New Guidelines for the detection of prostate cancer MRI instead of tissue samples

3 February 2020

The module on diagnostic prostate MRI for the NVU guidelines for prostate carcinoma took effect on 29 January 2020. According to these new guidelines, MRI scans should be performed in case of elevated values on a PSA blood test and when a prostate biopsy would otherwise be done. To date, tissue samples have been taken as a standard measure in such cases. This is a painful procedure that often leads to complications and over-treatment. The development of these guidelines, which could also lead to major reductions in the cost of care, is due in part to the efforts of Jelle Barentsz, a radiologist at Radboud university medical center, and Ivo Schoots, a radiologist at Erasmus MC.
 
Prostate cancer is the second most common type of cancer in men (following lung cancer). Each year, approximately 10 000 new patients are diagnosed in the Netherlands, 2 500 of whom will die. Prostate MRIs will now be required for men in whom prostate cancer is suspected (e.g. due to elevated PSA values). These guidelines replace the current method, in which a prostate biopsy (with 12 tissue samples) is performed following an elevated PSA value. If a scan does not reveal any abnormalities, the patient can be sent home with confidence, and without tissue samples. If the scan is abnormal, a biopsy can be performed, but with 3 needles instead of 12.
 
Lower cost of care and fewer complications and over-treatment
Each year, 40 000 men have elevated PSA values. With the old method, 25 000 of these men receive biopsies that will ultimately prove unnecessary. Around 1 200 of these men experience complications (e.g. bleeding and infection). Moreover, the biopsies often reveal non-aggressive types of cancer. Although these types of cancer do not need to be treated, they often are in practice, possibly leading to unnecessary impotence and incontinence. The use of high-level expert prostate MRIs could result in:
 

• 57% fewer biopsies (22 800 men)
• 16% less over-diagnosis and over-treatment (6 400 fewer men)
• 3% more aggressive cancers detected (1 200 more men)
• 9 times fewer tissue samples (51 600 needles instead of 480 000)
• 23 times fewer complications from tissue samples (52 men instead of 1 200)
• €375 cost savings per patient → €15 000 000 savings per year

These figures are in reference to the currently customary diagnostic procedure of PSA followed by tissue sampling.
 
MRI scan
Jelle Barentsz of Radboudumc is glad that these guidelines have been adopted. For years, he has been conducting research on the benefits of MRI scans relative to the standard tissue samples. In this research, he has collaborated with partners including Ivo Schoots of Erasmus MC, who notes, “It is important for men who are suspected of having prostate cancer to have a good MRI scan first. This clarifies the diagnosis and further steps to be taken.”
 
Jelle Barentsz continues, “As the guideline is only now taking effect, not all general practitioners are aware of the advantages of the combination of PSA+MRI, nor are all urologists aware of this. In the implementation of the revised guidelines, an action plan is needed in order to guarantee the quality of prostate MRIs and to facilitate the increase in the number of prostate MRIs (30 000–40 000) with regard to: (1) MRI capacity (particularly in light of the existing waiting lists in an average Dutch hospital); (2) staffing of MRI equipment (laboratory technicians); and (3) the assessment of examinations (abdominal radiologists). Because the Dutch Society for Radiology (NVvR) anticipated the passage of these guidelines, a number of radiologists and laboratory technicians have already been trained. This is not sufficient, however, and it will take some time before we are up and running. We are also working hard to develop a high-quality body for certification and training, but this now calls for a rapid follow-up.”
 
Additional information is available here (in Dutch). 
 
Guidelines for Prostate Carcinoma, module on diagnostic prostate MRI
The new guidelines for Prostate Carcinoma, module on diagnostic prostate MRI were established by the Dutch Association of Urology (NVU), in collaboration with partners including the Federation of Medical Specialists, the Dutch Society for Radiology (NVvR), the Dutch Society of Nuclear Medicine (NVNG), the Netherlands Society for Pathology (NVVP), the Dutch Society for Radiotherapy and Oncology (NVRO), and the Dutch Internists Association (NIV). The guidelines have been endorsed by the Dutch Prostate Cancer Foundation (ProstaatKankerStichting).