Thought leaders in the management of prostate cancer build a discussion on the challenges associated with the use of MRI to diagnose prostate cancer including insurance coverage and patient discomfort.
David Albala, MD: We’ve got the PSA [prostate-specific antigen] test. We do a digital rectal examination. We’re trying to consider patients for biopsies. We do a secondary or tertiary marker, whether urine or blood. How do you feel the role of MRI comes in? Over the last few years, a lot of the work from Samir Taneja and Peter Pinto has focused on MRI. How do MRIs play into this? That’s a really hot topic.
Judd W. Moul, MD: That’s a great question. I admit that I struggle with this a little, because at Duke Cancer Center, we have a very good radiologist who specializes in prostate MRI, and he’s put a lot of effort into it. So I know if I get an MRI at my institution, it’s a good-quality MRI. The downside is he prefers to use the endorectal coil, so most of the MRIs in my own practice or my institution, the men are not so delighted to have the endorectal coil because that probe is actually a little bigger than the probe that’s used for a biopsy.
The other challenge we’ve faced in North Carolina is that many of the insurance plans in our state will not reimburse for an MRI in the setting of no previous biopsy. So in the primary screening setting, where you’ve never had a biopsy before, a lot of the plans won’t cover it, and it’s expensive. Even the cash price at our institution is about $2500 if the patient chooses to have it outside insurance. The other challenge we’ve faced, and I’m sure you’ve faced this in at Crouse Hospital in Syracuse, New York as well, is that the quality of MRI varies around the community. Sometimes patients will come in from the outside with an MRI, and they want a fusion biopsy based on an outside MRI. That’s problematic because it’s difficult to take an outside MRI. So the patient dutifully brings that into the tertiary care center and says, “Here’s my MRI. I want a fusion biopsy.” Then we tell them, “You have to repeat the MRI at our institution before we do a fusion.” The key message is, it’s an expensive test. I’m still not convinced, despite excellent data from the NCI [National Cancer Institute]. I’m not disagreeing with the data, but in practical terms, in the trenches, is it really necessary or cost-effective to get an MRI in every single patient who presents with an elevated PSA? At least with the urine and blood tests, they’re not as expensive as an MRI, and they’re obviously less invasive. At my institution, an MRI is invasive.
David Albala, MD: That’s a great point. We’ve run into the challenges with coverage. We’ve worked around that a little, offering patients the option of paying out of pocket. We’ve negotiated an $800 to $1000 rate for an MRI if patients really want to have it. But you’ve alluded to some great points that have been important in trying to make the decision on how to integrate this.
Transcript edited for clarity.