Introduction
MRI-directed pathway
Clinical benefits
Patient selection for MRI
Statement | Organization |
---|---|
Guidance for early prostate cancer detection in asymptomatic men | |
Do not subject men to prostate-specific antigen (PSA) testing without counseling them on the potential risks and benefits | EAU 2020 |
Offer an individualized risk-adapted strategy for early detection to a well-informed man with a good performance status and a life expectancy of at least 10 to 15 years | EAU 2020, AUA 2019, NCCN 2019 |
Offer early PSA testing in well-informed men at elevated risk of having prostate cancer (> 50 years of age, > 45 years of age and family history of prostate cancer, African descent, BRCA2 mutations carriers) | EAU 2020 |
Guidance for MRI use for diagnosing prostate cancer | |
Do not use MRI as an initial screening tool for unselected men | EAU 2020 PI-RADS 2019 |
Adhere to PI-RADS guidelines for multiparametric magnetic resonance imaging (mpMRI) acquisition and interpretation and evaluate mpMRI results in multidisciplinary meetings with pathological feedback | EAU 2020 PI-RADS 2019 |
Carefully assess/reassess risk of significant disease using PSA metrics and/or risk calculators before and after MRI; combine clinical parameters and MRI results for deciding biopsy need | Current manuscript |
Guidance in biopsy naïve men | |
With negative MRI scans at low suspicion | |
Omit biopsy based on shared decision making | EAU 2020 PI-RADS 2019 |
Have robust ‘safety net’ for men who avoid immediate biopsy with roles and responsibility clearly defined | PI-RADS 2019 |
Discharge patients to primary care if the level of suspicion is low advise PSA follow-up at 6 months and then every year set PSA level at which to re-refer based on PSAD (0.15 ng/ml/ml) or velocity (0.75 ng/year) | NICE 2019 |
With negative MRI scans at high suspicion | |
Perform systematic biopsy based on shared decision | EAU 2020 |
Offer prostate biopsy if there is a strong suspicion of prostate cancer based on PSA density (> 0.15 ng/ml/ml) or PSA velocity (> 0.75 ng/year), or strong family history, taking into account life expectancy and comorbidities | NICE 2019 |
With positive MRI scans | |
Use MRI as a roadmap to guide biopsy procedures to increase precision of biopsy | PI-RADS 2019 |
Combine systematic and targeted biopsy focal saturation is a viable alternative | EAU 2019 PI-RADS 2019 |
In men with prior negative biopsies, when MRI is positive perform targeted biopsy only | EAU 2019 |
Multiple re-biopsy options exist in men with negative or non-explanatory histology after MRI-directed biopsy at persistent high risk | PI-RADS 2019 |
Guidance in prior negative biopsy men with persistent high suspicion | |
Perform MRI before biopsy | EAU 2020, AUA 2019, NCCN 2019 |
When MRI is positive perform targeted biopsy only | EAU 2020 |
When MRI is negative, perform systematic biopsy based on shared decision making with the patient | EAU 2020 |
Multiple re-biopsy options exist in men with negative or non-explanatory histology after MRI-directed biopsy at persistent high risk | PI-RADS 2019 |