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Guidelines Session: Omitting biopsy in case of normal MRI

The EAU Guidelines Office, led by Prof. James N’Dow (GB) uses the Annual EAU Congress to launch its annually-updated guidelines. The Guidelines Controversies sessions, two of which took place on Saturday at EAU19, are a way to highlight the latest additions and changes.

The chairs of each Guidelines panel and independent experts explore the evidence base for new recommendations and involve the audience in the decisions through voting and discussion.

The Prostate Cancer panel, led by Prof. Nicolas Mottet wanted to highlight changes in its recommendations on MRI imaging and the way it affects the decision to proceed with a biopsy. Prof. Caroline Moore (GB) and Dr. Sigrid Carlsson (USA) debated the pros and cons of foregoing biopsy after MRI, while Dr. Olivier Rouvière (FR) offered a “balanced” viewpoint to aid discussion.

“Hold fire, not end-fire”

Prof. Moore strongly argued that standard biopsy in men with a negative MRI can have unfortunate results. “Side-effects of biopsy are common,” Moore pointed out, “and current treatment rates are much higher than recommended. Even active surveillance has morbidity and cost associated with it.”

“Five-year detection rates of significant cancer in men with negative MRI and no TRUS biopsy are low [5%]. I recommend that we hold fire, rather than end-fire.”

Dr. Carlsson voiced her concerns on mpMRI being able to adequately detect all tumours: the technology might have a high enough sensitivity to detect, but there is massive inter-observer variability. The learning curve and the variance in each centre’s MRI capabilities also proved a challenge. Carlsson suggested several possible treatment pathways that could serve urologists and patients in future.

Addressing the concerns about MRI quality, Moore later told EUT Congress News that while there is increased confidence in MRI, there is also still a lot of discussion about its quality. “During the session, James N’Dow asked if we had enough long-term data. I think it’s not long-term data we need, it’s quality assurance across the board.”

“Many good centres can do MRI. What we haven’t shown is that every centre can be a good centre. I think we can get there and that it’s mainly a training issue,” Moore concluded.

Involving the patient

It was emphasised at the session that the patient should also be involved in the decision to perform biopsy if the MRI is negative. Moore: “Discussion with the patient is important and I’m pleased to see that in the 2019 EAU Guidelines. It’s a recognition that this is a preference-sensitive decision. A man might prefer greater certainty at the expense of side-effects and expense. Or he might be very confident in the fact we’re not missing the sort of disease that might impact his life and be happier to forego the biopsy.”

“In the UK, the discussion is reasonably well-framed about not detecting all cancer. A drive for maximum diagnosis can be a real problem. I think we will see people being sued for these harms. We can already see the beginnings of a backlash against over-diagnosis.”