CaP Update 2019: Is MRI Imaging Replacing Biopsy?
Phranq D. Tamburri, NMD
Over the past decade, as has been documented in my previous NDNR articles, my practice has specialized in the proper use of prostate imaging for concerned patients with an elevated prostate-specific antigen (PSA) who want to avoid a biopsy. Prostate imaging, whether via color Doppler transrectal ultrasound (TRUSP) or MRI, can be extremely useful as part of a comprehensive assessment of prostate cancer (CaP) risk. However, imaging should never be used as a sole diagnostic tool, since prostate imaging by itself can never legally diagnose a prostate cancer. This fact often confuses patients who have been misled by their online research that imaging can simply replace an intrusive biopsy.
Despite its diagnostic limitation, imaging has still been used successfully by medically progressive urologists for over a decade now. Used properly, prostate imaging can help a doctor make 2 important determinations: 1) whether a biopsy is immediately needed; and 2) why a PSA is increasing in the first place. It has only been within the last few years that qualitative prostate imaging without biopsy has become accepted by many conventional urologists. What has changed to make this happen? Has prostate imaging somehow improved? If imaging still can’t diagnose a prostate cancer, then why has it become more popular among the “anti-biopsy patient community” and cynical urologists? At the end of the day, the anxious patient simply wants to know if prostate imaging is right for him. And just about any educated layman will want to ask why modern imaging can’t be used to identify a CaP problem before his body is punctured with 12 random holes. Unfortunately, the results of current prostate imaging, as useful as they may be in the hands of an experienced practitioner, are not delivering the results and utility that many patients had initially expected.
This article will discuss the proper use of imaging, clarify what imaging should not be expected to reveal, and, in particular, explore the profound misunderstandings encountered by patients regarding the recent trend among conventional urologists to order local MRI imaging. This will be important for both the anxious patient with an elevated PSA and the physician considering a referral for prostate imaging.
The pendulum of medical opinions can often swing radically among physicians. The pragmatic reality or truth is usually somewhere in between the 2 extremes. That middle ground is especially relevant when a patient’s personalized case is viewed in context. In other words, a PSA should be assessed within the context of a patient’s urination symptoms, the size of his prostate, and the PSA rate of change over time, to name only a few considerations. Prior to the last decade, any PSA over 4.0 was considered biopsy-worthy. Eventually, PSA reliability was challenged by many patients, researchers, and physicians. The pendulum eventually swung the other way, with physicians deciding to forego PSA testing altogether. Unfortunately, this has led to a resurgence of CaP complications.
Like the PSA, prostate imaging has recently undergone a similar “whiplash-inducing” change in medical opinion. Before even a few years ago (circa 2015), physicians, including myself, who conducted imaging were considered wasting a patient’s time and money and giving them false hope. Some doctors even unfairly accused such physicians of improperly diagnosing cancer on imaging alone. But opinion has shifted. Now prostate imaging (particularly MRI) is being recommended and is accepted by an ever-expanding chorus of urologists on websites, in books, and even (reluctant) urologists themselves.
Similar to the PSA situation mentioned, the utility of prostate imaging is considerably dependent upon a patient’s specific case. Put another way, prostate imaging is (pun intended) not black or white… it’s gray.
CRITICAL POINT: Prostate imaging (currently) can never legally diagnose a prostate cancer. This point bears repeating because it must be clearly understood before we can discuss imaging any further. Why can’t imaging diagnose CaP? For liability reasons alone, a urologist will not be covered through his malpractice insurance, nor will the patient’s medical insurance pay the urologist for performing any proposed surgery or radiation unless a physical cancer cell has first been isolated – hence the requirement of urologists to procure a biopsy. The reality is that imaging – whether by advanced color Doppler ultrasound or 3T MRI – can only determine regions within the prostate that are highly suspicious for cancer.
What is “High Risk” on Imaging?
High-risk lesions typically identify on prostate imaging as darker (hypoechoic) areas than the surrounding (isoechoic) gland. Although TRUSP is more qualitative than MRI, the current new image-rating system for hypoechoic lesions on parametric MRI rates any such suspect CaP lesions on a 1-5 scale called PI-RADS (Prostate Imaging-Reporting and Data System). PI-RADS is a structured reporting scheme created by the European Society of Urogenital Radiology (ESUR) and which is being adopted by most current urology centers in the United States. A PI-RADS score of 1 is considered the lowest in hypoechoicity (and CaP risk), while a score of 5 is rated as highest risk, not only for cancer but also for a (legally) more aggressive variant of the cancer (ie, high Gleason Score). The main point here is that a suspect lesion is only that – an area of CaP suspicion. It could be cancer, but more often the case it is simply a region of inflammation. Statistically, inflammation of the prostate (prostatitis) is the most common reason for elevated PSA values between 2 and 10. Importantly, a static MRI/TRUSP image of a patient’s prostate that simply demonstrates a darkened area, regardless of the cause, cannot be confirmed as cancer rather than prostatitis. Unless, of course, a biopsy is performed.
