Too late for most men here, but Insist on pelvic MRI before submitting to a biopsy

[FCoffey]

This is a duplicate of a post I made in the Prostate Cancer group. Most men in this forum have already had biopsies and more. Perhaps this info will help prevent a few needless, dangerous additional biopsies.

This paper comments on the PRECISION study, which shows pelvic MRIs are excellent tools to determine if there is clinically significant prostate cancer.

europeanurology.com/article...

The results are quite strong:

659 MRI-negative men with no prior biopsy

395 had standard biopsy immediately after MRI, finding only only 12 clinically significant cancers.

An additional 264 men had a deferred biopsy within 48 mo, which revealed a further 24 cases of clinically significant cancer, representing 95% freedom from clinically significant disease by 48 months.

This confirms other reports that showed a negative MRI gave 98% confidence that there was no Gleason 7 cancer.

From the paper:

"Can we omit routine standard biopsy for all men with negative MRI? It certainly seems that no immediate harm will be done, as none of the men in the study progressed or died of prostate cancer during 4 yr of follow up. In addition, 95% freedom from clinically significant disease at 48 mo would be acceptable to many in order to avoid the known risks associated with biopsy. These risks increase with the sampling density of the biopsy..."

The risks of biopsy listed include

23% report urinary retention

20% report ED where there was none before the biopsy. This is usually but not always temporary, but temporary can mean 6 months or more.

There are some forms of prostate cancer that don't show on MRI, but they are rare. Being cancer, if you have them they are almost certainly going to grow to the point where they can be detected.

Like all decisions, there are risks and rewards no matter what you choose. MRI has very low chance of hurting you; mostly it is a bit uncomfortable being confined in the tube for 45 minutes or so. The downside of MRI only with no biopsy is you might miss a very rare cancer, but that's unlikely to cause long-term harm.

Biopsy has a significant chance of hurting you. In addition to urine retention and ED, there is strong evidence from breast cancer research (better funded than prostate cancer, but a similar cancer) showing that needle biopsies can cause tumors to spread. Men don't tie because their prostate is cancerous, they die because the cancer spreads.

The article concludes that

"the time has come for urologists to strive to make prebiopsy MRI available to all men being assessed for prostate cancer."

You can do your part by refusing biopsy until an MRI shows there is a need for this dangerous procedure. Your urologist may hate you, but you have to look out for yourself.

[Schwah]

Thanks FCoffey. Let me add a couple more important points to your post. First many men are still doing random needle biopsies. I had a random 14 needle biopsy prior to any mri after a rising PSA and a nodule being felt in a digital rectal exam. All 14 were negative. A few months later (after becoming much more knowledge) I had an MRI guided biopsy. They said this time they only needed three needles since they clearly saw what they believed was my cancer. This time they hit 3 for 3. All with 90% cores of Gleason 8. Hmmmm. O-14 vs 3-3. That says it all. Hard to believe the random biopsy even exists anymore. Also I had a good friend do a random needle biopsy and ended up in the hospital with an infection and almost died. All negative cores by the way. I sent him to my MO who had him do an MRI which was negative. He did not do another biopsy and is fine 7 years later although now monitors his PSA. Finally, as long as we are discussing biopsies, let me say every positive biopsy should be sent to Dr Epstein at Johns Hopkins for a second oppinion. In my search for answers on my own PC I heard many many differing opinions. However the one constant was that Epstein was the best pathologist in the country. It only costs a few hundred dollars. This advise to others has shown that perhaps some experienced Patholgists May be too conservative. He found at least two instances of previously diagnosed Gleason 7s being only pre cancerous ( I forget what he called it) and only requiring further monitoring but no treatment.

Schwah

[Dan59 in reply to Schwah]

It is important to have your biopsy reviewed by an expert. Everything I have read over the years says that Jon Epstien at Hopkins is the best pathologist. It is easy to call the place that did your biopsy and have it sent to him for review, cost was $200 when I did it. He confirmed me as a Gleason 10.

[FCoffey in reply to Schwah]

Strongly agree; 2 different reasons.

1) Dr Epstein at Johns Hopkins is the only endowed chair in Urinary Pathology in the world. Conduct yourselves accordingly.

2) Always, always, always get a second opinion.

[Tall_Allen]

An mpMRI-targeted biopsy should be reserved for 3 situations:

(1) after a first negative biopsy when suspicion remains (rising, unexplained PSA)

(2) for a confirmation biopsy for men contemplating active surveillance

(3) to track disease progression for men already on active surveillance

The negative predictive value is too low for routine use on a first biopsy. 2/3 of first biopsies are negative.

[tallguy2 in reply to Tall_Allen]

I just yesterday learned of the use of MRI for PC interception/detection from a friend of mine who has a PSA of 15, and two negative 12-point biopsies. He was exploring proton radiation in Knoxville, TN when he was referred for the MRI to a specialist in Chattanooga, TN. The MRI pin-pointed two areas of malignancy within the prostate, with the additional data that it is still encapsulated. My friend, who is 81 years old, will now get the proton therapy. The MRI results can and do influence treatment plans.

I wish the MRI had been available in 2012 when I was first diagnosed, or even earlier. Intercepting PC before is becomes Stage IV should be the aim of every urologist, in my opinion. For me waiting until the PSA hit 4.0 and doing a biopsy was too late.

BTW: with 3 of 6 Taxotere chemos under my belt my PSA is down to 0.2. This stuff works!

[geo3]

I agree, and would just add:

. . Make sure the MRI is multiparametric, and at least Tesla 3. Tesla 2 will not help.

. . If an anomaly is found in MRI, the MRI image can be fused to the ultrasound to better guide the biopsy.

. . Over-sample the MRI anomaly in the prostate, but don't ignore the rest of prostate. G3 and G4 have been biopsied where an MRI missed. G7 usu visible on MRI.

Sorry to state what is obvious to some, but remain surprised in Pca Support groups to learn this is not the standard of care at some hospitals.

Good luck.

[cesanon]

Yes.

An MRI should be a prerequisite for any surgery or major course of treatment.

[APL1881]

My husband’s doctor scheduled a pre-biopsy MRI and the insurance company wouldn’t pay for it, so he had the biopsy without it. 12/12 samples came back positive. Following the biopsy my husband had an MRI pre-surgery. Seven months later we’re still fighting with the insurance company to cover the $2,400 cost.

[Mormon1 in reply to APL1881]

please name the insurance company

[MrkP]

I had a biopsy that showed cancer in 6 of 12 cores. One core was Gleason 9. My subsequent 3T MRI was negative, so MRI before biopsy may not work for everyone.

[chascri]

Sounds like an excellent suggestion to me. I have long thought that biopsy increased the risk, rate and frequency of metastasis.

[j-o-h-n]

What and give up the pleasure of having someone shove a needle up you rectum and hearing those beautiful POW POW sounds while you're wide awake? One of the rare pleasures of life. Almost as much fun as being stuck in a traffic jam in Miami when you're air conditioning is on the fritz. Oh what a wonderful life.

Good Luck and Good Health.

j-o-h-n Monday 07/23/2018 1:27 PM EDT