By: Dan Sperling, MD
I recently spoke with a Florida patient whose healthcare coverage is through a PPO. Two years ago, the urologist he sees through his PPO performed a TRUS biopsy two years ago that found two small areas of early stage cancer. He chose to go on Active Surveillance, and monitor using PSA. During the last 12 months, his PSA has been gradually rising—not too rapidly, but enough to concern him. And enough for his urologist to suggest another biopsy.
At the time of the first biopsy, the patient had never heard of 3T multiparametric MRI. Nor had he heard of targeted biopsies. He has educated himself extensively since then, and he said to me, “If I knew about these advances two years ago, I never would have had a 12-core biopsy. How do I even know if it found all the cancer?” But here’s the rub: When he told his urologist about MRI detection, the urologist flat out refused to refer him. And his primary care doctor told him that if the urologist wouldn’t prescribe it, neither would she. He feels his only choice is to have another biopsy. I wish this story had a happier ending. This patient’s circumstances do not allow him to travel to our center, nor to pay out of pocket as he has to without the urologist’s referral. (Even were he to locate someone in Florida, his home state, he would still have to pay.)
This is a sad situation, but it’s very real for many patients. There are many reasons why the situation exists, but I want to address two key factors that are evolving all too slowly:
1. Geographically, there are not yet enough 3T magnets that are widely available. 3T means the equipment has a powerful field strength that is capable of generating very high quality, detailed images. Even where 3T magnets are available, not all radiology centers offer the specific multiparametric protocol that we use. This means that many men, like the Florida patient, can’t access a center because the travel expenses are a deterrent. Still, this is gradually changing as more radiology centers are either replacing their 1.5T magnets with more powerful equipment, or simply adding to what they already have. The second problem, in my opinion, is the more difficult nut to crack.
2. Urologists vary in their knowledge and receptivity to radiologic imaging. Since they themselves cannot offer the MRI, they rely on the ultrasound device in their own practice to do what they were trained to do and have come to rely on: a conventional TRUS biopsy. Despite its limitations, it certainly is widely available and patients don’t have to go out of network to have an in-office biopsy. But what I’m seeing, and am optimistic about, is the growing number of urologists who DO value what 3TmpMRI can do for their patients, and for their own ability to coach patients on treatment choices when cancer is found.
To give one example of my optimism, the 2013 annual meeting of the New England Section of the American Urological Association witnessed the presentation of a paper by a urology group out of Beth Israel Deaconess Medical Center (Boston). A presentation to one’s peers can have a powerful influence, especially when it comes through such a prestigious institution. Out of over 1,000 patient files, the presenters identified men who had 3TmpMRI after two negative biopsies. They evaluated “whether a novel MRI protocol can improve cancer yield, determined if detected tumors were clinically relevant, and compared MRI prompted biopsy results to those obtained with a concurrent systematic biopsy strategy.” They concluded that compared with systematic TRUS biopsy, MRI prompted biopsies had a 6-fold increase for tumor yield. The majority of those tumors were in prostate regions typically undersampled by TRUS biopsies, and the preponderance of tumors thus identified were clinically significant (likely to become life-threatening if left untreated).
So for those of you whose medical coverage or plan urologists don’t allow for out-of-network services, and your budget must also be taken into account, take heart. The leadership in urology, like the Deaconess team, is getting the word out about advanced prostate imaging and backing it up with data from their own experience. It’s frustrating when progress seems to move at a snail’s pace, yet slowly but surely there will be greater geographic availability of 3T magnets, which are of immense value for imaging of countless medical conditions besides prostate cancer.
[i] Yao D, DeWolf W, Sanda M, Bloch BN et al. Use of new high spatial resolution 3T MRI technique to identify prostate cancer missed on routine biopsy. New England Section, AUA, 78th annual meeting, 2013.