still do the standard biopsy until I can prove with my own institutional data that I don’t need it.”

Kelly Stratton, MD

Oklahoma City

Next:"I think the PRECISION study absolutely offers very compelling data.”“We have the Artemis platform here that a couple of my colleagues used, but I haven’t personally done them.

Potentially much of how MRIs are used have a lot to do with who is reading them, how consistent they are, and how confident they are in calling a lesion suspicious versus not-instead of calling everything indeterminate. For most people-including myself-to be convinced not to biopsy something, you need to have a convincing report and conversely you have to be very convinced that there’s no there, there.

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I think we’re moving in the direction, though, where the MRI will define our next steps-not quite there yet, but I think we’re moving that way.

Right now, people who are doing targeted biopsies still do the systematic biopsy, but in the future the goal would be to only biopsy the area that seems suspicious and be able to avoid extra biopsies. We’re not quite there, but almost. I think the PRECISION study absolutely offers very compelling data.”

Kelvin Moses, MD, PhD

Nashville, TN

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