Purpose: Patient and physician uncertainty about clinically staged low-risk prostate cancer often leads to a preference for radical treatment. This is often due to the known limitations of systematic biopsies that sample only 1% of the prostate that can understage patients in up to 25% of cases. Since the addition of mpMRI accurately rules out occult higher grade disease with a negative predictive value of > 90%, it was hypothesized that the results of these scans often influence recommendations for active surveillance (AS) at our academic institution.
Methods: A 10-question survey was distributed to radiation oncologists and urologists at 2 teaching hospitals who actively treat prostate cancer. Questions investigated whether the addition of a staging mpMRI influenced physician recommendations for AS, and frequency of surveillance biopsies during AS.
Results: The response rate was 100% (20 responses) and included 9 urologists and 11 radiation oncologists. A total of 84% have offered staging mpMRI for men with biopsy proven low-risk prostate cancer. The addition of mpMRI was reported by 65% of physicians to increase their likelihood of recommending AS. When mpMRI is available, 55% reported they would consider increasing the interval between surveillance biopsies when the results did not suggest the presence of occult higher grade or stage disease. None of the respondents perceived an increase in patient anxiety with the addition of mpMRI. Nearly all physicians (95%) reported that the addition of a staging mpMRI increases their confidence when recommending men to stay on AS vs the option of surveillance with systematic biopsies alone. Almost all physicians (95%) felt that mpMRI reassured patients pursuing AS, and none perceived that adding this additional test increased patient anxiety. All (100%) respondents agreed to participate in a prospective clinical trial comparing mpMRI to systematic biopsy for active surveillance for low-risk patients if offered at their institution.
Conclusions: The addition of mpMRI in men with low-risk prostate cancer increases clinician confidence for recommending AS. There is a need for well-designed clinical trials to ensure this imaging modality ensures proper selection of patients with a low risk of clinical progression.