Insist on pelvic MRI before submitting to a biopsy

[FCoffey]

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.

[FCoffey]

In the US insurance coverage for MRI is uneven. My pelvic MRI is usually covered, my whole body MRI is usually not covered. But when I go to a private place with the newest 3T MRI, the cost for the whole body scan is $650 including radiologist's fee. The enormous research hospital has a 2T MRI made in 1990, and charges $3,000 for an inferior scan.