As I have discussed in prior NDNR articles, imaging can demonstrate exceptionally important features that can help an experienced physician determine: the likelihood of CaP being present; the risk of such a CaP becoming metastatic; and the most likely causes of an elevated PSA. Since most educated patients are aware that “we have cancer in us all the time,” determining why a PSA is elevated is a more strategic approach to determining CaP risk. This is because the PSA alone is typically the instigating factor for a patient wanting a biopsy.
Why is MRI Imaging Suddenly So Popular?
The current popularity in prostate imaging is not necessarily related to a patient’s expectations of diagnosing a cancer without a biopsy. This point cannot be stressed enough to the anxious patient who is under the illusion that an MRI will show something that is equivalent to a needle biopsy, thus rendering the latter procedure moot. Unfortunately, this is not the case. Let’s explore why.
Most urologists have the patient’s best interests in mind. However, in my opinion, the main factors driving MRI imaging are (currently) both financial and to ward off liability. Since prostate cancer cannot be diagnosed without a biopsy, the practical urologist sees no advantage in an image alone without biopsy, since it can never lead to a definitive diagnosis and treatment. However, urologists have been pressured to perform such imaging from 2 directions. On the one hand, patients are increasingly demanding imaging due to their own misunderstanding of what the results can offer, based on a growing volume of websites and books promoting it. And on the other hand, urologists are concomitantly pressured by hospital administrators strapped for cash, who may strongly suggest to their urology departments to not turn away money from an anxious patient population of older men who often have disposable income. “Take their money, take their picture, then biopsy them later.” Although this sounds cynical, this very dynamic is being observed throughout the country by urologists, both privately and publicly.
Then How is MRI Imaging Being Used?
Unfortunately, MRI imaging is being utilized quite poorly for the integrative patient in terms of “moving the needle” toward appropriate treatment. This is simply because of the fact that identification of a suspicious hypoechoic lesion on imaging cannot move forward toward either further assessments or treatments without that region being biopsied.
The following hypothetical dialogue is an example of what transpires in a typical urologist’s office when he is confronted by a patient who prefers imaging over biopsy:
Urologist: Since your PSA is over 4.0, we must biopsy you to determine if cancer is present.
Patient: I refuse a biopsy, since I read online that MRI imaging can be better than biopsy.
Urologist: Fine, he says reluctantly, and schedules the patient for an MRI.
The following week the patient returns, feeling anxious and nervous as he and his wife await the MRI imaging results.
Patient: So, Doc, did you see something on my scan?
Urologist: Unfortunately, the radiologist identified a hypoechoic lesion at the posterior left apex.
Patient: Uh… in English, please, Doctor!
Urologist: Basically, there is a suspicious black spot on your prostate.
Patient: Well, does that mean it’s cancer?
Urologist: Not necessarily. It may instead simply be an area of inflammation.
Patient: I like the sound of “inflammation” rather than “cancer”! So how do we figure this out, then?
At this point, the urologist sits back with a slight grin, reminiscent of the Cheshire cat, and replies, I am glad you asked me that. We need to perform a biopsy.
For a few years now, I have observed this kind of dialogue unfold for many well-intentioned but anxious patients. They educated themselves and actively pursued MRI imaging as a way to “outsmart” the system and avoid a biopsy. Yet after all of their efforts, time, and money, the MRI was unexpectedly used simply as leverage by the urologist to further pressure his patient to have what the doctor wanted initially – a biopsy. The patient is often backed into the proverbial corner, since he is now left holding the very image he pressured the physician to order in the first place. Only now he has more anxiety over an identified “black spot” on an image, and it’s a result that has no patient-specific context associated with it. Although perhaps initiated with good intentions, the recent surge in MRI imaging in lieu of a biopsy is resulting in even more unexpected and pressured biopsies, and incurring even greater costs to our broken healthcare system.
Too Many Cooks in the Kitchen
Why is it that as more urologists offer imaging as an option, more biopsies are being performed? The bottom line is that recent MRI imaging is being used as a sole data point by multiple practitioners who typically do not interact to discuss a patient’s specific case. These practitioners do not individually feel the patient’s prostate immediately prior to imaging, and they simply do not have the time during a typical 8-minute consultation to collect a thorough-enough history to rule in non-cancer causes for either PSA elevations or suspect spots on imaging.
For example, the patient typically has his imaging conducted not by his primary urologist but rather by an MRI technician who is not allowed to confer with the patient about his case. Every patient who has undergone imaging can relate to the blank response of the technician when, on the heels of the procedure, the patient reflexively asks, “Did you see anything?” Moreover, the technician does not tailor the imaging session based on the patient’s chart notes or on what the prostate might have felt like prior to the scan. Instead, he simply follows a standardized technical protocol of measurements and angles that he was trained to follow with every patient. Employing creativity and medical judgment based upon the patient’s specific case during an imaging session is not allowed, to the disadvantage of the patient.
