Traditional systematic biopsy can miss clinically significant prostate cancers and often causes discomfort for patients along the way. While many countries have added MRI to prostate cancer workup protocols to determine which patients really need the needle, pre-biopsy MRI is used in only about one-third of U.S. prostate cancer workups – why?
More organized prostate cancer screening programs are popping up across the world. But a big challenge remains: deciding which patients with elevated PSA tests should undergo biopsy, and which ones can avoid or defer biopsy. That’s where MRI comes in…
- Australia, Canada, the U.K., and much of Europe have all adopted pre-biopsy MRI scans as the standard of care.
- Pre-biopsy MRI scans are noninvasive and much more sensitive than traditional systematic biopsies, which typically obtain 10-12 cores to find lesions (93% vs. 50%).
- The pace of MRI adoption for prostate cancer workup reflects ongoing disparities, with Black patients, people living outside cities, and Medicaid-eligible populations less likely to have access.
So, what’s the holdup in the U.S.? A new STAT article broke it down, finding:
- Many U.S. urologists haven’t been trained in using MRI findings and/or performing MRI-targeted biopsy.
- MRI access is still an issue across the country, especially in rural areas.
But something else may factor in: money.
- Biopsies can often be done in-house, so each procedure could mean up to $1.5k in reimbursement.
- Biopsies can detect low-grade cancers that might never become clinically significant, potentially leading to additional surveillance and repeat biopsies, which also generate revenue.
- Greater MRI use could reduce biopsy-related revenue.
Still, some organizations say yes to pre-biopsy scans, including the National Comprehensive Cancer Network, the American Urological Association, and the American Society of Clinical Oncology (albeit conditionally for the latter two).
- Plus, a 2020 paper won over insurance companies to cover prostate MRI — but not all clinicians know that.
- MRI scans have also proved helpful in other areas, like staging prostate cancer.
What could move the needle?
- Training, ideally in urology residency, to overcome the knowledge gap early.
- Education aimed at urologists and patients about reimbursement options and clinical benefits.
- Improved access to high-quality MRI across the U.S.
- Unified, implementation-focused programs like the one trialed in the Czech Republic, which led to a 10-percentage-point increase in pre-biopsy MRI utilization.
The Takeaway
The STAT article shows the U.S. is lagging far behind other countries in using MRI to diagnose and manage prostate cancer with more precision. Even though some major medical organizations are on board, broader implementation of MRI for patient workup requires overcoming limited training, barriers to technology access, and financial incentives that may favor biopsy.
