A recent scientific study published in the British medical journal The Lancet found that the use of an advanced imaging technology, known as multi-parametric MRI or mpMRI, can significantly improve the detection of aggressive cancers of the prostate and confirm the need for a diagnostic tissue biopsy.
It also can be used to more accurately gather a tissue specimen from the affected area of the gland, minimizing dangerous side effects, such as infection, pain and bleeding, and increasing the likelihood of effective treatment.
In a widely broadcast report on the study, the BBC news outlet quoted a British health expert who called the findings “a huge leap in prostate cancer screening.” The report said the National Health Service, the public health system that provides medical care to all British citizens, was reviewing whether the pricey technology should be used more broadly in the detection, diagnosis and treatment of prostate cancer.
Across the pond in Maine, the BBC report has made some waves.
“Some patients brought that story in and asked about it,” said Dr. Gregor Adey of Fore River Urology in Portland. “It’s a little bit of a weird story, because that technology already exists in the U.S. I use it a couple times a week.”
In Maine, the mpMRI technology is available at Maine Medical Center in Portland and at First MRI in Bangor. In Portland, it is augmented with a special software that fuses the mpMRI image with an ultrasound image for maximum precision.
Adey uses the augmented technology selectively in two groups of patients.
One group is men whose diagnosed prostate cancer is so slow-moving that aggressive treatment is not needed, only the “active surveillance” approach of regular monitoring to detect changes. The standard of care for that monitoring has traditionally included transrectal ultrasound in the urology office and, when indicated, a repeat biopsy.
“Now, MRI is being used to enhance that imaging,” Adey said, both to visualize changes and, when needed, to complete the biopsy.
The second group is men whose blood work shows increased levels of prostate-specific antigen, or PSA, but whose preliminary biopsies have been negative for cancer. PSA is a protein produced by both cancerous and noncancerous prostate tissue, but elevated levels are often associated with cancer. In men whose PSA continues to rise, Adey said mpMRI provides the best images to determine the presence of a tumor.
At Maine Medical Center in Portland, Dr. Matthew Hayn, medical director of the hospital’s genitourinary cancer program, said The Lancet report has stirred up new interest among his colleagues and patients.
“It’s definitely coming up more and more in our conversations,” he said.
Although the technology has been available at Maine Medical Center for about a year, he said, it is used only selectively and not as a front-line imaging tool. Transrectal ultrasound remains the standard of care, even though it is far less accurate.
“It’s a payor issue,” he said. “Insurance companies give us a lot of pushback on using the MRI on a guy without a cancer diagnosis or who hasn’t had a preliminary biopsy.”
Hayn wasn’t able to provide billing comparisons, but he noted that using mpMRI more broadly, while more expensive on a case by case basis, has the potential to reduce unnecessary treatment and complications across the health care system.
“It could result in cost savings, ultimately,” he said.
Hayn said Maine Medical Center is the only hospital to offer the augmented technology in Maine, and many patients from other parts of the state have sought treatment there.
At the state’s second-largest hospital, Eastern Maine Medical Center in Bangor, urologist Gideon Lorber said the significance of mpMRI is well recognized, and the hospital continues to follow the emerging scientific and medical data regarding its efficacy.
“We have actively reached out to the leading vendors offering this technology and are currently in the process of evaluating their products,” he said in an email.
Multi-parametric MRI has been in use at First MRI in Bangor for about 18 months. Images from that practice are sent electronically to Boston for fusing with ultrasound images when appropriate.
Second only to skin cancers, prostate cancer is the most common form of cancer in American men, with an estimated 180,890 cases diagnosed per year. And after lung cancer, it is the second most lethal cancer in men, responsible for more than 26,000 deaths per year.
African-American men have a significantly higher risk of developing prostate cancer, as do men who are obese or who have a family history of cancer. The risk for all men increases with age, with more than 85 percent of prostate cancers diagnosed in men who are 65 or older.
Symptoms may include difficult or painful urination; pain in the pelvis, lower back or hips; blood in the semen or urine; and painful ejaculation.
Early detection is key in treating all cancers. But prostate cancer poses a conundrum, since standard screening tools, which include an uncomfortable digital exam of the gland through the lining of the rectum and the measurement of PSA levels, are notoriously inaccurate and come with their own serious risks, including false-positive PSA results and the ease with which a lesion on the rectum may escape detection in the digital exam.
Current screening recommendations vary. The U.S. Centers for Disease Control specifically recommends against routine PSA testing in men of any age who do not have symptoms. Other groups, including the American Urological Association, the American Cancer Society and the American College of Physicians, recommend that men discuss the benefits and risks of PSA and digital screening with their physicians, beginning at age 50 or younger if they have other risk factors.
The use of mpMRI as a screening tool may increase over time, as more medical studies such as the one reported in The Lancet show its efficacy in improving care and lowering costs.
“Like so many things in medicine,” Adey said, “we have to keep our eyes and ears open, do the cost-benefit analysis and see what is actually helpful going forward.”