Next, the patient’s images are typically then sent to another third-party practitioner – the radiologist. In many hospitals today, in order to cut costs, a patient’s prostate images are sent overseas to be read by a radiologist in countries like India or the Philippines, where 24-hour turnaround times can be performed cheaply. Here again, a different practitioner, far removed from the patient’s specific case, simply identifies any abnormality observed on the scan. There is often no context provided for the patient’s specific case, nor has the radiologist conducted a digital rectal exam on the patient. Why is this important? Consider, for example, when a radiologist observes a hypoechoic lesion at the left prostate gland. This lesion could be cancer or simply inflammation. The former can be lethal, while the latter is not. Both, however, show up on imaging quite similarly, and both can increase the PSA. On the digital exam, cancer classically palpates as a hard nodule, whereas inflammation will palpate as soft and boggy. This means that a physician conducting imaging immediately after feeling the prostate can gain an immense amount of context when observing the image – information that a random third-party technician not engaged in the patient’s detailed case cannot.
Although this is becoming very common, the above scenario may not apply to every urologist. However it strongly highlights the disconnect that patients have been recently experiencing when they encounter inconclusive MRI results. This problem is compounded by the lack of a personalized CaP assessment through the current highly decentralized and fragmented medical system.
When is Imaging Useful?
Is prostate imaging therefore completely worthless? As noted earlier, prostate imaging, whether via color Doppler ultrasound or MRI, is extremely helpful when properly used as part of a comprehensive assessment. The problem outlined in this article is specifically focused upon the recent trend of using MRI imaging as a sole diagnostic tool.
The Ideal Scenario
The difference between these 2 uses of imaging (ie, prostate imaging used as part of a comprehensive assessment versus imaging used an overly-weighted lone tool) is quite profound. In essence, imaging should always be used in tandem with a comprehensive assessment. Complementary to any imaging is a comprehensive patient history that includes family history, the patient’s hormone exposures, PSA-inducing physical activities, and carcinogen exposures, etc. Furthermore a detailed PSA tracking history (PSA Velocity, Density, Pattern, etc), a thorough digital rectal exam, and even the new molecular CaP testing (SELECT MDX, EXO DX, etc), should also be performed in conjunction with any imaging of the prostate. The key is to have all of this comprehensive and CaP-relevant testing/information performed and provided by the same primary physician, so that any suspect hypoechoic lesion identified on imaging can more easily be ruled in or out as prostatitis rather than prostate cancer. This will provide the best opportunity for a patient to hopefully avoid an unnecessary biopsy, especially if the prostate is currently inflamed. As noted above, prostatitis is a very common reason for moderately elevated PSA values. The last thing a patient would likely want (or need) is 12 puncture holes through their rectum, filled with bacteria infiltrating an already inflamed gland. Since imaging cannot diagnose a cancer, the goal of imaging, rather than simply being to identify where to biopsy any suspect CaP region, should instead be to help assess whether a suspect lesion is worthy of a biopsy in the first place.
Despite the slightly cynical perspective discussed here, it should be restated that many physicians new to imaging are trying to incorporate it with the best of intentions for their patients. However, if the patient is unsure of how his urologist will utilize his prostate imaging, then I recommend that he simply ask him. For example, specifically say beforehand, “Doctor, if my prostate images return with a suspect lesion, will you help me determine, non-invasively, the possibility that it’s not cancer, or will you reflexively demand a biopsy?”
It cannot be stressed enough that prostate imaging is highly useful when used as part of an aggregate assessment approach to identifying why an individual’s PSA levels are increasing. Physicians who have utilized imaging over the past decade, when it was not previously accepted, have been forced to use this technology as part of a comprehensive assessment approach to avoiding unnecessary biopsies for their patients. As imaging costs decline, and physicians at large begin to have more experience interpreting these imaging results, imaging will become an ever-more powerful tool in the future for the typical urologist and practitioner. However, although more physicians are clamoring to offer their local imaging machines to their patients, as with any tool, prostate imaging is only as useful as the person wielding it.
Phranq D. Tamburri, NMD, is founder of Prostate Second Opinions, with an international patient clientele in Phoenix, Scottsdale, and Seattle. Dr Tamburri has been Professor of Urology at his alma mater, Southwest College of Naturopathic Medicine (SCNM), for 19 years, and educates in all media forums for both patients and physicians on pragmatic approaches to refining the diagnosis and tracking of prostate cancer. He was uniquely cross-trained, from western Mayo Clinic surgeons to Buddhist monks, while graduating from Kansai Gaidai, Japan. When not conducting digital exams, Dr Tamburri loves Arizona desert rides on his green Kawai while blaring Tangerine Dream.