Multiparametric MRI (mpMRI) is a simple, elegant way for men suspected of prostate cancer (PCa) to avoid an unnecessary biopsy. It’s especially beneficial in making treatment decisions that match the patient’s disease and its extent. And, for patients who are facing radical prostatectomy (RP), mpMRI can improve surgical outcomes by ruling out positive surgical margins.

However, urologists have been slow to adopt pre-treatment MRI. This is the finding of a new multicenter study published by the Journal of Urology in June, 2022.^[i] Not only is there a broad lack of adoption, but it seems markedly underused depending on the patient’s location and race.

Cole, et al. gathered case statistics on over 19,000 patients who underwent RP from 2003-2016, and calculated the proportion of men who had a preoperative MRI each year in each of 17 hospital referral regions (HRR). They also assessed the link between pre-treatment MRI and surgical outcomes (margin status, surgical complications).

Over the 13-year study period, they found that the percentage of men receiving pre-surgical MRI rose from 2.9% to 28.2%, and ranged from zero to 28.8% depending on the HRR. In terms of surgical outcomes, they found that pre-treatment MRI was associated with

• Less chance of positive surgical margins
• Lower odds of blood transfusions at 30 and 90 days.

Thus, it seems like a no-brainer that prostate MRI prior to surgery is to a patient’s advantage, yet a minority of patients undergo the scan.

Furthermore, there is an uneven distribution of who gets an MRI and who doesn’t. As the authors explain, “Patients who received MRI were more likely to be white, married, and living within the hospital region in which they were treated … Factors such as cost, health literacy, and availability of imaging may affect whether a man with prostate cancer receives an MRI.”^[ii]

In a statement put out by Brigham and Women’s Hospital, the study’s lead author, Dr. Alexander Cole, noted that these gaps must be addressed. His team is developing a program call the Mass General Brigham Prostate Cancer Outreach Clinic in collaboration withUnited Against Racism. More importantly, while broad utilization is trending upward, prostate MRI before treatment is sadly underused by urologic surgeons who are not referring their RP patients for a noninvasive scan that can improve surgical results. While Cole, et al. propose “efforts to support the dissemination of prostate MRI,” they note that this may lead to a need for “more resource-intensive cancer care overall.” The question remains: why aren’t more urologists using prostate MRI before surgery?

Some insight into this situation comes from a 2016 survey of urologists’ attitudes toward MRI. A study out of Washington University School of Medicine by Manley et al. surveyed 7,400 practicing American Urological Association physicians, asking about access, accuracy, cost, and role of prostate MRI in clinical practice.^[iii] They received 276 responses, calculated as follows:

Respondents felt that limited access and prohibitive cost of MP-MRI limits its use, 72% and 59% respectively. Academic urologists ordered more MP-MRI studies per year than those in private practice (43.3% vs. 21.1%). Urologists who performed more than 30 prostatectomies a year were more likely to feel that an MP-MRI would change their surgical approach (37.5% vs. 19.6%). Only 25% of respondents agreed or strongly agreed that MP-MRI should be used in active surveillance. For patients with negative biopsies and elevated PSA, 39% reported MP-MRI to be very useful.

Thus, in the same year that the Cole study wrapped up their analysis, the Manley survey reveals that both limited access to MRI, and a perception of high cost, were perceived as the main barriers to use. It’s not surprising that urologists in academic centers had a higher rate of usage than those in private practice, as the multidisciplinary teams at such institutions often set the pace for change in the field of urology. But, there’s reason for optimism. Since 2016, the trend of broader MRI adoption by urologists continues. An Aug. 23, 2021 issue of Urology Times commented, “The use of multiparametric-magnetic resonance imaging (MRI) to help guide prostate biopsies has been growing among urologists and was the subject of an American Urological Association (AUA) and the Society of Abdominal Radiology Prostate Disease Focused Panel standard operating procedure document.”^[iv]

At the Sperling Prostate Center, we are hopeful that the enormous advantages of prostate MRI for the detection, diagnosis, and treatment guidance of prostate cancer are now much more widely shared by our urologic colleagues, and there is still room to grow. We all want what’s in our patients’ best interests—and mpMRI is it.

NOTE: This content is solely for purposes of information and does not substitute for diagnostic or medical advice. Talk to your doctor if you are experiencing pelvic pain, or have any other health concerns or questions of a personal medical nature.

References

[i] Cole AP, Chen X, Langbein BJ, Giganti F et al. Geographic Variability, Time Trends and Association of Preoperative
Magnetic Resonance Imaging with Surgical Outcomes for Elderly United States Men with Prostate Cancer: A Surveillance, Epidemiology, and End Results-Medicare Analysis. J Urol. 2022 May 10:101097JU0000000000002736.
[ii] Yee, Kate Madden. Are all men benefiting from preop MRI for prostate cancer surgery? AuntMinnie.com. Jun 17,
2022. https://www.auntminnie.com/index.aspx?sec=sup&sub=mri&pag=dis&ItemID=136176
[iii] Manley BJ, Brockman JA, Raup VT, Fowler KJ, Andriole GL. Prostate MRI: a national survey of Urologist’s attitudes and perceptions. Int Braz J Urol. 2016 May-Jun;42(3):464-71.
[iv] Urology Times Staff. “Multiparametric-MRI in prostate cancer: an expert’s view.” UrologyTimes.com, Aug. 23, 2021. https://www.urologytimes.com/view/multiparametric-mri-in-prostate-cancer-an-expert-s-view