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ESOU 2019

ESOU 2019: Debate: mpMRI Should Not Be Used Routinely in Patients with an Elevated PSA, Only in Select Cases

Prague, Czech Republic (UroToday.com) As a rebuttal to Dr. Caroline Moore’s PRO stance on mpMRI for patients with an elevated PSA, Dr. Nicolas Mottet offered a response stating that mpMRI prior to biopsy should only be offered in select cases. To clarify, Dr. Mottet noted that this opinion is for patients with T1c disease and PSA <10 ng/mL. This is not for patients with locally advanced disease on DRE with high PSA or patients with abnormal DRE (≥cT2) where the added value of upfront MRI is unknown.

Dr. Mottet highlighted several points to consider:

  • Does mpMRI prior to biopsy relate to any PSA level? Or are there other parameters to consider?
  • If a systematic mpMRI is considered, it must lead to an improved outcome. This may include better biopsy tolerance or an added value for better staging.
  • Is an mpMRI reliable in real life?
Dr. Mottet notes that avoiding a biopsy in the setting of a normal mpMRI is attractive. However, based on the PROMIS data1, the NPV of 89% for Gleason Grade Group ≥3 is quite good, however not as robust when considering Gleason Grade Group ≥2 (NPV 76%). Dr. Mottet makes the argument that the free ERSPC calculator when taken into consideration actually performs quite well: if applied appropriately 30-40% of biopsies would be saved!

One of Dr. Mottet’s most important arguments is that the quality of mpMRI is a major issue. He notes that in PROMIS, 31% of the sites were not included because of poor quality mpMRI. Second, in PRECISION, 5 of the 25 centers included 330 of the 500 patients, which were clearly centers of excellence. Finally, in the MRI-First study, centers were specifically selected based on their mpMRI experience.

Dr. Mottet also makes the argument that mpMRI prior to biopsy is fiscally expensive for any medical jurisdiction. For instance, in France, a PSA tests cost €15, a mammogram costs €66 and a prostate mpMRI costs €250. For 150,000 men in France having a prostate biopsy, this would translate to €40 million yearly for mpMRIs.

Several other important counter-arguments made by Dr. Mottet include:
1. Does mpMRI lead to better tolerance for the patient? Assessing the PRECISION data2, there was no difference in the 24-hour or 30-day patient quality of life metrics. Furthermore, there was no difference in 30-day post-intervention complications.
2. Does mpMRI lead to better ISUP accuracy? Looking at patients in PRECISION2 that underwent radical prostatectomy (mpMRI n=30, TRUS n=27), 19 patients in each arm had concordant pathology, and similar rates were also seen among those patients upgraded and downgraded after RP.
Dr. Mottet concluded with several take-home points:

  • Pre-biopsy mpMRI must NOT be used in patients who do not have an indication for prostate biopsy.
  • Without a strict standardization of mpMRI interpretation and MRI-targeted biopsy technique, the “MRI pathway” may lead to suboptimal care outside of large volume expert centers.


Presented by: Professor Nicolas Mottet, MD, Ph.D., Head of the Urology Department, University Hospital, and Professor of Surgery, University Jean Monnet, Saint-Etienne, France. 

Written by: Zachary Klaassen, MD, MSc – Assistant Professor of Urology, Georgia Cancer Center, Augusta University/Medical College of Georgia, Twitter: @zklaassen_md, at the 16th Meeting of the European Section of Oncological Urology, #ESOU19, January 18-20, 2019 Prague, Czech Republic

References:
1. Ahmed HU, El-Shater Bosaily A, Brown LC, et al. Diagnostic accuracy of multi-parametric MRI and TRUS biopsy in prostate cancer (PROMIS): A paired validating confirmatory study. Lancet 2017;389(10071):815-822.
2. Kasivisvanathan V, Rannikko AS, Borghi M, et al. MRI-targeted or standard biopsy for prostate cancer diagnosis. N Engl J Med 2018;378(19):1767-1777.

Further Related Content:
Debate: mpMRI Should Be Used Routinely in Patients with an Elevated PSA