Posted by By R. Daniel Cinotto MBA, CRA
In my article “MRI for Prostate Cancer Detection” in the May/June issue of Radiology Management, I presented my case for using this new technology for the detection of prostate cancer. As a follow up, on May 9, 2017, The American Urological Association (AUA), the American Society for Radiation Oncology (ASTRO), and the Society of Urologic Oncology (SUO) released their updated guidelines for clinically localized prostate cancer (PCa). For any businesses that are either performing or are considering performing MRI for PCa, it is important to understand the new guidelines in order to better serve referring urologists and answer curious patients’ questions. In the document, approved by the AUA Board of Directors in April of this year, and released just ahead of their annual convention, they mention the use of MRI three separate times.
It is important to note that they preface their guidelines by classifying them as either ‘expert opinions’ or ‘clinical principles.’ An expert opinion is defined as “a statement, achieved by consensus of the Panel, that is based on members’ clinical training, experience, knowledge, and judgement for which there is no evidence.” A clinical principle is defined as a “statement about a component of clinical care that is widely agreed upon by urologists or other clinicians from which there may or may not be evidence in the medical literature.”
MRI is first mentioned in guideline 15, which reads “clinicians should consider staging unfavorable intermediate-risk localized prostate cancer patients with cross sectional imaging (CT or MRI) and bone scan.” This is considered to be an expert opinion. They go on to say:
Prostate MRI provides more accurate imaging of the prostate gland and has no associated radiation exposure compared to CT; however, the high quality prostate MRI may not be available at all sites.
This statement alone presents the opportunity to begin scanning MRI for PCa if you currently aren’t doing so. They further clarify the recommendation by saying that MRI should be considered if two or more risk factors are present (positive digital rectal exam, Gleason score of 7, or a PSA > 10).
The next time MRI is mentioned is guideline 22, which reads “clinicians should stage high-risk localized prostate cancer patients with cross sectional imaging (CT or MRI) and a bone scan.” This is considered a clinical principle. They go on to mention the need for further research.
The final guideline that mentions MRI is 28, which reads, “localized prostate cancer patients who elect active surveillance should have accurate disease staging including systematic biopsy with ultrasound or MRI-guided imaging.” This is considered a clinical principle. They go on to clarify:
The recent development of MRI imaging of prostate cancer promises to enhance the early identification of aggressive disease in men diagnosed with low-risk prostate cancer who are candidates for surveillance.
This seems to suggest using MRI as a tool during active surveillance. Its status as a clinical principle means that this is widely agreed upon by urologists. In this section, they further elaborate saying that the “appeal of serial MRI in men on surveillance is that it may allow a safe reduction in the frequency and number of follow up biopsies.” In that same paragraph they mentioned that a two year interval between MRIs has been suggested by authors.
If we aggregate this data further we can draw some conclusions:
- The opportunity exists for more facilities to offer quality prostate MRI.
- MRI is already being used to stage disease, as an active surveillance tool, and for MRI-TRUS fusion biopsy.
- More research is warranted, but frequent use is becoming common.
Bibliography
Sanda, MG, Chen, RC, et al. “Clinically Localized Prostate Cancer: AUA/ASTRO/SUO Guideline.” 2017. http://www.auanet.org/guidelines/clinically-localized-prostate-cancer-new-(aua/astro/suo-guideline-2017). Accessed June 21, 2017.
Daniel Cinotto MBA, CRA is the director of facility operations for FirstScan in Omaha, NE. He has years of experience in marketing IDTF’s and managing sales teams. FirstScan is a provider of bpMRI for early detection of prostate cancer. Daniel can be contacted at dan.cinotto@firstscanomaha.com or at (402) 934-1999.
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We have had pushback from Urologists and Radiologists wanting to perform all prostate MR on a 3.0T unit only. Since there is only one unit in town we have a bit of a snag. Do any of the guidelines advise against 1.5T imaging?
None of the guidelines specify Tesla strength. Most will say the industry standard is 3T given the gland’s location. However, in my professional experience, I have used both (and still do). All patients with bilateral hip replacements should be scanned on a 1.5T, not a 3T, due to increased artifact on a 3T. This should be standard procedure, and came from quite a bit of trial and error. The average age of diagnosis is roughly 65-66, so more than a few of those patients have new hips! The coil choice can have a direct impact as well on a 1.5T. A combination of surface and spine coils can get you decent images on a 3T, but likely not on a 1.5T. Feel free to email me and I can share which coils we use and when. There are a few other tricks that we’ve learned along the way I can share as well. Thanks for the reply Jose!
I think it depends on the age of the magnets. We have a 3T and 1.5T, but our 3T is older with older gradients and our 1.5T is GE’s newest. The prostate images look much better on our 1.5T and our radiologist WANTS them on the 1.5T.
It sure could Chad. We had some issues with the DWI on our 3T in the beginning as well, but the T2’s have always been far superior. The bottom line though is whatever the radiologist is more comfortable reading!