Four experts in prostate cancer diagnosis and screening will debate best practices during a Monday afternoon Controversies in Urology presentation titled Prostate: PSA of 4-10 Gets an MRI not a Biopsy. The 30-minute debate begins at 1 pm during the Prime Time plenary session in the Esplanade Ballroom at Moscone South.
Moderator Christopher Evans, MD, FACS, professor and Chair of the Department of Urology at the University of California, Davis, School of Medicine, said multiple factors complicate prostate cancer screening, creating different schools of thought on best practices.
“For example, MRI is less expensive in Europe compared to the United States, so that, in part, contributes to its great utilization in Europe,” said Dr. Evans, who is also President of the Society of Urologic Oncology. “There’s some data from the PROMIS trial that suggests prostate biopsy isn’t needed in some patients with negative MRI [magnetic resonance imaging], even when PSA [prostate specific antigen] is elevated. So the practice of many urologists, especially in Europe, would be to get a MRI, and if it’s negative to not do a biopsy. That’s not the standard practice in the United States because not everyone agrees with the data.”
Part of the controversy, he said, is how “significant cancer” is defined. In the PROMIS trial the definition of significant cancer was more aggressive than most U.S. urologists would use.
“Because our definitions vary, I think this debate will center on what is an acceptable risk for the patient,” Dr. Evans said. “You have to weigh the risk of biopsy and the risk of the cancer.”
During the presentation, Mark Emberton, FMedSci, professor of Interventional Oncology at University College, London, and Samir Taneja, MD, Director of the Division of Urologic Oncology in the Department of Urology at New York University Langone Health, will make the case for using MRI first in certain patients. They will argue that MRI will not only detect almost all significant prostate cancer, but that it’s also cost-effective and avoids an invasive procedure, Dr. Evans said.
On the other side of the debate, Mark Frydenberg, MBBS, FRACS, Clinical Director of the Prostate Cancer Research Group at Monash University in Clayton, Australia, and Daniel Lin, MD, professor and Chief of Urologic Oncology at the University of Washington School of Medicine, will argue that not performing a biopsy, even with a negative MRI, could mean missing up to 30 percent of what might be defined as significant cancer.
Dr. Evans said that despite the controversy surrounding the issue, he believes attendees will leave with a better understanding of the pros and cons of each approach so they can better discuss the options with patients and ultimately make the best decision about each.
“Physicians will be able to express these considerations to their patients so they can better understand what’s most important to the patient — avoiding a biopsy or being as sure as possible that they don’t have significant cancer,” Dr. Evans said. “Patient preference on the matter is an important part of this discussion.”
Available technology is also an important part of this decision, he said.
“Individual practices will always be influenced by the technology available to them. For most urologists in the United States, a multiparametric MRI is available,” Dr. Evans said. “However, a fusion biopsy is not available in every practice, which may limit the approaches to this problem for some clinicians.”