Do all patients with suspicious prostate cancer need Multiparametric Magnetic Resonance Imaging before prostate biopsy?

Abstract

Objectives: Multiparametric magnetic resonance imaging (mpMRI) is a useful tool to diagnose prostate cancer (PCa) but its cost is not negligible. In order to reduce costs and minimize time to diagnosis, it is necessary to establish which patients benefit the most from doing mpMRI prior to prostate biopsy (PB). Our aim was to test if mpMRI still predicts PCa and clinically significant PCa (csPCa) in patients with high clinical suspicion of cancer, defined as prostate specific antigen (PSA) > 10 ng/ml, PSA-Density (PSAD) > 0.15 ng/ml/cc or suspicious digital rectal examination (DRE). Materials and methods: We retrospectively collected data on 206 patients who underwent mpMRI before PB at our Department from January 2017 to July 2018. mpMRI results were classified using Prostate Imaging Reporting and Data System (PI-RADS) version 2. In primary analysis, we evaluated the association of mpMRI with PCa and csPCa and stratified this model for low and high clinical suspicion of cancer. In secondary analysis, we determined the rate of negative PB results in patients with high suspicion of cancer and compared theses rates with those obtained if only those with PI-RADS 3-5 would be biopsied. Results: In primary analysis and overall, mpMRI was predictive of PCa and csPCa. In stratified analysis, mpMRI was still significantly associated with csPCa in patients with PSA > 10 ng/ml and PSAD > 0.15 ng/ml/cc, but not in those with suspicious DRE. In secondary analysis, negative result rates were lower if only patients with PI-RADS 3-5 were biopsied, even in subgroups with high suspicion of cancer based on PSA and PSAD. In patients with suspicious DRE, however, the rate of negative results did not change significantly if only patients with PI-RADS 3-5 were biopsied. Conclusions: mpMRI is still useful in predicting csPCa in patients with PSA > 10 ng/mL and PSAD > 0.15 ng/ml/cc. If DRE is suspicious, though, mpMRI might be no longer useful in the prediction of PCa.

Cost-effectiveness analysis of short biparametric magnetic resonance imaging protocol in men at risk of prostate cancer

“…Although MRI is an expensive procedure, this approach has brought the best NMB, with spending values within the WTP threshold, with appropriate use of public money. Our analysis, based on age and PSA stratification, suggests that it can be cost-effective in all age and PSA categories we studied (11)(12)(13)(14)(27)(28). Use of contrast enhanced transrectal ultrasound (CE-TRUS) was also proposed but, unlike liver or pancreatic lesions, contrast enhanced ultrasound is less suitable in Pca detection (29)(30)(31).…”

“…The base case was a 65-year-old man, performing prostatic MRI because of elevated PSA levels and/or clinically significant DRE. These demographic features are based on the median age of the Pca onset (1,12). The model was tested by age groups in order to examine the cost-effectiveness, given varying levels of cancer prevalence and life expectancy.…”

“…We evaluated the cost-effectiveness of each strategy for three age groups with a different Pca prevalence. Several economic-based models assessed some hypothetical screening strategies based on PSA thresholds, in relation to age categories (11)(12)(13)(14)(15)(16). Our analysis, based on age and PSA stratification, try to better understand the potential impact of BP-MRI on QALY and costs.…”