How many of you have had a doctor recommend RP or EMRT without having first done an mpMRI?

[Bj1069]

When I was diagnosed everyone seemed quite in a rush to get me to do some radical treatment, either EMRT or RP followed by Androgen Deprivation. My own research seemed to show that mpMRI would provide me with clear evidence of the extent of the disease and enable me to make an informed choice. The first time a urologist tried to pitch me that shared decision making crap, I explained to him that the choice was mine, and only mine. It took me 4 doctors and 2000 miles of driving, but I still have my prostate, I'm not androgen deprived, and, while there was clear evidence that I had cancer, there is now clear evidence that I don't. Getting the MRI saved me from the malpractice that presently passes for a standard of care.

[Tall_Allen]

I didn't have one. It's use is controversial on the first biopsy because it is so rarely informative, and wastes a lot of money. However, there are two circumstances where it has proven value:

(1) If the first TRUS biopsy was negative, yet PSA continues to inexplicably rise

(2) If the first TRUS biopsy was positive but low grade and the patient is a candidate for active surveillance. In that case, the confirmatory biopsy may be mpMRI-targeted.

[Bj1069 in reply to Tall_Allen]

mpMRI is cheaper than a biopsy by about 40%. And every biopsy that it eliminates the need for also eliminates the possibility of biopsy induced sepsis. And a 3d fusion guided biopsy is 3 times as effective as a TRUS guided biopsy at finding cancer. Even if it were more expensive, it adds substantially to quality of life years. A major flaw in the studies claiming that mpMRI is more expensive is the assumption that each clinic would purchase its own machine, build its own theater, and hire its own urologist. But 3t machines are routinely used in screening for breast cancer, colon cancer, brain cancer and many others. It's not simply a question of how to guide a biopsy. It's a way to eliminate the need for many biopsies, and to improve the accuracy of needed biopsies so that the percentage of false negatives drops from the 30s to the single digits. The cost to patients from refusing to use the technology is counted in quality of life issues. It is traumatic to have RP, even more so in cases where post op pathology shows the surgery wasn't necessary. Add to that the discovery that return to continence is defined as not wetting yourself more than once a day and there is no undoing the unneeded damage. But it is also counted in lives lost. One in three cases of metastatic prostate cancer arises in people who had negative systematic biopsies, or biopsies that found low grade, but missed high grade cancers. Outcomes for this group are significantly worse than outcomes for those whose cancers were found, graded and staged accurately. Routine use of mpMRI would ensure that nearly all cases were accurately staged and graded. It is simply not justifiable to fail to provide the best care available. Prostate cancer kills more people in America than breast cancer both in percentage and raw numbers. That shouldn't be the case given that breast cancer is far less likely to be indolent. But doctors screening for breast cancer have the advantage of using 3t MRIs, the same machines used for prostate MRIs and can detect cancer at very early stages with virtually 100% accuracy. Try telling the ladies they should have breast ultrasounds because MRIs cost too much.

[Tall_Allen in reply to Bj1069]

I wish your faith in mpMRI were justified by the statistics. An mpMRI-targeted biopsy is NOT less expensive than a TRUS guided biopsy - it is more than twice the cost. And it is LESS sensitive than a TRUS biopsy at finding cancer- it is only more sensitive at finding SIGNIFICANT cancer. But its false negative rate for significant cancer is 10-20% -- too high to avoid a biopsy entirely based on it, which would be a TRUS biopsy anyway.

There has been a huge proliferation in mpMRIs in recent years because patients like you are demanding them. Unfortunately, radiologist experience and training has not kept up. Even using the most recent PIRADS 2 guidelines, there is a wide disparity among radiologists in reading the scans. One should stick to the largest tertiary care centers where it is more likely that radiologists will be more experienced.

There is no difference in QOL of life whether a person has a TRUS-guided biopsy or an mpMRI targeted biopsy as first biopsy.

[Bj1069 in reply to Tall_Allen]

You seem confused. mpMRI is more sensitive, not less. It is much more cost effective for patients have a second or third biopsy, and somewhat more cost effective for biopsy naive patients.There are studies that claim the opposite but they rely on each clinic amortizing the cost of its own machine and radiological staff. That's not how it works. Most clinics refer patients to a radiologist who provides the service using the same 3t machine used for breast cancer patients. The cost is amortized across scores or even hundred of patients. As to quality of life, I still have a fully functional erectile system, a largely intact prostate, and I don't suffer from either urinary or fecal incontinence. I sleep through the night, have a normal sex life, and I don't smell like a stale diaper. Had I followed the guidance of the first 3 doctors I saw, at least some of those afflictions would be the case, perhaps all. Also, I don't worry over what comes next. It is a huge difference in quality of life.

False negative TRUS biopsies, or TRUS biopsies that result understaging lead to people doing watchful waiting or active surveillance when they should have done something more aggressive.This group accounts for nearly a third of all cases of metastatic prostate cancer in the US.

There's a reason that more men are dying of prostate cancer while breast cancer death rates are falling. Number 1 is screening. As women move from mammogram to 3t MRI, men muddle along with PSA and biopsies that are little better than guesses. It's shameful.

[Tall_Allen in reply to Bj1069]

I am not confused. mpMRI is very bad at detecting low grade and insignificant PC.

link.springer.com/article/1...

On a first biopsy, it doesn't significantly outperform TRUS for detection of clinically significant PC, as found in the following meta-analysis;

clinicaloncologyonline.net/...

The first randomized trial of mpMRI vs TRUS targeted biopsy in biopsy-naive patients found "MP-MRI/TRUS-fusion targeted biopsy did not improve PCa detection rate compared with TRUS-guided biopsy alone in patients with suspected PCa based on PSA values."

europeanurology.com/article...

If you have any contrary info, I would certainly love to see it.

You seem to be conflating all the different ways in which mpMRI can be used in men with PC. It certainly has a use for a second targeted biopsy when suspicion remains, on a confirmatory biopsy and follow-up for men on active surveillance, and possibly to help define the site of a local recurrence.

While an mpMRI before a first biopsy may make economic sense in EUROPE, it will not pencil out in the US. Here's a good analysis of the cost/benefits that may interest you:

ncbi.nlm.nih.gov/pmc/articl...

[Hidden in reply to Tall_Allen]

It is time to stop allowing the cost of detection to cloud this discussion. TRUS-B has a proven 20-30% false negative rate. It may be low cost and widely accepted but it is based on statistics of chance (ie spacing/location of core samples), unable to sample a significant area of the prostate (anterior and apex) and IMHO, borders on medieval medicine given the risks. Shoving rectal bacteria contamination directly into the prostate with the expectation that increasingly ineffective antibiotics will clean up the mess is russian roulette (my urologist stated in patients like myself where antibiotics have been used recently, the severe morbidity risk was about 60%!). I understand that advanced imaging costs more than stabbing around with a biopsy needle hoping that statistics are working in my favor, but they cost LESS than ANY treatment option, WAY less than hospitalization due to biopsy complications and the procedures carry NO physical risk. The argument that mpMRI might miss some cancers is lame given that TRUS-B has the same flaws AND carries significant medical risks. That said, guided biopsies (TPB) DO have a place in confirming, grading and deciding/planning active treatment based on the imaging and blood tests (PSA, PHI, 4K)

I am not advocating that imaging has evolved to the state where it alone can diagnose cancer but mpMRI combined with SWE may well be the combination that provides that level of detection and at the very least, provides urologist with a detailed map of where to biopsy with much greater certainty of sampling areas of concern. TRUS itself was a MAJOR advance in realtime prostate imaging but it did come with associated costs which over time became insignificant. mpMRI likely will never be an insignificant cost but by leveraging the equipment over many medical disciplines, the costs can be amortized to a per use that is acceptably low.

Racing into major life altering treatment seems so engrained in the prostate cancer world that we, the patients, seldom have time to gather, process and understand the TRUE ramifications of what is being proposed let alone that treatment options exists. We are talking about WAY more than just detecting/treating cancer here. This is about a core element of what makes us who we are and the emotional impact such decisions will inflict. As I told my urologist, I am quite attached to my prostate and would hugely prefer to keep it. I am thankful to live where I have access to cutting edge medicine and an enlightened urologist that listens.

[Tall_Allen in reply to Hidden]

Easy for you to say since you can afford it. Some of us are not so lucky. MpMRI has a false negative rate of 10-20% and is HIGHLY dependent on the skill of the radiologist.

[TimCo]

An amazing journey thank you BJ. Bottom line do your due diligence and follow you gut- wherever that takes you.